PUD Management :

1- Initial management is conservative with medication against H pylori :

a- 14 day Triple therapy with bismuth and tetracycline and metronidazole , if fail then
b- Quadruple therapy with bismuth and omeprazole and tetracycline and metronidazole
2- Indication for surgery :. for PUD(Billroth 1 or 2 ) : Refractory syndromes despite appropriate medical
treatment Or , Complications that cannot be treated endoscopically like perforation , hemorrhage ,
obstruction , , inability to rule out malignancy , failure to achieve hemostasis endoscopically

Types of surgery for Patient with persistent Gastric Ulcer :

1- Billionth 1 : Distal gastrectomy with gastroduodenostomy
2- Billionth 2 : Distal gastrectomy with gastrojejuostomy ( Main Complication rupture of duodenal
stump, cancer of anastomosis site, Alkaline reflux leading to inflammation which increase risk for
cancer ) or Afferent loop syndrome (ALS), .Efferent loop syndrome.

perforated appendicitis, a culture is taken from the abdominal fluid. Which of the
following bacteria is the most likely to grow?
The Most common aerobic bacteria is E. Coli and the most common anaerobic bacteria is Bacteroidis
Fragilis

E.coli in 77%
s.viridans 44%
GDS 27%
p,aeruginosa 18%

FAP

Treatment of choice: Total proctocolectomy with ileal pouch–anal anastomosis (IPAA).

info

nasogastric tube aspirate that contains bile and no blood effectively rules out upper tract bleeding in
most patients.

Therapy with nitrates for controlling the discomfort in patients with STEMI should be
avoided in patients who present with low systolic arterial pressure (<90 mmHg) or in
whom there is clinical suspicion of RV infarction (inferior infarction on ECG, elevated
jugular venous pressure, clear lungs, and hypotension)

Psych

Cloazapine , Olanzapine & Quetiapine are associated with Anti-cholenergic effects(constipation)

Confabulation is a type of memory error in which gaps in a person's memory are

unconsciously filled with fabricated, misinterpreted, or distorted information. 1 When
someone confabulates, they are confusing things they have imagined with real
memories. A person who is confabulating is not lying.

Dystonia is a movement disorder in which a person's muscles contract uncontrollably

Fluvoxamine, sold under the brand name Luvox among others, is an antidepressant of the
selective serotonin reuptake inhibitor (SSRI) class
Perphenazine is a typical antipsychotic drug.

Phenelzine, sold under the brand name Nardil, among others, is a non-selective and
irreversible monoamine oxidase inhibitor (MAOI)

Not all patients require hospitalization; some can be treated on an outpatient basis.
But the absence of a strong social support system, a history of impulsive behavior, and a suicidal plan
of action
are indications for hospitalization.
To decide whether outpatient treatment is feasible, clinicians should use a straightforward
clinical approach: Ask patients who are considered suicidal to agree to call when they become
uncertain about their ability to control their suicidal impulses. Patients who can make such an
agreement with a doctor with whom they have a relationship reaffirm the belief that they have
sufficient strength to control such impulses and to seek help.

KAPLAN AND SADOCK PAGE 769

The most common signs of catatonia are immobility, mutism, withdrawal and refusal
to eat, staring, negativism, posturing (rigidity), rigidity, waxy flexibility/catalepsy,
stereotypy (purposeless, repetitive movements), echolalia or echopraxia,
verbigeration (repeat meaningless phrases).

1st line Tx in JIA is NSAIDs

2nd line would be DMRD(Methotrexate)- add steroids if severe Extra-articular symptoms is present.
Internal

This is Zollinger Ellison,

remember that this is endocrine pancreatic head tumor that secrets gastrin (induces acid secretion
and causes (refractory) ulcers). Also pt has diarrhea.
Gastrin must be high, if low r/o ZE.
If equivocal results (gastrin is not low, but somwhere @ midrange) do secretin test - it won't stop
gastrin secretion.

Also, if you don't know about ZE - remember that the pt is on PPI - which one of it's Side Effects is
hypergastrinemia, therefore - you stop it regardless.

 Contrast nephropathy
 Definition: AKI after IV administration of iodinated contrast medium
 Risk factors
o Chronic kidney disease (CKD): esp. in patients with diabetes mellitus, multiple
myeloma

 Creatinine is highest after 3–5 days after injury and usually falls back to the
baseline level within 1 week.
 Always evaluate kidney function before administering a contrast agent.

Evans syndrome is an autoimmune disease in which an individual's immune system attacks

their own red blood cells and platelets, the syndrome can include immune neutropenia.[1][2] These
immune cytopenias may occur simultaneously or sequentially.[1][3]
Its overall phenotype resembles a combination of autoimmune hemolytic anemia and immune
thrombocytopenic purpura.
‫לעבור בקטנהה‬

Ampicillin is added if patients are at risk of Listeria spp. infection (e.g., newborns, pregnant women,
the elderly, or immunocompromised patients) because cephalosporins are ineffective against Listeria
spp.
AMBOSS

LMU, Dec 17, 2020 20:26

Age > 1 month to < 50 years
Vancomycin [38]
PLUS one of the following third-generation cephalosporins:
Cefotaxime [38]
Ceftriaxone [38]
AMBOSS

LMU, Dec 17, 2020 20:27

Age < 1 month:
Ampicillin [38]
PLUS an aminoglycoside (e.g., gentamicin ) [38]
AND/OR a third-generation cephalosporin
Cefotaxime [38]
If cefotaxime is unavailable: ceftazidime [38]
Ceftriaxone is contraindicated in patients aged < 1 month because of a higher risk of biliary sludging
and kernicterus. [46]
AMBOSS

LMU, Dec 17, 2020 20:27

Age > 50 years
Vancomycin [38]
PLUS ampicillin [38]
PLUS one of the following third-generation cephalosporins:
Cefotaxime [38]
Ceftriaxone [38]

Antimicrobial prophylaxis should be applied in clean wounds at high risk of wound infection, clean-
contaminated wounds and contaminated wounds.
In clean wounds without a risk, there is no indication for prophylaxis.
risk factors that require prophylaxis:
Patient-related risk factors for surgical wound infections are advanced age, negative nutritional status,
obesity, diabetes mellitus, cigarette smoking, presence of infection, immunodeficiency or
immunosuppressive use, steroid use, recent surgery, long preoperative hospitalization and
colonization with microorganisms.

Sabiston pg. 11-4 2020

A sliding hernia occurs when an internal organ composes a portion of the wall of the hernia sac. The
most common viscus involved is the colon or urinary bladder. Most sliding hernias are a variant of
indirect inguinal hernias, although femoral and direct sliding hernias can occur. The primary danger
associated with a sliding hernia is the failure to recognize the visceral component of the hernia sac
before injury to the bowel or bladder. The sliding hernia contents are reduced into the peritoneal
cavity, and any excess hernia sac is ligated and divided. After reduction of the hernia, one of the
techniques described earlier can be used for repair of the inguinal hernia

Bacteria that commonly cause cholangitis are :- Escherichia coli

Klebsiella,
Enterococcus,
Enterobacter,
Pseudomonas, and anaerobes.

The patient is presenting with signs and symptoms of Small Bowel Obstruction (SBO) which is evident
by the abdominal distention, pain, vomiting and constipation.
The abdomen being soft with no signs of peritonitis (guarding, rigidity, rebound tenderness, diffuse
pain) rules out perforation.
Imaging confirms the diagnosis of SBO demonstrating dilated loops and collapse after the point
where the obstrucion is (Terminal Ileum, as the bowel after it has collapsed)
Now some causes of SBO are hernias, adhesions, tumors, or as demonstrated in the question
gallstones which is hinted at by the presence of pneumobilia.

Contrast-enhanced CT scans can identify/rule out a mechanical colonic obstruction and possible
complications (colonic ischemia/perforation). Patients with acute/chronic megacolon can often be
treated conservatively with bowel rest, dietary modifications, prokinetic drugs, and/or neostigmine.
Colonoscopic decompression is often successful in patients with acute megacolon. Surgical
intervention for acute/chronic megacolon (colectomy and ileorectal anastomosis) is indicated if
conservative treatment fails.
The chromogranin A (CgA) blood test is a good marker to help detect and monitor the activity of
carcinoid tumors. This includes the tumors that release (secrete) the hormones that are associated
with carcinoid syndrome
Right side heart failure

Diagnostic method :
1- ECG : RV hypertrophy (V1 : R higher than S )
2- Findings on ECHO for patient with right side HF: RA +RV dilatation + pulmonary hypertension +
JVP increase
3- X rays : IVC inferior vena cava dilatation (will be > 0,7 mm) (most sp)

Enterotomy is the surgical incision into an intestine. It may be purposeful or a

complication of an abdominal surgery, such as exploratory laparotomies or hernia
repair. An enterotomy can be done to remove an obstruction or foreign body from
the intestine.

- Discontinue warfarin at least 5 days prior to surgery.

- Give LMWH as prophylaxis for VTE due to increased risk (cancer).

dcis

Early stage disease

Breast-conserving therapy (BCT): lumpectomy followed by radiation therapy
Contraindications: large tumor-to-breast ratio, multifocal tumors, fixation to the chest wall, excision
with negative tumor margins (> 2 mm) not guaranteed, clustered microcalcifications on imaging,
involvement of the skin or nipple, a history of chest radiation
Surgical margins need to be tumor free . Otherwise, repeat resection or consider mastectomy.
Consider mastectomy for anyone unable to undergo BCT or who requests a more aggressive
management.
AMBOSS
HIV positive patients should have pap smear twice a year until the result is negative then follow up
annually for consecutive 3 negative years.

Immunization
Killed virus, toxoid, or recombinant vaccines may be given during pregnancy. The American College
of Obstetrics and Gynecology recommends that all pregnant women should receive the injectable
influenza vaccine during the season (October–March). The “flu shot” is safe when given in any
trimester. Furthermore, if administered during pregnancy, the vaccine appears to reduce the risk of
infant respiratory disease within the first 6 months of life. Diphtheria and tetanus toxoid, hepatitis B
vaccine series, and killed polio vaccine may be administered during pregnancy to women at risk.
Live attenuated vaccines (varicella, measles, mumps, polio, and rubella) should be given 3 months
before pregnancy or postpartum. Live virus vaccines are contra-indicated in pregnancy secondary to
the potential risk of fetal infection. Viral shedding occurs in children receiving vaccination, but they
do not transmit the virus; consequently, vaccination may be safely given to the children of pregna

Antiphospholipid syndrome (APS)

Tx - warfarin for life + ASA daily

For pregnancy - LMHW + ASA

Nonstress Test
Fetal movements associated with accelerations of fetal heart rate (FHR) provide reassurance that the
fetus is not acidotic or neurologically depressed. A reactive and therefore reassuring nonstress test
(NST) is defined as 2 or more FHR accelerations, at least 15 beats/min above the baseline and lasting
at least 15 seconds within a 20-minute period.
Lange 429

PRETERM LABOR is defined as labor occurring after 20 weeks’ but before 37 weeks’
gestation...UTERINE CONTRACTIONS..Documented cervical change in dilation or effacement of at least
1 cm or A CERVIX THAT IS WELL EFFACED AND DILATED (AT LEAST 2 CM) ON ADMISSION is
considered diagnostic..The administration of corticosteroids to accelerate fetal lung maturity has
become the standard of care in the United States for all women between 24 and 34 weeks’ EGA at risk
of preterm delivery within the following 7 days. It has been shown to decrease the incidence of
neonatal respiratory distress,intraventricular hemorrhage, and neonatal mortality. Steroids can be
given according to 1 of 2 protocols:(1)BETAMETHASONE(!!!)12 MG INTRAMUSCULARLY(!!!)(IM)every
24 hours for a total of 2 doses;or(2) dexamethasone 6 mg IM every 12 hours for a total of 4 doses.The
optimal benefits of ANTENATAL CORTICOSTEROIDS are seen 24 hours after administration,peak at 48
hours,and continue for at least 7 days(Lange,11e,671).

PRETERM LABOR is defined as labor occurring after 20 weeks’ but before 37 weeks’
gestation...UTERINE CONTRACTIONS..Documented cervical change in dilation or effacement of at least
1 cm or A CERVIX THAT IS WELL EFFACED AND DILATED (AT LEAST 2 CM) ON ADMISSION is
considered diagnostic..The administration of corticosteroids to accelerate fetal lung maturity has
become the standard of care in the United States for all women between 24 and 34 weeks’ EGA at risk
of preterm delivery within the following 7 days.It has been shown to decrease the incidence of
neonatal respiratory distress,intraventricular hemorrhage, and neonatal mortality. Steroids can be
given according to 1 of 2 protocols:(1)BETAMETHASONE(!!!)12 MG INTRAMUSCULARLY(!!!)(IM)every
24 hours for a total of 2 doses;or(2) dexamethasone 6 mg IM every 12 hours for a total of 4 doses.The
optimal benefits of ANTENATAL CORTICOSTEROIDS are seen 24 hours after administration,peak at 48
hours,and continue for at least 7 days(Lange,11e,671).

Just to make it simple;

option (A Laparoscopic sacrocolpopexy) +(B Abdominal sacrocolpopexy) would be used if the

woman was still young, medically fit.
on the other hand we use Lefort- colpoclesis for women with advanced vaginal prolapse(grade4 in
this senario) who no longer desire coital function as it is a less invasive procedure.
As for the last option I think they meant "Bruch procedure" , wich is used as surgical treatment for
Stress Urinary incontenice.

In which of the following situations is intraoperative prophylaxis with antibiotics

indicated in addition to the preoperative antibiotic treatment?

A: Cesarean section due to placenta accreta with hemorrhage of 1800 ml

Card this ->

Based on measured pharmacokinetic values, additional doses of ANTIBIOTICS should be administered

when the operation exceeds 3 hours and blood loss is greater than 1500 mL

 Prophylaxis of thromboembolism (e.g., stroke) in patients with the following:

o Valvular atrial fibrillation and nonvalvular atrial fibrillation

o Heart valve replacement

Phenprocoumon
o Heart failure
Warfarin indications
 Myocardial ischemia

 Standard target INR: 2.0–3.0

 (higher in mechanical heart valves or in special high-risk circumstances; usually 2.0

Ethylenediaminetetraacetic acid (EDTA) is a well known metal-chelating agent,
extensively used for the treatment of patients who have been poisoned with heavy metal
ions such as mercury and lead.
Cyclosporin for refractory ulcerative colitis

Intravenous cyclosporin (with or without continued intravenous corticosteroids) is effective

in 50–80% of patients with severe ulcerative colitis.

Treatment of latent TB

rifampin (rifampicin) for 4 months

or
Isoniazid for 6/9 months

Immediate CXR should be performed to rule out pleural effusion, a complication of pneumonia

Initially treat DKA with normal saline and short-acting (regular) insulin.
Zinc deficiency – give zinc in cirhosis

 In patients with liver cirrhosis: associated with accelerated progression of cirrhosis and
aggravated clinical symptoms (e.g., hepatic encephalopathy).

 Acrodermatitis enteropathica: congenital deficiency of the zinc/iron-regulated transporter-

like protein (ZIP)
 To remember that translocation t(12;21) commonly manifests with pediatric B-ALL and
usually has a favorable outcome, think: “Kids flip back to health!” (the number 12 is 21 flipped
around).

most common complication of endoscopic retrograde cholangiopancreatography

(ERCP)? -> Pancreatitis

(not cholangitis)

 Pericarditis - Improves on sitting and leaning forward

 Induction and inhibition: CYP induction increases the rate of metabolism of the
substrate, while CYP inhibition decreases it.
o The effects of drugs that are activated by CYP enzymes (e.g.,
prodrugs) are increased by enzyme induction and decreased by
enzyme inhibition.
o The effects of drugs that are broken down by CYP enzymes are
decreased by enzyme induction and increased by enzyme inhibition.

In healthy people an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is
generally an effective therapeutic range for people taking warfarin
 Thrombotic thrombocytopenic purpura TTP

 Serum chemistry
o ↑ LDH, ↑ indirect bilirubin (hemolytic anemia)
o ↑ BUN and ↑ creatinine (impaired renal function)

While PT and aPTT are normal or only mildly elevated

in TTP and HUS (no consumption coagulopathy), they are markedly
elevated in DIC (consumption of platelets and all coagulation factors).

TTP requires urgent diagnosis and treatment! Waiting for test results to
confirm ADAMTS13 deficiency should not delay treatment.

 Prompt initiation of plasma exchange therapy (PEX)

 Glucocorticoids (e.g., prednisone)
 Rituximab is reserved for severe cases.

Granulomatosis with polyangiitis (GPA, previously known as Wegener

granulomatosis) is a systemic vasculitis that affects both small
and medium-sized vessels.
GPA triad: necrotizing vasculitis of small arteries, upper/lower respiratory
tract manifestations, and glomerulonephritis.
 Hypovolemia

 BUN to serum creatinine ratio > 20:1 → renal hypoperfusion due to hypovolemia
 Urine osmolality: See sodium imbalance for more information.
o < 800 mOmol/L → renal free water loss
o > 800 mOmol/L → extrarenal free water loss

A urine specific gravity test compares the density of urine to the density of water.
This quick test can help determine how well your kidneys are diluting
your urine. Urine that's too concentrated could mean that your kidneys aren't
functioning properly or that you aren't drinking enough water.

ITP

Splenectomy is indicated in acute ITP only for life-threatening bleeding. Approximately 80%
of children have a spontaneous resolution of ITP within 6 months after diagnosis. (Nelson)
Faecal calprotectin (or fecal calprotectin) is a biochemical measurement of the
protein calprotectin in the stool. Elevated faecal calprotectin indicates the migration
of neutrophils to the intestinal mucosa, which occurs during intestinal inflammation, including
inflammation caused by inflammatory bowel disease. Under a specific clinical scenario, the test
may eliminate the need for invasive colonoscopy or radio-labelled white cell scanning.
The main diseases that cause an increased excretion of faecal calprotectin are inflammatory
bowel diseases, coeliac disease, infectious colitis, necrotizing enterocolitis, intestinal cystic
fibrosis and colorectal cancer.[6][7]

Anaphylaxis
Thallasemia -> simple read

https://next.amboss.com/us/article/tT0Xs2?q=beta-thalassemia
%20major#Z9552febc6ff0fe89018c863980027e53

Blunt Trauma (if needed)

https://next.amboss.com/us/article/GL0B_g?q=blunt
%20trauma#Zeac0c0d8fb1cfc5f204487c30d1038b3

Shigellosis -> Shigellosis usually resolves without specific treatment.[1] Sufficient fluids by mouth
and rest is recommended.[1] Bismuth subsalicylate may help with the symptoms
Treatment: in severe cases,
antibiotic therapy with fluoroquinolones or 3 generation cephalosporins
rd
 Celiac – HLA testing: second-line testing after unclear initial evaluation
 Anti-endomysial antibody (EMA): Potential second-line confirmatory test (high-specificity)
[6]
most common serious bacterial infection in neonates presenting with fever?
 Answer: Urinary tract infection (not meningitis)

Read Inherited Hyperbilirubinemia

https://next.amboss.com/us/article/iM0Jog?q=crigler-najjar
%20syndrome#Zbbd3dd53008009926961cef66cee3b64

here is a common fuck up->

CPR is most successful when administered as quickly as possible. It should only be

performed when a person shows no signs of life or when they are:

 unconscious
 unresponsive
 not breathing or not breathing normally (in cardiac arrest, some people will
take occasional gasping breaths – they still need CPR at this point. Don’t wait
until they are not breathing at all).

CPR is indicated for any person unresponsive with no breathing or breathing only in
occasional agonal gasps, as it is most likely that they are in cardiac arrest.[5]:S643 If a person still
has a pulse but is not breathing (respiratory arrest) artificial ventilations may be more appropriate
Nontuberculous mycobacteria -> Lymphadenitiscan be caused by various species that differ from one
place to another, but again, MAC is the main cause worldwide. Most patients are aged less than
5 years, but the incidence is rare for children having BCG vaccine. -> Tx w/ Cefalexin

Transient hypoparathyroidism is common during the first few days of life in preterm
infants, infants of mothers with diabetes mellitus, infants of mothers with hypercalcemia, and
infants with a prolonged delay in parathyroid gland responsiveness.
https://next.amboss.com/us/article/3O0SHT?q=premature%20rupture%20of
%20membranes#Z5c4f5412a41bbd89f148e0e642253b6b
A 29-year-old woman has genital Herpes on her 30th week of gestation -> Prophylactic
acyclovir from 36 weeks of gestation until delivery

Preeclampsia –

BP elevated 2 occasion! -> EMERGENCY

Combined oral contraceptive decrease the risk of:
Ovarian cancer

Endometrial Cancer

Increased Risk

Breast Cancer
Contraindication -> answer was coagulopathy

Epidural and spinal ansesthesia – same contraindications

Wasn’t in exam but might come up FAS
Bilateral finding

Wasn’t tested but can come up

Read: High chance on exam

https://next.amboss.com/us/article/W40PRT?q=congenital%20adrenal
%20hyperplasia#Zc0dd217779f8de5c748cfc48d0deccdc

this was easy to answer – nothing on US picture

Spontaneous abortion – before 20 weeks

Stillbirth – after 20 weeks

suspected uterine anomaly in a 7-year-old girl?

 MRI (not US)

What are the absolute contraindications for a transvaginal ultrasound?

 Paediatric age group.

 Premature rupture of the membranes.
 Bleeding associated with known placenta praevia.
 Patient refusal to sign consent despite informed discussion with the sonographer.

What are the relative contraindications for a transvaginal ultrasound?

 Virginal status.
 Vaginitis: this might cause increased patient discomfort.
Hydrosalipinx (post PID) -> infertility

-> Salpingectomy and in vitro fertilization

You generally know but good to go over since its asked a lot

https://next.amboss.com/us/article/io0JbS?q=disseminated%20intravascular
%20coagulation#Zfe7e3ae8c22fecf85e6b257def2f006b

First line for ovarian cyst – COContraceptives (think they referring to PCOS)
 Complications low yield

 Chorionic villus sampling (CVS) ->

 Miscarriage (approximate risk: 2–3%)

 Limb defects

 Amniocentesis ->

 Miscarriage (approximate risk: 0.5–1%)

 Premature rupture of the membranes

 Infection

Might come up

Functional ovarian cysts

negative prognostic factor in thyroid cancer?
AGES M4 - Age>40, poor Grade, Extrathyroid or capsule/vascular invasion, Sex male, Mets, >4cm

Confirmation anki card I made was right -> delete this after going over 1 time more

Breast mass – go over breast cancer https://next.amboss.com/us/article/_k05qT?

q=breast%20cancer#Z3186a2e5e91124c9021effe4344433c7
Reminder

Really?

GO OVER EKG’s – fill in gaps of knowledge- av blocks and so on

Breast Cancer – important! Many questions

https://next.amboss.com/us/article/_k05qT?q=breast
%20cancer#Z3186a2e5e91124c9021effe4344433c7
Go over once more and delete
Penetrating object still in situ?? -> LAPAROTOMY

https://next.amboss.com/us/article/_P05hT#Z27ee2fb8e73649a5d0f45668d31914ce
CHEST TRAUMA
 Breast cancer therapy – related to question on adjunctive chemoradiation

Dumb question on cancer you got wrong

Mesenteric ischemia -> CT angiography (just reminder)

Ringer lactate solution-> doesn’t contain Magnesium

Can review further:
https://next.amboss.com/us/article/fM0kLg?q=Ringer%20lactate
%20solution#Z800598366c24db7f73d74c8305008f95

go over and delete- just reminder

Simple, yet got wrong!
Pharmacotherapy [8]

 Agents: calcimimetics (e.g., cinacalcet)

Simple – go on high yield mode – high chance stuff might come up

https://next.amboss.com/us/article/Kh0UUf?q=wound
%20healing#Z26d46d9b39eb5e840b4fda458902f6bd

Know phases and cells involved

Q was: most involved in first 2 days -> neutrophils
 ->>

Review and delete

Laparoscopy- read a bit more on amboss – concise

Learned the lesson- femoral hernia signs of SBO review

Tumor markers- worth a look

https://next.amboss.com/us/article/ol00BT#Z73e68e2795ade06af2a200e2a5ec7503

Cholangiocarcinoma- surgery

Pylephlebitis is an uncommon thrombophlebitis of the portal vein or any of its branches (i.e.
a portal vein thrombosis) that is caused by infection. It is usually a complication of intra-
abdominal sepsis, most often following diverticulitis, perforated appendicitis, or peritonitis.

Maybe worth to look into liver abscess -esp Tx

https://next.amboss.com/us/article/8L0Ozg?q=hepatic
%20abscess#Z788a2a21048346d74a8bba1dfdff33c5
gallstone ileus
Important cholelithiasis – asymptomatic, read further https://next.amboss.com/us/article/V30Ghf?
q=cholelithiasis#Zc3e341724400466518024a2ce72c8489
Go over compartment syndrome and pelvic fracture https://next.amboss.com/us/article/n307Qf?
q=pelvic%20fracture#Z544b712c23d3ef03b19d39780b703412
https://next.amboss.com/us/article/330SRf#Z61c4968a7b66b7eb9a7c572b909717f8

Rectal vs Colon Cancer

https://next.amboss.com/us/article/TS06_2?q=treatment%20of%20rectal
%20cancer#Z05123ebdafd694e00b0074d20d8a9889

Esophageal stenosis from cancer, might come up

Anal fissures - Just reminder- delete

Small vs large bowel obstruction

Incarcerated inguinal hernia – answered dumb
Plavix = Clopidogrel! In patients with AFib and a lower risk for stroke who are intolerant of
ASAs, clopidogrel can be a useful alternative, especially when the risk of hemorrhage is
potentially increased by VKA therapy.

Reminder-delete
 POD1 Postoperative Day 1 Surgery

Messed this easy one up

Confusing question – how is this answer right? IBC has peau dorange – not clear
Perioperative management – go over
https://next.amboss.com/us/article/550ikg?q=preoperative%20steroid#JAXsk00
Perioperative steroids
Weird question..
Resprim forte = TMP SMX
Biperiden = anticholinergic for parkinsons
Depaletpt= valproate
Lamictal = lamotrigine
Reminder

Electrocovulsive therapy
https://next.amboss.com/us/article/wM0hIg?q=electroconvulsive
%20therapy#Z4ad261c0f08ad05f41a33812b8344685
no absolute contraindications!

Some important psyche subjects to review if you have exra time

https://next.amboss.com/us/article/MP0M2T?q=somatic%20symptom
%20disorder#Zb701b80b7bc848a5de0d752ec9b8e934
https://next.amboss.com/us/article/lP0vUT?q=ptsd#Zfe47fcd50f23f3860202b9e4c5b7321b
https://next.amboss.com/us/article/PP0WUT?q=depression
%20(psychiatry)#Z1f104e7daf14d39fb270b5b75766553d

https://next.amboss.com/us/article/AN0Rdg?q=neuroleptic%20malignant
%20syndrome#Z6c0fe1657cdcb5393902367c654c75de
https://next.amboss.com/us/article/zN0rdg?
q=lithium#Za0b9c3c070ec11170f26f0620f287d7d
https://next.amboss.com/us/article/CN0qWg?
q=benzodiazepines#Ze66461a89ab9a7899565fa476a741909
Clinical signs of appendicitis :
Pain in the Pouch of Douglas: pain elicited by palpating the rectouterine pouch on rectal examination

Fetal effects of Hyperglycemia:

mostly affect the infants at the first 8 weeks
Cardiac- ASD, VSD, Transposition of great vessels, Aortic coarctation, TOF, Cardiomegaly
CNS- NTD, anencephaly
renal- Renal agenesis, Hydronephrosis, Ureteral duplication
GI- Duodenal/Anorectal atresia
Spinal- Sacral agenesis, caudal regression syndrome

Superimposed preeclampsia
Evidence of preeclampsia (proteinuria, renal insufficiency, thrombocytopenia, elevated liver enzymes,
pulmonary edema, cerebral edema) that occurs in a patient with chronic hypertension (BP > 140/90
mm Hg with an onset after 20 weeks' gestation).

A 40-year-old woman, 36-week pregnancy, presents with severe headaches. Mild hypertension is
known since her 18th week, and blood pressure at the emergency room is measured 168/98
mmHg and 170/91 mmHg an hour apart. Spot urinary protein +2

’
Probably wont repeat

Infertility is defined as the inability of a couple to conceive within 1 year.

Sterility implies an intrinsic inability to achieve pregnancy, whereas infertility implies a decrease in the
ability to conceive and is synonymous with subfertility.

Primary infertility applies to those who have never conceived, whereas

secondary infertility designates those who have conceived at some time in the past.

Fecundity is the probability of achieving a live birth in 1 menstrual cycle.

Fecundability is expressed as the likelihood of conception per month of exposure. Goes down the
longer it takes to get pregnant.

Fertility, as well as infertility, of a woman or couple is best perceived as fecundability, as few infertile
patients are sterile. It also allows for a direct comparison of treatment options over a more functional
time frame.

In normal fertile couples having frequent intercourse, the fecundability is estimated to be

approximately 20–25%.

Which of the following is true regarding sperm test? A normal test does not need to be
repeated

Which of the following instructions should be given to a patient referred to a sperm test?
The patient should avoid intercourse for 2-5 days and bring the sperm to the laboratory within 1
hour from ejaculation
Read on Chorioamnionitis
https://next.amboss.com/us/article/gM0FLg?q=intrauterine%20infection#RcXlXC

Cervical factors infertility associated w/ abnormal Pap, postcoital bleed, crytotherpay, conization and
DES exposure in utero.
Dx - speculum to show cervicitis or cervical stenosis.
Tx - bypass the mucus of cervix w/ ovarian stimulation + Intra Uterine Insemination - when it is
stenosed or abnormal
If cervicitis - doxycycline.
If refractory to these tx – IVF

Dunno if important really

Gamete intrafallopian transfer (GIFT) uses multiple eggs collected from the ovaries. The eggs are
placed into a thin flexible tube (catheter) along with the sperm to be used. The gametes (both eggs
and sperm) are then injected into the fallopian tubes using a surgical procedure called laparoscopy.
The doctor will use general anesthesia.

Zygote intrafallopian transfer (ZIFT) combines in vitro fertilization (IVF) and GIFT. Eggs are stimulated
and collected using IVF methods. Then the eggs are mixed with sperm in the lab. Fertilized eggs
(zygotes) are then laparoscopically returned to the fallopian tubes where they will be carried into the
uterus. The goal is for the zygote to implant in the uterus and develop into a fetus.

vulvodynia
inflammation of the vestibular gland from unknown etiology .
pain during intercourse , sitting
pain increase during physical exam with cotton applicator
tx --> topical cortisone and lidocaine , surgical excision
Answer was: Local lignocaine and pelvic floor physiotherapy
Thus endometrial hyperplasia, both typical and atypical, and
endometrial carcinoma are more frequent in patients with PCOS and long-term anovulation. Many of
these markedly atypical endometrial features can be reversed by large doses of progestational agents,
such as megestrol acetate 40–60 mg/d for 3–4 months. Follow-up endometrial biopsy is mandatory to
determine endometrial response and subsequent recurrence.
Lange 1163

atypical endometrial hyperplasia, treat: MDPA magestrol (follow up with biopsy)

Maybe worth to go over these types of surgeries

SACROSPINOUS LIGAMENT FIXATION—A popular method of vaginal vault suspension is that of

unilateral or bilateral fixation to the sacrospinous ligament.

Vaginal vault suspension to 1 or both sacrospinous ligaments has the potential of injury to the
pudendal nerve or pudendal vessels and is often technically difficult. Because gluteal and posterior leg
pain is a potential complication of this procedure, particularly if the branches of the sacral plexus are
disturbed by suturing deep to the ligament, the procedure requires a skilled vaginal surgeon and
should be undertaken only by those familiar with the technique.
Lange 1220

Sacral colpopexy is a surgical procedure used to repair apical pelvic prolapse.

The vertex position is the position your baby needs to be in for you to give birth vaginally.
Most babies get into a vertex, or head down, position near the end of your pregnancy,
between 33 and 36 weeks. Even babies who are breech up until the very end
of pregnancy can turn at the last minute
Complicated inguinal hernias
Strangulated hernia and/or signs of mechanical bowel obstruction: emergency surgery (within hours)
Incarcerated hernia without strangulation: Consider manual reduction of inguinal hernia.
Successful manual reduction: close monitoring; consider surgery during the same hospital admission
Unsuccessful manual reduction: urgent surgery
Uncomplicated inguinal hernia: elective surgery; consider watchful waiting in select patients

OGilivie’s –
Contrast-enhanced CT scans can identify/rule out a mechanical colonic obstruction and possible
complications (colonic ischemia/perforation). Patients with acute/chronic megacolon can often be
treated conservatively with bowel rest, dietary modifications, prokinetic drugs, and/or neostigmine.
Colonoscopic decompression is often successful in patients with acute megacolon. Surgical
intervention for acute/chronic megacolon (colectomy and ileorectal anastomosis) is indicated if
conservative treatment fails.
Confirming card- can delete

Stop all before surgery except the following (allow them unless mentioned) –

Beta Blockers, CBB, nitrates, statins, anti HTN (but stop if ACEi, ARB, diuretics),

anti eplipetics,

neuroleptics (but stop if lithium)

in obstruction that we dont know how to solve (cancer) we do loop colostomy ..temporary

..

Breast imaging is usually negative in Paget's disease and therefore breast conserving surgery
including nipple resection with ipsilateral axillary evaluation is a valid option.

ERCP
Gallstone Ileus -> enterotomy

The chromogranin A (CgA) blood test is a good marker to help detect and monitor the activity of
carcinoid tumors. This includes the tumors that release (secrete) the hormones that are associated
with carcinoid syndrome.
Elevated urinary levels of 5-HIAA measured during 24 hours with high-performance liquid
chromatography are highly specific although not sensitive. For the last decade, chromogranin A (CgA)
has been a well-established marker for carcinoid disease; it is elevated in more than 80% of
patients with NETs. CgA alone may be used for the diagnosis of NETs, given its specificity of 95%
Should’ve got right…

Uncomplicated diverticulitis (Modified Hinchey stage 0 and stage Ia)

Complicated diverticulitis (Modified Hinchey stages Ib–IV)

hemangioma – asymptomatic <5cm
Total abdominal colectomy spares the rectum (which is spared in UC) unlike

Total PROCTOCOLECTOMY which resects

Although a restorative proctocolectomy with IPAA as a single stage

procedure has been reported for toxic megacolon, proctectomy
and anastomosis are generally ill-advised in the acutely ill
patient with an unprepared bowel. Total proctocolectomy in the
urgent setting carries a prohibitively high mortality rate, and the
leak rate from a primary anastomosis is unacceptably high.

Whereas the goal in elective surgery is to remove all the colonic

or dysplastic mucosa, the aim in emergent surgery is to rescue the
patient from a life-threatening situation. A total abdominal colectomy
with ileostomy and preservation of the rectum is therefore
the preferred operation for this condition.
sabiston page 1344 SECTION X Abdomen
Dunno.. just reminder.. delete
CLL Classification – go up to down w/ sketch

•Serology showing hemolytic anemia

↑ LDH
↑ indirect bilirubin
↑ reticulocyte count
↓ haptoglobin
any anemia at first look for reticulocyte index if existed
if reticulocyte index >2 the cause is destruction (hemolysis or bleeding)
if reticulocyte index<2 the cause is production (defect in production --microcytic causes or macrocytic
causes--then you decide )

Transcatheter aortic valve replacement = (TAVR)

o Surgical AVR: Recommended for patients with Low to moderate surgical risk, Higher surgical risk AND severe multivessel
coronary artery disease

o Transcatheter AVR (TAVR): Recommended for patients with high or prohibitive surgical risk and predicted survival of > 12
months

o Percutaneous balloon valvuloplasty: Indicated in children, adolescents, and young adults without AV calcification.
Meningitis –> Ceftriaxone + vancomycin

Ampicillin is added if patients are at risk of Listeria spp. Infection

(e.g., newborns, pregnant women, the elderly, or immunocompromised patients) because

cephalosporins are ineffective against Listeria spp.
AMBOSS

Prerenal aki question reminder

myelodysplastic syndrome – read high yield, simple

https://next.amboss.com/us/article/3T0Sq2?q=myelodysplastic
%20syndrome#Zfda61924b603eb5304faf491e8ded93f
OHSS is a rare complication of ovarian stimulation
OHSS: abdominal distention ,discomfort ,nausea, respiratory distress and electrolyte disturbance
hypoamenorrhea -means light amenorrhea
metrorrhagia- intermenstrual bleeding
polymenorrhea - period less than 21 days
amenorrhea - absence of a menstrual period
oligomenorrhea- period occur more than 35 days
messed this one up

Partial mole is - shows fetal parts, positive p57, positive fetal RBC, focal hyperplasia, triploid 69, HCG<
50,000
Honeycomb on US
Q. about Vasa previa velamentous insertion.. definitely offputing..
It is recommended that women with vasa previa should deliver through elective cesarean prior to rupture of the membranes. Given the timing of membrane rupture is
difficult to predict, elective cesarean delivery at 35–36 weeks is recommended. This gestational age gives a reasonable balance between the risk of death and that of
prematurity.
Dr MADA comment

CMV Dx -
Must have both positive for CMV IgG + IgM.
IgM positivity alone is useless.

Once both are positive, do CMV IgG avidity test

If low - infnx in the last 4 months
If high - can r/o infxn in the last 6 months
Real confusing got IRUR.. anyway B seems like most legit eventhough not straightforward for TOLAC
Tricked me.. its HYPOglycemia

Effects
Macrosomia: birth weight > 90thpercentile or > 4000–4500 g/8 lb 13 oz–9 lb 15 oz (due to stimulated
growth and adipogenesis) → increased risk of birth injuries (e.g., shoulder dystocia)
Polycythemia (associated with an increased risk of hyperviscosity syndrome and hyperbilirubinemia)
Neonatal hypoglycemia
Electrolyte imbalances (hypocalcemia, hypomagnesemia)
Respiratory distress (due to insufficient production of pulmonary surfactant)
Hypertrophic cardiomyopathy (polycythemia → redistribution of iron → iron deficiency in cardiac
tissue and hypoxemia → impaired cardiac remodeling)
Polyhydramnios (fetal hyperglycemia → fetal polyuria)

functional hypothalamic amenorrhea - Hypogonadotropic hypogonadism

also known as functional hypothalamic GnRH deficiency
excludes pathological disease
risk factors
eating disorders, excessive exercise, and stress

Dr. MADA Comment:

Acute appendicitis during pregnancy:

• Most cases occur in the 2nd & 3rd trimesters.
• Incidence not increased during gestation.
• Rupture of appendix occur 2-3 times more often during pregnancy.
Sx: RLQ pain, 80% vaginal/ rectal tenderness
diagnosis: US MRI ---- CT
treatment: Immediate surgical treatment. Appendicitis is the most prevalent extra uterine indication
for surgery during pregnancy
Confirming you know.. be more confident
Explanation on Dr MADA

Cystic adnexal masses of the ovaries, fallopian tubes, and surrounding tissues can be gynecologic or
nongynecologic on origin and benign or malignant in nature.
Factors such as the location of the mass, age and reproductive status of the patient, and family history can help to
determine the nature of this common OB/GYN occurrence. Although the majority of adnexal masses are benign, a
chief goal is to rule out malignancy. Postmenopausal women, women with a strong family history of breast
and/or ovarian cancer, and women with a hereditary ovarian cancer syndrome are at highest risk for an ovarian
cancer.
Simple ovarian cysts can be observed as long as the patient is low risk, asymptomatic. The same is true for
asymptomatic complex cysts, which are presumed benign such as endometriomas, dermoids, and hydrosalpinx.
The risk of malignancy must always be assessed and excluded. The exclusion of a neoplastic process should be
performed mainly through use of imaging modalities. For instance, sonographic indices (see table) should
indicate whether the adnexal mass is at high risk for involving a neoplastic process.
CA-125 is elevated in many patients with ovarian cancer, but a normal CA-125 does not exclude the diagnosis of
cancer and does not represent a reason to delay surgery.
The decision to intervene is based on cyst size, ultrasound characteristics, and clinical symptoms.
Surgical technique used for removal of an adnexal mass may be performed laparoscopically or via a laparotomy.
The choice of surgical approach depends upon the degree of suspicion of malignancy and surgeon and patient
preference.
The differential diagnoses for cystic adnexal masses include ectopic pregnancy, pelvic inflammatory disease,
torsed adnexa, tubo-ovarian abscess, endometriosis, fibroids, and ovarian neoplasms.

Uterine serous carcinoma - highly malignant form of endometrial cancer

Confirm knowledge
Thought during exam levongenstrel was estrogen based.. its progesterone based!

Could’ve easily got this right

Comment:

indications for levongesterol IUD

1) age >35
2) smoker
Schiller's iodine solution is applied to the cervix under direct vision. Normal cervical mucosa contains
glycogen and stains brown, whereas abnormal areas, such as early cervical cancer, do not take up the
stain.

The abnormal areas can then be biopsied and examined histologically. The composition of Schiller's
iodine is the same as Lugol's iodine, the latter being more concentrated. When Schiller's iodine is not
available, Lugol's iodine can be used as an alternative.

Schiller's test is not specific for cervical cancer, as areas of inflammation, ulceration and keratosis may
also not take up the stain, and will also be NON STAINING…
A non-staining Shillers test is a positive test (positive for possible neoplasia)
IRUR Q. – but nonetheless – according to comments can be

1. Dopamine useful in the treatment of heart failure or shock, especially in newborn babies.

2. it is a case of perimyocarditis (post viral disease) with signs of acute heart failure, that need
IMMEDIATE TREATMENT WITH DOPAMINE
Comment: Normal saturation on the right is around 75%,

and even if it would be Normal, if you see oxygenation increase between RA and RV ----> you have a
septal defect my friend

Birth Traumas: skim through

https://next.amboss.com/us/article/S40yiT?q=birth-related%20clavicular
%20fracture#Z463068127e83c14624316e450b477b93

Comment Hemorrhagic disease of the newborn

Hemorrhagic disease of the newborn, a disease more common among breastfed infants, occurs in the
first few weeks of life. It is rare in infants who receive prophylactic intramuscular vitamin K on the first
day of life. Hemorrhagic disease of the newborn usually is marked by generalized ecchymoses,
gastrointestinal hemorrhage, or bleeding from a circumcision or umbilical stump; intracranial
hemorrhage can occur, but is uncommon.
testicular enlargement-> pubic hair -> penis enlargement

Ataxia Telangiectasia

Sturge Weber

VHL numerous benign and malignant tumors – autosomal dominant

Scarlet fever. Skim through phases mainly
meningitis reminder

Bacterial meningitis is diagnosed by CSF examination. Typical findings are: elevated opening pressure,
elevated protein and hypoglycorrhachia. The fluid appearance may be cloudy or turbid. The CSF
leukocyte concentration is usually elevated with a neutrophilic pleocytosis. CSF Gram stain
examination is associated with rapid and accurate organism identification in up to 90 percent of
bacterial meningitis cases.
lymphangitis -> 1st gen cephalosporin

sinusitis
3 months - cooing and gurgling
6 months - babbling
Normal development

Other complications of terminal ileal resection include vitamin B12 deficiency, which might not appear
until 1-2 yr after parenteral nutrition is withdrawn. Long-term monitoring for deficiencies of vitamin
B12 , folate, iron, fat-soluble vitamins, and trace minerals, such as zinc and copper, is important.
nelson 21- 7958
a case of Sickle Cell Anemia (Acute painful crises)
one of common complications is Acute splenic sequestration (peak age 6 mos to 3 yrs); can lead to
rapid death
− Altered splenic function → increased susceptibility to infection, especially with
encapsulated bacteria (S. pneumococcus, H. influenzae, N. meningitidis)
Treatment—Prevent complications:
° Immunize (pneumococcal regular plus 23-valent, meningococcal

Normal reference range of RDW in human red blood cells is 11–15%

Anemia = RBC < 4.5 million/mcL (< 4.5 × 1012/L).

Got wrong.. its chronic lymphocytic thyroiditis (also called Hashimoto or autoimmune thyroiditis).

Variable Value Normal values

TSH 30 picomol/L 0.5-4.5
Free T4 9 picomol/L 10-20

How they showed acute adrenal insufficiency (crisis).. just reminder..

Congenital Immunodef. Synd. If you have time.. just main points maybe
https://next.amboss.com/us/article/tM0Xqg?q=Chronic%20granulomatous%20disease%20%28CGD
%29%3A#Z24ea2081be7d99a9a8c65112cb690bff

Current recommendations are to administer venom

immunotherapy to individuals who have had a systemic lifethreatening
reaction from an insect sting and have positive
venom skin tests or elevated venom-specific IgE. All persons
with a history of systemic reactions to stinging insects should
be instructed in the use of an epinephrine auto-injector and
encouraged to wear medical information jewelry. Children
younger than 16 years of age who have had only a cutaneous
reaction generally do not require immunotherapy because their
risk of life-threatening reaction is low.
Nelson Essentials of Pediatrics 8th ed. 334p

Developmental dysplasia of the hip (DDH)

DDH risk factors:
F amily history
F irst born
F emale
F luids (oligohydraminous)
F ive (multiple gestation)
F at (large for gestational age)
F art (breech presentation)

diagnosis of DDH :
<1 MONTH : physical examination .
1-4 months : ultrasound
>4 m: Xray
Not clear..comment..
The most important condition to exclude before confirming a diagnosis of
toxic synovitis is septic arthritis. Children with septic arthritis usually appear
more systemically ill than those with transient synovitis. The pain associated
with septic arthritis is more severe, and children often refuse to walk or move
their hip at all. High fever, refusal to walk, and elevations of the erythrocyte
sedimentation rate, serum C-reactive protein, and white blood cell count all
suggest a diagnosis of septic arthritis. If the clinical scenario is suspicious for
septic arthritis, an ultrasound-guided aspiration of the hip joint should be
performed to make the definitive diagnosis (see Chapter 705 ). An exception to
these criteria is hip septic arthritis due to Kingella kingae , which may have
minimal inflammation and low-grade or no fever (see Chapter 705 ). MRI may
be needed to detect an associated osteomyelitis.
nelson 21- 13988
Toddler fractures occur in young ambulatory children. The age range for this fracture is typically from
around 1-4y
The injury often occurs after a seemingly harmless twist or fall and is often unwitnessed. It is a result
of a torsional injury.
The classic symptom is refusal to bear weight, which can manifest as pulling up the affected extremity
or florid display of protest. The other common sign is point tenderness at the fracture site. The AP and
lateral views of the tibia-fibula might show a nondisplaced spiral fracture of the distal tibial
metaphysis.
TX: treated with a below-knee cast for approximately 3 wk.
NELSON 21e p.14151
Muscular dystrophies diagnosis

ADHD>Differential diagnoses :
Hearing or visual impairment
Absence seizures
Thyroid disorders
Sleep disorders
Stable hypernatremia => free water given oral or nasogastric tube
If unstable hypernatremia (like in this case )=> normal saline 0.9% is given
subglottic hemangioma:
more common in females, usually symptoms appear after 3 months of age, including biphasic stridor,
and in 50% of cases cutaneous leisons, treatment includes:
-observation
-trachestomy
-systemic steroids
-laser
-propranolol

Foreign body -> rigid

Strange. And hard

Antibiotic choice should be guided by results

of Gram stain and culture but initially should include agents with
aerobic and anaerobic coverage. Treatment regimens should include a
penicillinase-resistant agent active against S. aureus and anaerobic coverage, typically with
clindamycin or ticarcillin/clavulanic acid.
nelson 20 - 3104
Another hard one – when debating epiglottitis, think of Bact. Trach.

Bacterial tracheitis

is an acute bacterial infection of the upper airway

that is potentially life threatening.

S. aureus (see Chapter 181) is the most commonly isolated pathogen with isolated reports of
methicillinresistant S. aureus. S. pneumoniae, S. pyogenes, Moraxella catarrhalis,
nontypeable H. influenzae, and anaerobic organisms have also been implicated. The mean age is
between 5 and 7 yr. There is a slight male
predominance. Bacterial tracheitis often follows a viral respiratory
infection (especially laryngotracheitis), so it may be considered a bacterial complication of a viral
disease, rather than a primary bacterial illness. This life-threatening entity is more common than
epiglottitis in vaccinated populations.
nelson 20 - 2984

Some extras.. skim

Breast Cancer -DCIS Comments:

DCIS < 2cm == lumpectomy

DCIS > 2cm == lumpectomy with 1cm margin & radiation
DCIS diffused == simple mastectomy

Treatment recommendations for a patient with DCIS are based

on the extent of disease within the breast, histologic grade, ER
status, and presence of microinvasion as well as patient age and
preference. Treatment options for DCIS include mastectomy,
breast-conserving surgery with irradiation, and breast-conserving
surgery alone. When the patient is treated with breast conservation or unilateral mastectomy, there is
also the option of adjuvant hormonal therapy with tamoxifen to reduce the risk for future
breast cancers.
sabiston 20 – 875

DCIS:
1.Breast conservative therapy(also called lumpectomy,excisional biopsy or partial mastectomy).
2.radiation therapy plus minus hormonal therapy.
IF RADIATION IS CONTRAINDICATED OR SMALL BREAST WITH LARGE TUMOR OR MULTICENTRIC
DISEASE(DIFFUSE).......
THEN DO MASTECTOMY WITH SENTINEL LN...
1.IF THE SENTINEL LN IS POSITIVE THEN DO AXILLARY LN DISSECTION FOR NODE STAGING.
Anal Fissure
Sigmoid Volvulous – reminder that its decompression

Treatment of the sigmoid volvulus begins with appropriate resuscitation and, in most cases, involves
nonoperative decompression. Decompression relieves the acute problem and allows resection as an
elective procedure, which can be accomplished with reduced morbidity and mortality. Patients with
signs of colonic necrosis are not eligible for nonoperative decompression.
sabiston 20 - 1361
Graft Rejection

Of the three types of rejection, only acute rejection can be successfully reversed once it is established.
T cells constitute the core element responsible for acute rejection, often termed T cell–mediated
rejection. There is also a form of acute rejection that is particularly aggressive and involves vascular
invasion by T cells known as acute vascular rejection.
sabiston 20 - 643

Just reminder..

• Cardiac Risk assessment:

• Patients >40 years old with no cardiac history:
• Obtain EKG→if normal , no other workup needed.
• For patients with any age , with cardiac history , obtain: • EKG , echocardiogram , stress test.
More recent guidelines suggest titrating the dosage of glucocorticoid replacement to the degree of
surgical stress (see Box 108). Minor operations such as hernia repair under local anesthesia may not
require any additional steroid.
Moderate operations such as open cholecystectomy or lower
extremity revascularization require 50 mg bolus and 75 mg/day of hydrocortisone equivalent for 1 or
2 days. Major operations such as colectomy or cardiac surgery are covered with 100 mg
bolus and 150 mg/day of hydrocortisone equivalent for 2 to 3 days. Inadequacy of the hypothalamic--
pituitary-adrenal axis in the perioperative period can lead to unexplained hypotension.
sabiston 20 - 237

pharmacologic thromboprophylaxis

1. Hospitalized patients who have active malignancy and acute medical illness or reduced mobility
should be offered pharmacologic thromboprophylaxis in the absence of bleeding or other
contraindications.
2. Hospitalized patients who have active malignancy without additional risk factors may be offered
pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications

3. Routine pharmacologic thromboprophylaxis should NOT be offered to patients admitted for the
sole purpose of minor procedures or chemotherapy infusion, nor to patients undergoing
stem-cell/bone marrow transplantation.

Reminder of Classes of Hemorrhagic Shock by blood loss percentage

Lousy mistake

LETHAL TRIAD in Trauma:

1- ACIDOSIS
2- HYPOTHERMIA
3- COAGULOPATHY

Rewarming technique (heating in trauma to prevent Lethal Triad ) 2 types :

1- PASSIVE :
Dry the patient, Warm fluids ,Warm blankets , and sheets Head covers Warm the room
2- ACTIVE:
a- EXTERNAL (Bair Hugger Heated , warmers LAMPS , Radiant warmers )
b- Internal ( Warmed fluids IV , Heat ventilator , Cavity lavage, chest tube, abdomen, bladder,
Continuous arterial or venous rewarming, Full or partial bypass

Damage control in trauma patient mean : stop bleeding and infection in an unstable trauma patient
When do Hernias go to OR?
1. Emergent = Black/Blue, Acute Abdomen, Sepsis
2. Urgent = Acutely irreducible or +SBO without Emergent
3. Elective = reducible hernia and Ø SBO and Ø Acute Abd
Acute inflammation of the duodenum can lead to mechanical obstruction, with a functional gastric
outlet obstruction manifested by delayed gastric emptying, anorexia, nausea, and vomiting. In cases of
prolonged vomiting, patients may become dehydrated and develop a hypochloremic hypokalemic
metabolic alkalosis secondary to the loss of gastric juice rich in hydrogen and chloride.

Umbilical Hernia In general, umbilical hernia has a tendency to close on its own in
approximately 80% of cases, and therefore elective repair should be deferred until
approximately 5 years of age. The umbilical hernia rarely presents with complications,
but there are unique exceptions to this general rule for which an earlier elective repair
should be considered. Although rare, a history of incarceration clearly warrants prompt
surgical repair, irrespective of age. Enlarging umbilical hernia over time, in particular with
a large skin proboscis more than 3 cm or a significantly large umbilical fascial defect (>2
cm), is unlikely to resolve spontaneously;

therefore, surgical repair should be considered at an early age. Sabiston,20e,p1884.

diagnostic laparoscopy -> primary limitation being the recognition of retroperitoneal
processes

Ascending cholangitis secondary to choledocholithiasis is a surgical emergency that

requires urgent drainage of the biliary system. Key factors in diagnosing
choledocholithiasis are the presence of a grossly dilated intrahepatic biliary duct system
and cholelithiasis, which is likely the source of the stone. Bilateral intrahepatic duct
dilatation suggests that the stone is located in the common bile duct. Fever with chills,
right upper quadrant pain and symptoms of obstructive jaundice (pale stools, tea-
colored urine and scleral icterus) make up Charcot’s triad of symptoms suggestive of
ascending cholangitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is a highly sensitive and

specific investigation that offers the advantage of being both diagnostic and therapeutic.
During this procedure, the biliary tree stone may be cleared with a combination of a
sphincterotomy and balloon or basket trawling of the common bile duct. The lack of
filling defect on adjuvant cholangiography confirms stone clearance. However, an ERCP
does not eliminate the risk of recurrent biliary tree obstruction by stones. Patients would
have to eventually undergo cholecystectomy.
cholecystectomy in asymptomatic patients:
children
sickle cell disease
during bariatric surgery (after bypass there will be no approach)
portal hypertension
porcelain gallbladder
large >2.5 cm stones
before transplantation
spinal cord injuries

The rest -> Follow up w/ dietary and lifestyle changes

TABLE 50-1 Bacteria Commonly Isolated in Perforated Appendicitis

Anaerobic:
Bacteroides fragilis 80%
Bacteroides thetaiotaomicron 61%
Bilophila wadsworthia 55%
Peptostreptococcus spp. 46%
Aerobic:
Escherichia coli 77%
Viridans streptococcus 43%
Group D streptococcus 27%
Pseudomonas aeruginosa 18%
Lookout for this – check algorithm

Comment

In case of 1) Peritonitis or 2)Shock or 3)Evisceration an urgent Laparotomy has to take place.

If none of the latest is present a local exploration of the wound is done. An intact Fascia allows and
immediate discharge. Fascia penetrated Patient has to be monitored for 24 hours ( with Hg control
every 8 hours ) after which if everything goes Okey dokey he or she can go home.
Bilateral adrenal hyperplasia is the most common cause of primary hyperaldosteronism,
and is treated medically. An aldosterone-producing adenoma is an important differential
diagnosis.
Bad prognosis sign on CT of patient with adrenal incidentaloma ( and in general ) :
1- Hypervascularity
2- Slow contrast excretion
3- Necrosis within the mass
4- Invisible border

Characteristics suggestive of a BENIGN lesion on CT scan include :

1- homogeneous appearance,
2- well-defined borders,
3- high lipid content,
4- rapid washout of contrast material
5- low degree of vascularity

Reminder
The tissue types of STS (Soft tissue sarcoma) origin include
skeletal muscle, adipose cells, blood and lymphatic vessels, and connective tissue or those cells with a
common mesoderm origin (Fig. 31-1 and Table 31-1). Also included are peripheral nerves derived
from the neuroectoderm.
sabiston 20 – 777

Desmoid tumor
Aggressive fibromatosis
A slow-growing, benign but locally aggressive tumor caused by the proliferation of fibroblasts. Is
often associated with familial adenomatous polyposis (sporadic desmoid tumors are rare). Can arise
from any part of the body, most commonly, the extremities, the abdominal wall, and abdominal cavity.
May be asymptomatic until they grow large enough to compress adjacent structures (e.g.,
bowel/ureteric obstruction).

Four principles guide the administration of an antimicrobial

agent for prophylaxis:
1. Safety
2. An appropriate narrow spectrum of coverage of relevant pathogens
3. Little or no reliance on the agent for therapy of infection (because of the possible induction of
resistance with heavy use)
4. Administration within 1 hour before surgery and for a defined brief period thereafter (no longer
than 24 hours, 48 hours for cardiac surgery, and ideally, a single dose)
sabiston 20 - 272
Megaloblastic anemia from vitamin B12 deficiency only rarely develops after partial gastrectomy but is
dependent on the amount of stomach removed. Vitamin deficiency occurs secondary to poor
absorption of dietary vitamin B12 because of the lack of intrinsic factor. Patients undergoing subtotal
gastrectomy should be placed on life-long vitamin B12 supplementation. If a patient develops a
macrocytic anemia, serum vitamin B12 levels should be determined and, if abnormal, treated with
long-term vitamin B12 therapy.
sabiston 20 – 1237
Acute wound failure (wound dehiscence or a burst abdomen) refers to postoperative separation of the abdominal
musculoaponeurotic layers.
BOX 12-1 Factors Associated With Wound Dehiscence:
Technical error in fascial closure
Emergency surgery
Intra-abdominal infection
Advanced age
Wound infection, hematoma, and seroma
Elevated intra-abdominal pressure
Obesity
Long-term corticosteroid use
Previous wound dehiscence
Malnutrition
Radiation therapy and chemotherapy
Systemic disease (uremia, diabetes mellitus)
sabiston 20 – 303

Wound infection is the most common cause of healing delays.

Other Causes of Abnormal Wound Healing:
Hypoxia
Diabetes
Ionizing Radiation
Aging (Older patients are more likely to experience delayed healing and surgical wound dehiscence.)
Malnutrition
 80% to 95% of duodenal ulcers and
approximately 75% of gastric ulcers are associated with H. pylori infection.

Due to partial resection and resection margins are not free of neoplastic tissue, a surgical resection is required by
segmental colectomy.