Part 1 book “Surgery - A case based clinical review” has contents: Nausea, vomiting, and left groin mass, abdominal pain, nausea, and vomiting, new palpable mass in right breast, abnormal screening mammogram, chest pain and syncope, neck mass that moves with swallowing,… and other contents.
Christian de Virgilio Editor Areg Grigorian Associate Editor Paul N Frank Assistant Editor Surgery A Case Based Clinical Review 123 Surgery Christian de Virgilio Editor Surgery A Case Based Clinical Review Areg Grigorian Associate Editor Paul N Frank Assistant Editor Editor Christian de Virgilio Department of Surgery Harbor-UCLA Medical Center Torrance, CA, USA Assistant Editor Paul N Frank Department of Surgery Harbor-UCLA Medical Center Torrance, CA, USA Associate Editor Areg Grigorian Department of Surgery University of California, Irvine Orange, CA, USA ISBN 978-1-4939-1725-9 ISBN 978-1-4939-1726-6 (eBook) DOI 10.1007/978-1-4939-1726-6 Springer New York Heidelberg Dordrecht London Library of Congress Control Number: 2014958665 © Springer Science+Business Media New York 2015 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer Permissions for use may be obtained through RightsLink at the Copyright Clearance Center Violations are liable to prosecution under the respective Copyright Law The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) To my wonderful wife and fellow surgeon Kelly, my five kiddos, Nick (my soccer buddy), Michael (my aspiring protégé), Emma and Sophia (my twin philotherians), and Andrew (my ninja turtle pal), who have always made coming home a pleasure, and to all the UCLA students over the last two decades who have inspired me to teach Christian de Virgilio To my mentors – thank you for introducing me to the wonderful world of surgery To my family: Jores, Ani, and Rebecca – thank you for your continued love and support And to my biggest inspiration, my mom, Dr Vehanoush Zarifian, who has helped instill in me compassion for my fellow man and the resilience to conquer life’s biggest challenges Areg Grigorian To my Mom and Dad, my first mentors and biggest supporters Paul N Frank Foreword Christian de Virgilio MD was a third year medical student at UCLA when I was a general surgery resident on the Pediatric Surgery service I remember him clearly as he was such an interested student and was at my side throughout the day and night Those were different times-goals and objectives for learning did not formally exist We used our patients primarily as our teaching tool Our quest for data had to be done by using text books and journals in the library as electronic devices full of fingertip information did not exist yet Dr de Virgilio was one of best presenters- he could synthesize information and present it in a manner which all could understand and remember Many of the assignments I used to give to the medical students were on topics that I needed more information on – little did they know that they were my human Google or Safari! In this wonderful medical student textbook which Dr de Virgilio has created, he has taken all of those patients who we met and made teaching stories about them so our contemporary medical students can learn prior to meeting such a patient and review once they have met that patient to reinforce the information In each chapter, the patient story includes the history, physical examination, pathophysiology, diagnosis, and management In addition, teaching points concerning where one can get in trouble and where there are controversies are outlined to help the student understand the complexity of some of the surgical problems that the patient has Finally, the essential take home points are summarized allowing the student to feel like they have mastered the topic and are ready to analyze the next patient they meet with such a diagnosis The student is then challenged with Surgery Shelf type questions which are very believable patient vignettes, and the answers are given with appropriate explanations of the correct answer This type of exercise prepares the student for future examinations that they will need to take to complete medical school, residency, fellowship and board certification and re-certification Dr de Virgilio enlisted the help of fourth year medical students to be his assistant editors – what a great way to teach students how to teach! I could not be more proud of my previous medical student! He has championed the role of the teacher his entire academic life and serves as Vice Chair for Education and Director of the General Surgery training program as well as the Co-chair of the College of Applied Anatomy at the Harbor-UCLA School of Medicine campus He remembers that teaching is a natural behavior of all of us who have the privilege to teach medical students – we need to always remember that someone taught us – so we need to teach with all our energy Our students leave us with their diploma and their dreams The future belongs to those who believe in their dreams, Eleanor Roosevelt Human Health Services, School of Medicine University of California, Davis Sacramento, CA, USA Julie Ann Freischlag, MD vii Preface When starting my third year clerkship (last century), I was terrified I figured the only way to succeed was to something spectacular It was quickly apparent (within minutes) that I was never going to come up with an obscure diagnosis that had stumped my chief resident and there was no way I would impress the team with my bumbling attempts at knot tying In my dreams, I imagined rescuing my attending by deftly stepping in to suture an exsanguinating aortic injury, but of course it never happened (don’t try it) I learned that the best way to make a great impression was by coming to the hospital each day as fully prepared as possible From experience, a great way to that is by reading The goal of our book is to help you make a great impression on your surgery clerkship and to help you to prepare for the shelf examination To help you reach that goal, we’ve assembled a team of collaborators that include numerous surgery program directors, surgery clerkship directors, and various award winning surgical educators We’ve also included several medical students who were handpicked for their outstanding performance In fact my two co-editors (Areg Grigorian and Paul Frank) are starting their surgical internship this year The intent is to assure that the content of the book is comprehensive, and relevant to what a medical student needs to know Additionally, we feel our book is an excellent adjunct to the curriculum offered to nursing students, physician assistant students, and surgical interns Before discussing how to use our book, let me share a few pearls about the surgery clerkship First the “do’s” Surgery is a team based discipline Always look for ways to help your team Take an active role Strive to make yourself irreplaceable, but so with an air of humility Treat others like you would your family (assuming you get along with them) Be an effective communicator Ask a lot of questions (but make it clear from your questions that you’ve been reading) Ask how you can help Now the “don’ts” Don’t be arrogant Don’t try to upstage your co-student or intern And finally…don’t worry! If you work hard, display enthusiasm, and take an active role, people will notice! You’ll also be surprised to discover that most surgeons enjoy teaching (and aren’t as mean as portrayed on TV) And you may even get bit by the surgery bug! Now let’s move on to how to use this book The book is case based and is in a short question and answer format A risk of a case based book is that you only learn that one specific case To prevent falling into such a pitfall, we’ve also included pertinent differential diagnoses for each case, and discuss how to distinguish them We’ve tried to limit anatomy and pathophysiology to those that are clinically relevant We’ve tried to exclude most cancer staging systems, as these constantly change, are hard to memorize, and are infrequently tested We’ve tried to arrange the management in a “what’s the next step” format, as such questions are frequently asked We’ve purposely avoided too many details about specific aspects of surgical procedures as those are beyond the scope of a student For those that want a bit more, we’ve added “areas where you can get in trouble” which are pitfalls in the diagnosis or management, and “areas of controversy” At the end of each chapter there is a Summary of Essentials that permits a quick review Finally, we’ve created questions and answers (with an emphasis on why the wrong answers are wrong) It’s important to realize that the questions are not intended to test your understanding of the reading Rather, many of the questions are ix Infant Born with Abdominal Wall Defect 34 Justin P Wagner and Steven L Lee An infant at 39 weeks gestation is born to a thin 19-year-old Caucasian G1P0 woman with no prior medical history She quit smoking when she discovered she was pregnant The pregnancy was planned, and it has been uncomplicated Prenatal maternal laboratory studies were significant for an elevated serum alpha-fetoprotein level Prenatal ultrasound examinations showed a fetus with free loops of intestine present in the amniotic cavity extruding through a small abdominal defect lateral to the base of the umbilical cord The infant’s APGAR scores are and at birth and minutes later, respectively Vital signs are within normal limits The abdomen is scaphoid with loops of matted and inflamed small bowel protruding from a defect to the right of the umbilicus Diagnosis What is the Differential Diagnosis for a Newborn With Abdominal Wall Defect and What Are The Common And Distinguishing Features? Diagnosis Gastroschisis Common features Medial abdominal wall defect with evisceration of abdominal contents Omphalocele Midline abdominal wall defect with herniation of abdominal contents Bladder or cloacal exstrophy Extra-abdominal/pelvic sac containing herniated hemibladders, urethra, and possibly kidney and intestine Prune belly syndrome Abdominal wall hypoplasia Urachal abnormality Communication of bladder and anterior abdominal wall, may be associated with cyst or sinus Distinguishing features No membrane over abdominal contents Evisceration usually to the right of umbilical stalk Higher risk to intestinal viability Diagnosis impossible before 12 weeks Amnioperitoneal membrane covers abdominal contents Umbilical cord inserts into membrane Associated with other birth defects Diagnosis possible before 12 weeks if liver herniation present Defect usually inferior to umbilical stalk Two hemibladders separated by intestine Extensive defects associated with omphalocele and epispadias Abdominal viscera contained within collagenous wall 95 % are in males Associated with hypoplastic prostate, bilateral undescended testes, infertility, and bladder outlet obstruction Communication between bladder and a cystic mass pathognomonic for patent urachus Often associated with omphalocele and neural tube defects J.P Wagner, MD (*) Department of Surgery, David Geffen School of Medicine at UCLA, 757 Westwood Plz, Rm B711, Los Angeles, CA 90095, USA e-mail: jwagner@mednet.ucla.edu S.L Lee, MD Department of Surgery, Division of Pediatric Surgery, Harbor-UCLA Medical Center, 1000 W Carson Street, Box 25, Torrance, CA 90509, USA e-mail: slleemd@yahoo.com C de Virgilio (ed.), Surgery: A Case Based Clinical Review, DOI 10.1007/978-1-4939-1726-6_34, © Springer Science+Business Media New York 2015 349 350 J.P Wagner and S.L Lee Fig 34.1 Gastroschisis (a) and omphalocele (b) What Is the Most Likely Diagnosis in This Case? The most likely diagnosis is gastroschisis in this case The infant’s mother has several risk factors associated with gastroschisis, including young age, Caucasian race, low body mass index (BMI), singleton pregnancy, and recent tobacco use Prenatal ultrasound detects gastroschisis in about 70 % of cases It is effective in distinguishing gastroschisis from omphalocele, and it is useful to evaluate visceral blood flow In this case, the patient is born with eviscerated bowel and no sac, strongly suggesting a diagnosis of gastroschisis (Fig 34.1a) History and Physical Examination Which of the Above Diagnoses Are the Most Common? Gastroschisis occurs in in 2–10,000 live births, while omphalocele occurs in in 4–5,000 live births The rest of the conditions are rare, occurring in fewer than in 40,000 live births What are the Specific Differences Between Gastroschisis and Omphalocele? Factor Location Defect size Cord insertion Membrane Contents Bowel Malrotation Abdominal cavity Maternal AFP level GI function Associated GI anomalies Other associated anomalies AFP, alpha-fetoprotein Gastroschisis (Fig 34.1a) Paraumbilical (usually right-side) Often small (