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1. Critical Care

2. Head & Neck

2.1. Nodule

2.1.1. Midline Thyroglossal Duct Cyst US & FNA Moves w tongue protrusion Thyroid Nodule US TFTs FNA FHx or H/o Radiation <4cm

2.1.2. H&P H/o neck RTx Fam Hx Endocrinopathy Cancers LNs Risk factors Tobacco EtOH

2.1.3. Work-Up TSH/ TFTs/ Ca FNA US guided Abnormal LN also Indeterminate or NonDx Voice Changes Laryngoscopy

2.1.4. Parotid mass Imaging No FNA Superficial Parotidectomy

2.2. Hyperthyroidism

2.2.1. Grave's Dz ABs to TSHR LATS and TSIs Medical Tx PTU Methamizol Propranolol Surgery If Recurrent Severe Hyperthyroid Age>55 Symptomatic goiter Or Radioablation

2.2.2. Multinodular Goiter Surgery vs. RIA Surgery if compressive Sx Awake fiberoptic intubation Euthyroid RIA works 50%

2.2.3. Toxic Adenoma Hot on T-Scan Resect RIA if warranted

2.2.4. Thyroid Storm Sx Hyperthermia MS Changes Diarrhea, N/V Tachycardia Tx Propranolol PTU Dexamethasone

2.3. Hyperparathyroidism

2.3.1. Primary Adenoma Hyperplasia

2.3.2. Secondary

2.3.3. Tertiary

3. Genitourinary

3.1. Kidney

3.2. Ureter

3.2.1. Injury Proximal Ureteroureterostomy Ureteropelicostomy Ureterocalicostomy Distal Ureter does not reach

3.3. Bladder

3.4. Gonads

3.4.1. Testes

3.4.2. Ovaries

3.5. Pudenda

3.5.1. Penis

3.5.2. Vagina

4. Breast

4.1. Mass

4.1.1. Fibroadenoma Core Bx Excise if

4.1.2. Cyst Simple Aspiration Complex US guided Biopsy

4.2. Pain

4.3. Nipple discharge

4.3.1. PE focus on culprit quadrant

4.3.2. Calculate GAIL Risk

4.3.3. Imaging

4.3.4. Fluid type Serous/bloody If duct ID'd If not Milky Prolactin level Do not send it for Histology No galactogram

4.3.5. Concerning Spontaneous Unilateral Recurrent

4.4. Screening

4.4.1. Self exam @20 Qm Clinical exam @3y Start @40 MMG & CE yearly

4.4.2. MRI if BRCA + Li-Fraumeni Radiation to chest Calculated lifetime risk >25%

4.5. Infection

4.5.1. PO ABx

4.5.2. I&D if abscess Excise/Bx if recurrent

4.5.3. Lactation

5. Thoracic

5.1. Esophagus

5.1.1. Motility Disorders Esophagram PH Probe EGD Manometry TREATMENT DES Nutcracker Eo

5.1.2. Diverticuli Zenker's Endoscopic Open Resection EGD Parabronchial Diverticulum Traction TB or Lung CA

5.1.3. Achalasia Characteristics Medical Endoscopic Surgical

5.1.4. Stricture R/o CA Bx EUS R/o Achalasia Manometry Balloon dilation Nissen for GERD control

5.1.5. Barrett's Nondisplastic GERD control LGD ReBx in 3 mos Treat GERD HGD Surveillance Q 3 mos CA W/U Indeterminate GD Place on high dose PPI Length >3cm <3cm

5.1.6. Reflux Try Non-Surgical Per-op W/U Trans-Thoracic Trans-abdominal Short-Esophagus

5.1.7. Perforation General Approach Find it Thin barium swallow Highly unstable pt Cervical esophagostomy T tube drainage

5.1.8. Malignancy

5.1.9. Caustic Inj R/o perf + Perf EGD 1st degree 2-3rd degree

5.2. Aorta

5.3. Cardiac

5.4. Lung

5.5. Mediastinal

6. Vascular

6.1. Peripheral arterial

6.1.1. Claudication Exercise regimen Quit smoking Do not operate if still smoking Life-limiting ischemia

6.1.2. Critical limb ischemia Ulcer/ open wound Rest pain Neuropathy

6.1.3. Popliteal aneurysm Check for other aneurysms Asymptomatic Thrombosed Non-thrombosed Symptomatic Elective bypass Limb-threatening Emergent bypass Fogarty thrombectomy

6.2. Peripheral venous

6.3. Carotid

6.3.1. H&P Sx Intervene if > 60% Plaque ulcer A/Sx Intervene if > 70%

6.4. Abdominal aorta

6.4.1. AAA H&P C-Scope Check for pop aneurysm CT Angio Offer EVAR Open repair Ruptured CTA Prep & Drape before induction Get supra celiac control Incidental Post-op Colonic ischemia

6.5. Acute Mesenteric Ischemia

6.5.1. CT Scan w IV Embolic Dz Suspected source Evidence of end-organ injury Thrombotic Dz Source Bypass to supraceliac aorta preferred Bypass to inferior aorta may kink

6.6. Aorto-enteric Fistula

6.6.1. HD stable

6.6.2. Unstable Lap Prox-Dist Control

6.6.3. Any GIBleed after Aortic bypass AEF UPO

6.7. Infected Graft

6.7.1. Extra-anatomic bypass Then Resection

6.8. Chronic Mesenteric Ischemia

6.8.1. CT Angio Bypass Supraceliac Retrograde Endovascular stenting

7. Trauma

7.1. Liver

7.1.1. Blunt Grade I-II Serial H/H Grade III-IV ICU Admit +Blush on CT Angio-Embolization

7.2. Rectum

7.2.1. Procto

7.2.2. Laparotomy Extraperitoneal Inj Primary Repair if Feasible Loop Colostomy Presacral Drainage Intraperitoneal Inj Repair Resection& Anastomosis GU Involved Repair both Divert Both Interpose tissue Anal Sphincter Involved Sphincteroplasty after healing

7.3. Thoracic

7.3.1. Transmediastinal GSW HD unstable To OR No pericardiocentesis Post-Repair Esophagram

7.3.2. Subclavian inj Unclear Median sternotomy Left Unstable Stable

7.3.3. Tracheal Injury Cervical Collar incision Thoracic R Thoracotomy

7.4. Pelvic Fx

7.4.1. Stable

7.4.2. Unstable Absent Intraabdominal Issues Pre-Peritoneal Pelvic Packing Angio if available FAST+ or possible peritonitis Ex-Lap

7.5. Diaphragmatic Inj

7.5.1. Primary repair Non-absorb sutures #o Interrupted horizontal mattress

7.5.2. Large defect Goretex Graft Porcine Graft If contaminated

8. Hernias

8.1. Inguinal

8.2. Ventral

8.3. Diaphragmatic

8.4. Laparoscopy

8.4.1. Inguinal

8.4.2. Ventral

8.4.3. Diaphragmatic

9. Hepatobiliary

9.1. Gallbladder

9.1.1. Gallstone ileus Small laparotomy Milk bowel for stone Run entire bowel Enterotomy to extract Don't touch the GB

9.1.2. Acalculous Cholecystitis Stable Lap Chole Unstable CT or US-guided Perc Cholecystotstomy IR unavailable

9.1.3. Cholecystitis ina Cirrhotic Partial cholecystectomy

9.2. Biliary tract

9.2.1. Cholangitis Stabilize IV Cipro/Flagyl ERCP or PTC CBDE Extract stone T-Tube if pt unstable Duodenotomy Sphincterotomy

9.2.2. Primary sclerosing cholangitis Ursodeoxycholic acid Sx relief Surgery Transplant

9.2.3. Post-Lap Chole Jaundice Labs Occlusion ERCP PTC RUQ Exploration Stenosis ERCP Balloon dilation Late presentation Retained/Primary stones

9.2.4. Obstruction Malignant Unresectable Dz Cannot dissect out CBD Stone Dz Choledochotomy Transduodenal Sphincteroplasty Unextractable stone Post-Op Stricture Choledochoplasty

9.3. Liver

9.3.1. Abscess IV ABx Colonic Source H/o Cholangitis Perc Drain Not if Multiple If peritoneal source Lap for source

9.3.2. Amebic Abscess IV Flagyl No Drain/No OP

9.3.3. Variceal bleeding Tx IV octreotide Vasopressin EGD Banding 10% failure

9.3.4. Ascites Max med Tx Lasix 160mg/day Spironolactone 400mg/day

9.3.5. Cysts Simple Watch Imaging Ecchinococal Congenital Cystadenoma Symptomatic Perc drain Eccinococcal Albendazole Open cystectomy PAIR

9.3.6. Scoring Systems Child's-Pugh Components Mortality MELD Components 3 Mo. Mortality

9.4. Pancreas

9.4.1. Pancreatitis Mild Severe ICU Admission Blood Cx Serial CT, Hb/Hct Necrosis on CT Infected IV Primaxin Hemorrhagic Angio-Embo Sequelae Pseudocyst Necrosis

10. Small Bowel & Colon

10.1. Oncology

10.2. Infectious

10.2.1. C. Diff Colitis Toxic Megacolon ICU Admit D/C offending agent IV Flagyl, PO Vanc MTx Failure HD Instability Diarrhea PO or IV Flagyl PO Vanc PR Vanc PO Rifaximin Fecal transplant

10.3. Diverticulitis

10.3.1. Uncomplicated Cipro flagyl Add Amp NPO IVF Until better cliniclly

10.3.2. Complicated Abscess Hinchey I Hinchey II Hinchey III Hinchey IV Perforation Hartmann Resection impossible Fistula Hartmann Stricture Do not plasty New node

10.4. Diverticula

10.4.1. Duodenal Resect if Sx Stent duct if necessary to avoid it Transduodenal is better

10.4.2. Meckel's Resect only if Sx Appendectomy

10.5. Bleeding

10.5.1. Approach NGT Aspiration Foley, IVs, Type and Cross IVF Challenge 2L Transfuse 2U PRBCs DRE, Proctoscopy Work-up Nuclear Scintigraphy Colonoscopy Angiography

10.5.2. Diverticular Numbers 25% lifetime risk Work-Up Colonoscopy Nuclear scintigraphy Angio Surgery Unstable Tx >6u/24h Intra-op Localization Unable to localize

10.5.3. Angiodysplasia Localized Dz Resect Diffuse Tamoxifen

10.5.4. Occult bleeding Small bowel sources Angioectasia Workup Capsule endoscopy Angiography EGD and push enteroscopy CT enteroscopy Deep enteroscopy Provocative endoscopy Doesn't work!! Admin anticoag??

10.6. Inflammatory Bowel Disease

10.6.1. Crohn's Medical Tx Steroids 5-ASA Immunomodulators Colonoscopy Bear-Claw Ulcers Abscess Perc Drain NPO, TPN IHOP Operate Appendicitis Incidental Crohn's Stricture Short <10cm Long 10-20

10.6.2. Ulcerative colitis Extra intestinal Dz Pyoderma gangrenosum Ocular dz Primary sclerosing cholangitis ankylosing spondylitis Toxic Megacolon Bowel Rest Ab XR Q 12h ICU Admission IV ABx IV Steroids Peritonitis Failure MTx in 24h Fulminant Colitis S/Sx IV Steroids Cancer Risk 20% @ 20 years of dz 10% @10y + 1% per year after Total colectomy

10.6.3. Indeterminate (10%)

10.7. Rectum

10.7.1. Cancer

10.7.2. Ulcer Characteristics Non-surgical Tx

10.7.3. Prolapse Evaluation Mucosal Partial Procidentia

10.7.4. Fissure Acute Fiber, Sitz Chronic Fiber, Sitz + Topical Tx

10.7.5. Radiation Proctitis Sucralfate enemas Loop diversion if failure Formalin enemas Argon beam fulguration

10.7.6. Fistula in Ano Fibrin plug Sphincters

10.8. Colon

10.8.1. Volvulus Cecal Sigmoid Transverse Necrotic Clamp mesentery prior to detorsion

10.8.2. Pearls Distal obstruction Proximal colonic compromise

11. Abdominal

11.1. Pain

11.1.1. OIder pt with arthritis Perf'd Gastric ulcer

11.1.2. Transplant pt Epigastric pain + steroids Gastric ulcer

11.2. Obstruction

11.2.1. GI Tumor Rectal Ca Prox divert Colon

11.2.2. Ogilvie's Abd XR Cecum >10cm Cecum >14cm NPO, IVF Q12h Abd XR Serial exams MTx Fail in 24h ICU Bed Sx of Perf Subtotal Colectomy & Ileostomy

11.2.3. Pediatric Pyloric Stenosis Duodenal atresia Duodeno-jejunostomy Jejunal atresia Segmental Rsxn Intussusception BE Laparotomy Hirschprung's Decompress with soft rectal tube Unstable

12. Stomach & Duodenum

12.1. Para esophageal Hernias

12.1.1. Symptoms

12.1.2. W/U Esophagram EGD Assess ulceration Manometry

12.1.3. Treatment Type I A/Sx Symptomatic Type II & III

12.2. PUD

12.2.1. Gastric Ulcer Dz Types Type I (60%) Type II (15%) Type III (20%) Type IV (<10%) Type V Stress Gastritis Treatment Medical Mgmt x 6 mos Check for ZES Surgery

12.2.2. Duodenal Ulcer Dz

12.2.3. H.Pylori Testing Serum ABs UBT Stool Ag Suspected PUD Treatment Triple-Tx + PPI

12.2.4. IHOP = Surgery Intractable Hemorrhage Duodenum Gastric Obstruction EGD Perforation Difficult stump Nissen-Cooper repair

12.3. Gastric CA

12.4. Periampullary Tumor

12.5. Duodenal Diverticula

12.6. UGIB

12.6.1. Gastric EGD Pulsatile or Visible vessel Nonpulsatile or clot Endocscopic Tx PPI Surgery

12.6.2. Duodenal EGD Duodenotomy Direct suture ligation Definitive Tx

12.6.3. Obtain Hx H/o sx Use of NSAIDs Use of steroids Liver Dz

12.6.4. Angioembolization

12.6.5. Esophageal Mallory-Weiss 90% Self-limiting Bleeding on EGD Varices

12.6.6. Varices Esophageal Band ligation Gastric Cyanoacrylate Inj IV Octreotide Beta-blockade

12.7. Gastric Outlet Obstruction

12.7.1. PUD stricture Antrectomy B II

12.7.2. Can r/o CA G-J & HSV

12.8. Dumping Syndrome

12.8.1. Post-Gastrectomy Early Diet mod trial Late Diet modification

12.9. Pyloric Stenosis

12.9.1. 1-2 mos old

12.9.2. Low K

12.9.3. Paradoxical aciduria

12.9.4. Palpable "Olive"

12.9.5. Treat Hydrate IV Ramstedt Divide muscle to submucosa NGT test for leaks Start feeds 4hrs post-op

12.10. Difficult duodenal stump

12.10.1. Nissen-Cooper Suture duodenum to posterior ulcer bed Tube duodenostomy Wide drainage Post-op 3 weeks