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Part 2 book “The ABSITE review” has contents: Cardiac, gastrointestinal hormones, statistics and patient safety, pediatric surgery, orthopedics, neurosurgery, gynecology, hernias, abdomen, and surgical technology, biliary system, pancreas, small bowel,… and other contents.
CHAPTER 25 THORACIC ANATOMY AND PHYSIOLOGY Azygous vein runs along the right side and dumps into superior vena cava Thoracic duct runs along the right side, crosses midline at T4–5, and dumps into left subclavian vein at junction with internal jugular vein Phrenic nerve – runs anterior to hilum Vagus nerve – runs posterior to hilum Right lung volume 55% (3 lobes: RUL, RML, and RLL) Left lung volume 45% (2 lobes: LUL and LLL and lingula) Quiet inspiration – diaphragm 80%, intercostals 20% Greatest change in dimension superior/inferior Accessory muscles – sternocleidomastoid muscle (SCM), levators, serratus posterior, scalenes Type I pneumocytes – gas exchange Type II pneumocytes – surfactant production Pores of Kahn – direct air exchange between alveoli PULMONARY FUNCTION TESTS Need predicted postop FEV1 > 0.8 (or > 40% of the predicted postop value) • If it is close → get qualitative V/Q scan to see contribution of that portion of lung to overall FEV1 → if low, may still be able to resect Need predicted postop DLCO > 10 mL/min/mm Hg CO (or > 40% of the predicted postop value) • Measures carbon monoxide diffusion and represents oxygen exchange capacity • This value depends on pulmonary capillary surface area, hemoglobin content, and alveolar architecture No resection if preop pCO2 > 50 or pO2 < 60 at rest No resection if preop VO2 max < 10–12 mL/min/kg (maximum oxygen consumption) Persistent air leak – most common after segmentectomy/wedge Atelectasis – most common after lobectomy Arrhythmias – most common after pneumonectomy LUNG CANCER Symptoms: can be asymptomatic with finding on routine CXR; cough, hemoptysis, atelectasis, PNA, pain, weight loss Most common cause of cancer-related death in the United States Nodal involvement has strongest influence on survival Brain – single most common site of metastasis • Can also go to supraclavicular nodes, other lung, bone, liver, and adrenals Recurrence usually appears as disseminated metastases • 80% of recurrences are within the 1st years Lung CA overall 5-year survival rate 10%; 30% with resection for cure Stage I and II disease resectable; T3,N1,M0 (stage IIIa) possibly resectable Lobectomy or pneumonectomy most common procedure; sample suspicious nodes Non–small cell carcinoma • 80% of lung CA • Squamous cell carcinoma usually more central • Adenocarcinoma usually more peripheral • Adenocarcinoma is the most common lung CA (not squamous) TNM STAGING SYSTEM FOR LUNG CANCER • T1: < cm T2: > cm but > cm away from carina T3: invasion of chest wall, pericardium, diaphragm, or < cm from carina T4: mediastinum, esophagus, trachea, vertebra, heart, great vessels, malignant effusion (all indicate unresectability) • N1: ipsilateral hilum nodes N2: ipsilateral mediastinal or subcarinal (unresectable) • N3: contralateral mediastinal or supraclavicular (unresectable) • M1: distant metastasis Small cell carcinoma • 20% of lung CA; neuroendocrine in origin • Usually unresectable at time of diagnosis (< 5% candidates for surgery) • Overall 5-year survival rate < 5% (very poor prognosis) • Stage T1,N0,M0 5-year survival rate – 50% • Most get just chemo-XRT Paraneoplastic syndromes • Squamous cell CA – PTH-related peptide • Small cell CA – ACTH and ADH • Small cell ACTH – most common paraneoplastic syndrome Mesothelioma • Most malignant lung tumor • Aggressive local invasion, nodal invasion, and distant metastases common at the time of diagnosis • Asbestos exposure Non–small cell CA chemotherapy (stage II or higher) – carboplatin, Taxol Small cell lung CA chemotherapy – cisplatin, etoposide XRT can be used for lung CA as well Chest and abdominal CT scan – single best test for clinical assessment of T and N status PET scan – best test for M status Mediastinoscopy • Use for centrally located tumors and patients with suspicious adenopathy (> 0.8 cm or subcarinal > 1.0 cm) on chest CT • Does not assess aorto-pulmonary (AP) window nodes (left lung drainage) • Assesses ipsilateral (N2) and contralateral (N3) mediastinal nodes • If mediastinal nodes are positive, tumor is unresectable • Looking into middle mediastinum with mediastinoscopy • Left-side structures – RLN, esophagus, aorta, main pulmonary artery (PA) • Right-side structures – azygous and SVC • Anterior structures – innominate vein, innominate artery, right PA Chamberlain procedure (anterior thoracotomy or parasternal mediastinotomy) – assesses enlarged AP window nodes; go through left 2nd rib cartilage Bronchoscopy – needed for centrally located tumors to check for airway invasion For lung CA, patients need to 1) be operable (eg have appropriate FEV1 and DLCO values) and 2) be resectable (ie can’t have T4, N2, N3, or M disease) Pancoast tumor – tumor invades apex of chest wall and patients have Horner’s syndrome (invasion of sympathetic chain → ptosis, miosis, anhidrosis) or ulnar nerve symptoms Coin lesion • Overall, 10% are malignant • Age < 50 → < 5% malignant; age > 50 → > 50% malignant • No growth in years, and smooth contour suggests benign disease • If suspicious, will need either guided biopsy or wedge resection Asbestos exposure increases lung CA risk 90X Bronchoalveolar CA – can look like pneumonia; grows along alveolar walls; multifocal Metastases to the lung – if isolated and not associated with any other systemic disease, may be resected for colon, renal cell CA, sarcoma, melanoma, ovarian, and endometrial CA CARCINOIDS Neuroendocrine tumor, usually central • 5% have metastases at time of diagnosis; 50% have symptoms (cough, hemoptysis) Typical carcinoid – 90% 5-year survival rate Atypical carcinoid – 60% 5-year survival Tx: resection; treat like cancer; outcome closely linked to histology Recurrence increased with positive nodes or tumors > cm BRONCHIAL ADENOMAS Mucoepidermoid adenoma, mucous gland adenoma, and adenoid cystic adenoma → all are malignant tumors Mucoepidermoid adenoma and mucous gland adenoma • Slow growth, no metastases • Tx: resection Adenoid cystic adenoma • From submucosal glands; spreads along perineural lymphatics, well beyond endoluminal component; very XRT sensitive • Slow growing; can get 10-year survival with incomplete resection • Tx: resection; if unresectable, XRT can provide good palliation HAMARTOMAS Most common benign adult lung tumor Have calcifications and can appear as a popcorn lesion on chest CT Diagnosis can be made with CT Do not require resection Repeat chest CT in months to confirm diagnosis MEDIASTINAL TUMORS IN ADULTS Most are asymptomatic; can present with chest pain, cough, dyspnea Neurogenic tumors – most common mediastinal tumor in adults and children, usually in posterior mediastinum 50% of symptomatic mediastinal masses are malignant 90% of asymptomatic mediastinal masses are benign Location • Anterior (thymus) – most common site for mediastinal tumor; T’s → • Thymoma (#1 anterior mediastinal mass in adults) • Thyroid CA and goiters • T-cell lymphoma • Teratoma (and other germ cell tumors) • Parathyroid adenomas • Middle (heart, trachea, ascending aorta) • Bronchiogenic cysts • Pericardial cysts • Enteric cysts • Lymphoma • Posterior (esophagus, descending aorta) • Enteric cysts • Neurogenic tumors • Lymphoma Thymoma • All thymomas require resection • Thymus too big or associated with refractory myasthenia gravis → resection • 50% of thymomas are malignant • 50% of patients with thymomas have symptoms • 50% of patients with thymomas have myasthenia gravis • 10% of patients with myasthenia gravis have thymomas Myasthenia gravis – fatigue, weakness, diplopia, ptosis; antibodies to acetylcholine receptors • Tx: anticholinesterase inhibitors (neostigmine); steroids, plasmapheresis • 80% get improvement with thymectomy, including patients who not have thymomas Germ cell tumors • Need to biopsy (often done with mediastinoscopy) • Teratoma – most common germ cell tumor in mediastinum • Can be benign or malignant • Tx: resection; possible chemotherapy • Seminoma – most common malignant germ cell tumor in mediastinum • 10% are beta-HCG positive; should not have AFP (alpha-fetoprotein) • Tx: XRT (extremely sensitive); chemotherapy reserved only for metastases or bulky nodal disease; surgery for residual disease after that • Non-seminoma – 90% have elevated beta-HCG and AFP • Tx: chemo (cisplatin, bleomycin, VP-16); surgery for residual disease Cysts • Bronchiogenic – usually posterior to carina Tx: resection • Pericardial – usually at right costophrenic angle Tx: can leave alone (benign) Neurogenic tumors – have pain, neurologic deficit Tx: resection • 10% have intra-spinal involvement that requires simultaneous spinal surgery • Neurolemmoma (schwannoma) – most common • Paraganglioma – can produce catecholamines, associated with von Recklinghausen’s disease • Can also get neuroblastomas and neurofibromas TRACHEA Benign tumors: adults – papilloma; children – hemangioma Malignant – squamous cell carcinoma Most common late complication after tracheal surgery – granulation tissue formation Most common early complication after tracheal surgery – laryngeal edema • Tx: reintubation, racemic epinephrine, steroids Post-intubation stenosis – at stoma site with tracheostomy, at cuff site with ET tube • Serial dilatation, bronchoscopic resection, or laser ablation if minor • Tracheal resection with end-to-end anastomosis if severe or if it keeps recurring Tracheo-innominate artery fistula – occurs after tracheostomy, can have rapid exsanguination • Tx: place finger in tracheostomy hole and hold pressure → median sternotomy with ligation and resection of innominate artery • This complication is avoided by keeping tracheostomy above the 3rd tracheal ring Tracheo-esophageal fistula • Usually occurs with prolonged intubation • Place large-volume cuff endotracheal tube below fistula • May need decompressing gastrostomy • Attempt repair after the patient is weaned from ventilator • Tx: tracheal resection, reanastomosis, close hole in esophagus, sternohyoid flap between esophagus and trachea LUNG ABSCESS Necrotic area; most commonly associated with aspiration Most commonly in the superior segment of RLL Tx: antibiotics alone (95% successful); CT-guided drainage if that fails • Surgery if above fails or cannot rule out cancer (> cm, failure to resolve after weeks) Chest CT can help differentiate empyema from lung abscess EMPYEMA Usually secondary to pneumonia and subsequent parapneumonic effusion (staph, strep) Can also be due to esophageal, pulmonary, or mediastinal surgery Symptoms: pleuritic chest pain, fever, cough, SOB Pleural fluid often has WBCs > 500 cells/cc, bacteria, and a positive Gram stain Exudative phase (1st week) – Tx: chest tube, antibiotics Fibro-proliferative phase (2nd week) – Tx: chest tube, antibiotics; possible VATS (video-assisted thoracoscopic surgery) deloculation Organized phase (3rd week) – Tx: likely need decortication; fibrous peel occurs around lung • Some are using intra-pleural tPA (tissue plasminogen activator) to try and dissolve the peel • May need Eloesser flap (open thoracic window – direct opening to external environment) in frail/elderly CHYLOTHORAX Milky white fluid; has ↑ lymphocytes and TAGs (> 110 mL/µL); Sudan red stains fat Fluid is resistant to infection 50% secondary to trauma or iatrogenic injury 50% secondary to tumor (lymphoma most common, due to tumor burden in the lymphatics) Injury above T5–6 results in left-sided chylothorax Injury below T5–6 results in right-sided chylothorax Tx: 2–3 weeks of conservative therapy (chest tube, octreotide, low-fat diet or TPN) • If above fails and chylothorax secondary to trauma or iatrogenic injury, need ligation of thoracic duct on right side low in mediastinum (80% successful) • For malignant causes, need talc pleurodesis and possible chemo and/or XRT (less successful than above) MASSIVE HEMOPTYSIS > 600 cc/24 h; bleeding usually from high-pressure bronchial arteries Most commonly secondary to infection, death is due to asphyxiation Tx: place bleeding side down; mainstem intubation to side opposite of bleeding to prevent drowning in blood; rigid bronchoscopy to identify site and possibly control bleeding; may need lobectomy or pneumonectomy to control; bronchial artery embolization if not suitable for surgery SPONTANEOUS PNEUMOTHORAX Tall, healthy, thin, young males; more common on the right Recurrence risk after 1st pneumothorax is 20%, after 2nd pneumothorax is 60%, after 3rd pneumothorax is 80% Results from rupture of a bleb usually in the apex of the upper lobe of the lung Tx: chest tube Surgery for recurrence, air leak > days, non-reexpansion, high-risk profession (airline pilot, diver, mountain climber), or patients who live in remote areas Surgery consists of thoracoscopy, apical blebectomy, and mechanical pleurodesis OTHER CONDITIONS Tension pneumothorax – most likely to cause arrest after blunt trauma; impaired venous return Catamenial pneumothorax – occurs in temporal relation to menstruation • Caused by endometrial implants in the visceral lung pleura Residual hemothorax despite good chest tubes → OR for thoracoscopic drainage Clotted hemothorax – surgical drainage if > 25% of lung, air–fluid levels, or signs of infection (fever, ↑ WBCs); surgery in 1st week to avoid peel Broncholiths – usually secondary to infection Mediastinitis – usually occurs after cardiac surgery Whiteout on chest x-ray • Midline shift toward whiteout – most likely collapse → need bronchoscopy to remove plug • No shift – CT scan to figure it out • Midline shift away from whiteout – most likely effusion → place chest tube Bronchiectasis – acquired from infection, tumor, cystic fibrosis • Diffuse nature prevents surgery in most patients Tuberculosis – lung apices; get calcifications, caseating granulomas • Ghon complex → parenchymal lesion + enlarged hilar nodes • Tx: INH, rifampin, pyrazinamide Sarcoidosis – has non-caseating granulomas Recurrent pleural effusions can be treated with mechanical pleurodesis • Talc pleurodesis for malignant pleural effusions Airway fires – usually associated with the laser • Tx: stop gas flow, remove ET tube, re-intubate for 24 hours; bronchoscopy AVMs – connections between the pulmonary arteries and pulmonary veins; usually in lower lobes; can occur with Osler–Weber–Rendu disease • Symptoms: hemoptysis, SOB, neurologic events • Tx: embolization Chest wall tumors • Benign – osteochondroma most common • Malignant – chondrosarcoma most common CHAPTER 26 CARDIAC CONGENITAL HEART DISEASE R → L shunts cause cyanosis • Children squat to increase SVR and decrease R → L shunts • Cyanosis – can lead to polycythemia, strokes, brain abscess, endocarditis • Eisenmenger’s syndrome: shift from L → R shunt to R → L shunt • Sign of increasing pulmonary vascular resistance (PVR) and pulmonary HTN; this condition is generally irreversible L → R shunts cause CHF – manifests as failure to thrive, ↑ HR, tachypnea, hepatomegaly; CHF in children – hepatomegaly 1st sign L → R shunts (CHF) – VSD, ASD, PDA R → L shunts (cyanosis) – tetralogy of Fallot Ductus arteriosus – connection between descending aorta and left pulmonary artery (PA); blood shunted away from lungs in utero Ductus venosum – connection between portal vein and IVC; blood shunted away from liver in utero Fetal circulation to placenta – umbilical arteries Fetal circulation from placenta – umbilical vein Specific drugs aminoglycosides, 21 amoxicillin, 21 ampicillin, 21 antifungal drugs, 22 antituberculosis drugs, 22 antiviral drugs, 22 Augmentin, 21 Bactrim, 21 carbapenems, 21 clindamycin, 22 erythromycin, 22 first-generation cephalosporins, 21 linezolid, 22 metronidazole, 22 monobactam, 21 nafcillin, 20 oxacillin, 20 penicillin, 20 piperacillin, 21 quinolones, 21 second-generation cephalosporins, 21 Synercid, 22 tetracycline, 22 third-generation cephalosporins, 21 ticarcillin, 21 Timentin, 21 Unasyn, 21 vancomycin, 22 Zosyn, 21 Spermatocele, 253 Spherocytosis, 215 Sphincterotomy, lateral internal, 241 Spigelian hernia, 247 Spinal anesthesia, 29 Spinal cord injury, 261 Spinal headaches, 30 Spine tumors, 262 Spleen anatomy and physiology, 213–214 arterial blood flow, 213 Felty’s syndrome, 216 hemolytic anemias (See Hemolytic anemias) Hodgkin’s disease, 215 hypersplenism, definition, 214t idiopathic thrombocytopenic purpura, 214 non-Hodgkin’s lymphoma, 215 postsplenectomy sepsis syndrome, 214 postsplenic sepsis prevention, 216t sarcoidosis of spleen, 216 splenectomy, 216t thrombotic thrombocytopenic purpura, 214 Splenectomy, 216t Splenic artery aneurysms, 161 Splenic rupture, spontaneous, 216 Splenic vein thrombosis, 193, 209–210 Splenorenal shunt, 192 Splenosis, 216 Split-thickness grafts, 89 Split-thickness skin grafts (STSGs), 89 Spondylolisthesis, 268 Spontaneous bacterial peritonitis, 17, 191 Spontaneous pneumothorax, 141 Spontaneous splenic rupture, 216 Squamous cell carcinoma, 95 hypopharyngeal, 101 nasopharyngeal, 101 oropharyngeal, 101 Staging system breast cancer, 131t colorectal cancer, 231t gynecologic, 256t lung cancer, 137t Standard pancreaticoduodenectomy, 210 Stanford classification, 150 Staphylococcus aureus, 16 Staphylococcus epidermidis, 16 Starvation, 37–38 injury responses, metabolic differences, 37t Statin drugs, 25 Statistics null hypothesis, 282 qualitative variables, 282 quantitative variables, 282 trials and studies, 282 type I error, 282 type II error, 282 Steatorrhea, causes of, 218 Stensen’s duct laceration, 103 Sterilization, 20 Sternal fractures, 65 Steroid hormone, Steroids, 45, 51 Stevens–Johnson syndrome, 91 Stewart–Treves syndrome, 135 Stomach anatomy and physiology, 176–177 arterial blood supply, 176 chronic gastritis, 182 duodenal ulcers, 179–181 gastric cancer, 182–183 gastric lymphomas, 183 gastric ulcers, 181–182 gastric volvulus, 177 Mallory–Weiss tear, 177 morbid obesity jejunoileal bypass, 185 Roux-en-Y gastric bypass, 183–184, 184 mucosa-associated lymphoid tissue lymphoma, 183 pepsin, 39 postgastrectomy complications afferent-loop obstruction, 185 alkaline reflux gastritis, 185 blind-loop syndrome, 185 chronic gastric atony, 185 dumping syndrome, 185 efferent-loop obstruction, 186 post-vagotomy diarrhea, 186 small gastric remnant, 185 stress gastritis, 182 upper gastrointestinal bleeding, 179 vagotomies, 177–178 Zollinger–Ellison syndrome, 180 Stomas, 224 Stones black, 196 brown, 197 nonpigmented, 196 pigmented, 196 Streptokinase, Stress gastritis, 182 Stress incontinence, 253 Stricturoplasty, 222 Stroke volume, 77 Struvite stones, 250 Student’s t test, 282 Stump pouchitis, 228 Subarachnoid hemorrhage, 261 Subclavian steal syndrome, 159 Subdural hematoma, 59, 260 Sublingual drugs, 24 Sublingual glands, 99 Submandibular glands, 99 Submucosa, 54 Substernal goiter, 115 Succinylcholine, 28 Sucking chest wound, 63 Sucrose, 39 Sudan red stain, 218 Sulbactam, 21 Sulfamylon (mafenide sodium), 90 Sulfonamides, 20, 24 Superficial parotidectomy, 102 Superficial spreading melanoma, 94 Superficial thrombophlebitis, 163 Superior laryngeal nerve, 99 Superior mesenteric artery, 204 embolism, 160 thrombosis, 160 Superior parathyroids, 120 Superior vena cava (SVC) syndrome, 146 Suppressor T cells, 12 Suppurative parotitis, 103 Suppurative tenosynovitis, 265 Suppurative thrombophlebitis, 163 Supracondylar humeral fracture, 265 Surgical spine decompression, 61 Surgical technology argon beam, 248 harmonic scalpel, 248 laser, 249 Nd:YAG laser, 249 ultrasound, 248 Swallowing mechanism, 168 Swan–Ganz catheter, 78 Symptomatic blunt neck trauma, 62 Symptomatic breast mass workup, 129 Synercid, 22 Systemic inflammatory response syndrome (SIRS), 83–85 T Tamoxifen, 42 Taxol, 42 TB See Tuberculosis T cells activation, 13 cytotoxic T cells, 12 helper T cells, 12 infections, 12 intradermal skin test, 12 lymphomas, 44 suppressor T cells, 12 thymus, 12 Telophase, Temporal arteritis, 162 Temporal skull fractures, 60 Tenosynovitis, suppurative, 265 Tensile strength, in wound healing, 54 Tension, 92 Tension pneumothorax, 65, 141 Teratoma, 139, 280 Tertiary hyperparathyroidism, 122 Testicular cancer, 250–251 Testicular torsion, 252 Tetanus, 14 Tetanus immune globulin, 14 Tetanus-prone wounds, 14 Tetracycline, 22, 24 Tetralogy of Fallot, 144 Thioamides, 115 Third-generation cephalosporins, 21 Thoracic aortic disease See under Vascular disorders Thoracic duct anatomy and physiology, 136 Thoracic outlet, anatomy, 159 Thoracic outlet syndrome, 159–160 Thoracolumbar spine, 61 3-Hole esophagectomy, 173 Thrombin, 5, 55 Thrombolytic use, contraindications to, 10t Thrombolytics, Thrombophlebitis, suppurative, 163 Thrombotic thrombocytopenic purpura (TTP), 214 Thromboxane, Thymoglobulin, 45 Thymoma, 139 Thymus See T cells Thyrocervical trunk, 100 Thyroglossal duct cyst, 115, 272 Thyroid See also Hyperthyroidism anatomy and physiology, 113–114 asymptomatic nodules, 114–115 descent abnormalities lingual thyroid, 115 pyramidal lobe, 115 thyroglossal duct cyst, 115 gland injuries, 63 hormone, 2, 52 recurrent laryngeal nerves, 113 storm, 114 Thyroid cancer anaplastic thyroid cancer, 118 follicular thyroid carcinoma, 117–118 Hürthle cell carcinoma, 118 medullary thyroid carcinoma, 118 papillary thyroid carcinoma, 117 Thyroidectomy, 115 Thyroiditis, causes of bacterial thyroiditis, 117 De Quervain’s thyroiditis, 117 Hashimoto’s disease, 116 Riedel’s fibrous struma, 117 Thyroxine, 119 Ticarcillin, 21 Tidal volume (TV), 81 Tight junctions, Timentin, 21 TIPS See Transjugular intrahepatic portosystemic shunt Tissue expansion, 92 Tissue valves, 145 TMJ dislocations, 103 Tonsillar CA, 100 Tonsillectomy, Tooth extraction, Torus fracture, 268 Torus mandibular, 100 Torus palatine, 100 Total body water, 32 Total lung capacity (TLC), 81 Toxic epidermal necrolysis (TEN), 91 Toxic megacolon, 234 Toxic multinodular goiter, 116 Toxic shock syndrome, 258 Trachea, 140 Tracheal injuries, 63 Tracheobronchial injury, 63 Tracheoesophageal fistulas (TEF), 275 Tracheo-innominate artery fistula, 140 Tracheostomy, 105 Traction diverticulum, 169 Transfusion-related acute lung injury (TRALI), 11 Transhiatal approach, 173 Transjugular intrahepatic portosystemic shunt (TIPS), 192 Transplant immunology, 45 Transplantation drugs ATGAM, 45 azathioprine, 45 cyclosporin, 45 FK-506 (prograf), 45 heart, 48 immunology, transplant, 45 kidney complications, 46 living kidney donors, 47 liver, 47–48 lung, 48 mycophenolate, 45 opportunistic infection fungal, 48 protozoan, 48 viral, 48 pancreas, 48 rejection accelerated, 46 acute, 46 chronic, 46 steroids, 45 thymoglobulin, 45 zenapax, 45 Transverse rectus abdominus myocutaneous (TRAM) flap, 92–93, 93 Trapezius flap, 100 Trauma bladder, 74 blunt abdominal, 57 chest, 63–65 aortic transection, 64 approach for specific injuries, 64 aspiration, 64 cardiogenic shock, 65 chest tube, 63 diaphragm, 63 esophageal injury, 63 flail chest, 64 myocardial contusion, 64 sternal fractures, 65 sucking chest wound, 63 tension pneumothorax, 65 tracheobronchial injury, 63 chest roentgenogram, 64 colon, 69 duodenal, 67–68 genital, 74 head injury, 56, 59 liver, 69–70 maxillofacial, 61–62, 61t neck, 62, 62–63 orthopaedic, 72, 73t pancreatic, 71 pediatric, 74 pelvic, 65–67 penetrating abdominal injuries, 57 anterior abdominal trauma, 57 chest injury, 65 colon, 69 neck trauma, 62 pancreatic, 71 rectal, 69 renal, 74 small bowel, 69 during pregnancy, 75–76 rectal, 69 renal, 74 small bowel, 69 spine cervical spine, 60 thoracolumbar spine, 61 spleen, 70 testicular, 74 vascular, 71–72 Traumatic intraventricular hemorrhage, 59 Triacylglycerides (TAGs), 39 Trichilemmal cyst, 98 Trigeminal nerve, 99 Trigger finger, 265 Trimethoprim, 20 Tripod fracture, 62 Truncal vagotomy, 178 Trypanosoma cruzi, 238 Tryptophan, 40 Tuberculosis, 142 skin test, 12 Tubular adenoma, 228 Tumor markers, 41 suppressor genes, 43 Tumor lysis syndrome, 34 Tumor necrosis factor-alpha (TNF-α), 50 Tumor-infiltrating lymphocytes (TILs), 14 Turcot’s syndrome, 232 21-Hydroxylase deficiency, 110 Tylenol overdose, 26 Type I collagen, 92 Type I error, 282 Type I hypersensitivity reactions, 49 Type II error, 282 Typhoid enteritis, 225 U Ulcerative colitis, 233–235 Ulnar nerve, 264 Ultrasound biliary system, 197 gynecologic, 255 Umbilical hernia, 247, 278 Unasyn, 21 Undescended testicles, 280 Unsaturated fatty acids, 39 Unusual burns See under Burns Upper esophageal sphincter, 167 Upper extremity, 159–160, 264–265 Upper extremity thoracic outlet, 159 Upper gastrointestinal bleeding, 179 bleeding ulceration treatment, 179 Urea production, 39 Uremia, Ureteral duplication, 253 Ureteral trauma, 252 Ureterocele, 253 Ureteropelvic obstruction, 253 Uric acid stones, 250 Urobilinogen, 189 Urology anatomy and physiology, 250 benign prostatic hypertrophy, 252 bladder cancer, 252 incontinence overflow, 253 stress, 253 kidney stones, 250 neurogenic bladder, 253 neurogenic obstructive uropathy, 253 prostate cancer, 251 renal cell carcinoma, 251–252 testicular cancer, 250–251 testicular torsion, 252 ureteral trauma, 252 Urticaria, 11 Uterine endometrial polyp, 258 Uterine fibroids (leiomyomas), 258 Uterine rupture, 75 UV radiation, 93 V Vaginal cancer, 256 Vagotomies, 177–178 Vagus nerve, 99 in carotid endarterectomy, 148 Valve disease aortic insufficiency, 150 aortic stenosis, 145 calcification, 145 mitral regurgitation, 145 mitral stenosis, 145 stenosis, 145 tissue valves, 145 Vancomycin, 20, 22 Vancomycin-resistant Enterococcus, 20 Varicose veins, 163 Vascular disorders abdominal aortic disease abdominal aortic aneurysms, 151–154 aortic graft infections, 154 aortoenteric fistula, 154 endoleaks, 153, 153t inflammatory aneurysms, 153 mycotic aneurysms, 154 rupture, 152 acute arterial distinctions, 158t acute arterial emboli, 158 acute arterial thrombosis, 158 amputations, 158 aneurysms, 161–163 femoral, 162 femoral pseudoaneurysm, 162 iliac, 161 popliteal, 161 renal, 161 visceral, 161 atherosclerosis stages, 147 Buerger’s disease, 162 cerebrovascular disease, 148–150 cystic medial necrosis syndromes Ehlers–Danlos syndrome, 162 Marfan’s disease, 162 fibromuscular dysplasia, 162 immune arteritis (See Immune arteritis) lymphatics lymphangiosarcoma, 164 lymphedema, 164 lymphocele, 164 mesenteric ischemia chronic mesenteric angina, 161 median arcuate ligament syndrome, 161 mesenteric vein thrombosis, 161 nonocclusive mesenteric ischemia, 161 superior mesenteric artery embolism, 160 superior mesenteric artery thrombosis, 160 peripheral arterial disease (PAD), 155–157 radiation arteritis, 163 Raynaud’s disease, 163 renal vascular disease, 158–159 thoracic aortic disease ascending aortic aneurysms, 150 descending aortic aneurysms, 150 dissections, 150–151 transverse aortic arch aneurysms, 150 upper extremity occlusive disease, 159 subclavian steal syndrome, 159 thoracic outlet, 159 thoracic outlet syndrome, 159–160 venous disease, 163–164 Vasectomy, 253 Vasoactive intestinal peptide, 165 Vasopressin, 80 venous Doppler ultrasound, normal, 164 Venous insufficiency, 163 Venous thrombosis, 164 Venous ulcers, 163 Ventral pancreatic bud, 205 Ventricular septal defect (VSD), 144 Verner–Morrison syndrome, 211 Verrucous ulcer, 100 Vertebral artery bleeds, 63 Vertebral artery (circle of Willis), 259 Vertebrobasilar disease, 150 Vesicoureteral reflux, 253 Villous adenoma, 228 Vinblastine, 42 Vincristine, 42 VIPoma (Verner–Morrison syndrome), 212 Viral hepatitis, 190 Viral infection, 12 Virchow’s nodes, 182 Virchow’s triad, Visceral sarcomas, 96 Vital signs by age, 75t Vitamin D, 34 Vitamin K, Volkmann’s contracture, 265 Volume overload, 32 Volume replacement estimates, 32 Von Hippel–Lindau syndrome, 252 von Willebrand’s disease, 6–7 Vulvar cancer, 256 W Waldeyer’s fascia, 228 Warfarin, Warfarin-induced skin necrosis, Warthin’s tumor, 101 Warts (verruca vulgaris), 97 Water restriction, 33 Waterhouse–Friderichsen syndrome, 107 Wedge, 78 Wernicke’s area, 262 Wet gangrene, 157 Wide pubic diastasis, 66 Wilms tumor, 273 staging, 273t Wolff–Chaikoff effect, 114 Wound infection, 16 ischemia, 55 Wound healing epithelial integrity, 53 essentials for, 54 impediments to, 54 myofibroblasts, 54 phases, 53 platelet granules, 55 tensile strength, 54 time line of phases, 53 X Xanthine oxidase, 86 Xanthoma, 97 Xenografts, 89 XRT See Radiation therapy Y Yersinia, 238 Z Zenapax, 46 Zenker’s diverticulum, 169 Zofran, 25 Zollinger–Ellison syndrome (ZES), 180, 211 Zosyn, 21 Zygomatic bone, 62 ... the right Recurrence risk after 1st pneumothorax is 20 %, after 2nd pneumothorax is 60%, after 3rd pneumothorax is 80% Results from rupture of a bleb usually in the apex of the upper lobe of the. .. commonly due to atherosclerosis Statin drugs (lovastatin) – #1 preventive agent for atherosclerosis Homocystinuria can ↑ risk of atherosclerosis; Tx: folate and B 12 Claudication: medical therapy first... Subclavian vein – passes over the 1st rib anterior to the anterior scalene muscle, then behind clavicle • Brachial plexus and subclavian artery – pass over the 1st rib posterior to the anterior scalene