GS SMLE Notes.pdf

HIGH YIELD SMLE NOTES GENERAL SURGERY Telegram Channel: https://t.me/+6zlIOrZbk8Y3YTBk Resources: Books (Washington Manual, Schwartz) Courses (Dr. Aldilaijan - Dr. Thawaba) Channels (Quick recall) Files (Dr. Abeidi's - Dr. J - Hamza) Previou...

HIGH YIELD SMLE NOTES GENERAL SURGERY Telegram Channel: https://t.me/+6zlIOrZbk8Y3YTBk Resources: Books (Washington Manual, Schwartz) Courses (Dr. Aldilaijan - Dr. Thawaba) Channels (Quick recall) Files (Dr. Abeidi's - Dr. J - Hamza) Previous recalled questions (2019-2022) Done by: Omar ‫ال تنسوني من دعائكم‬ HIGH YIELD SMLE NOTES Intubation: □Facial and mandibular fracture, secure airway by; Cricothyroidectomy □Trial of endotracheal intubation, secure airway by; Cricothyroidectomy □Most vulnerable to injury in emergent surgical airway (Cricothyroidectomy); Anterior jugular veins □Tracheal injury; use fiberoptic intubation □Suspicion of cervical injury; use bougie □Conscious and oriented; use nasopharyngeal airway □Provide non-surgical airway when endotracheal intubation is not possible; Laryngeal mask □Confirm endotracheal tube placement; End- tidal CO2 detection □When to consider tracheostomy after failure of extubation; 10 days. Neck injuries: □Hard signs of vascular injury; ►absent pulse, bruit or thrills, pulsatile or expanding hematoma, active hemorrhage, distal ischemia. □Neck injury: ►If unstable or hard signs; OR (neck exploration then ligate then repair) ►If stable with soft signs; CTA If CTA (+); look at the zone: -Zone (1 or 2); OR (angio or bronhoscpy or osephageogram), -Zone (3); angioembolization (Endovascular Repair), ►If stable and Asymptomatic; CTA only if Zone 1 □Between cricoid and angle of mandible; Zone 2 HIGH YIELD SMLE NOTES □Found in zone 1; Superior mediastina / great vessels. □Complete transection of external carotid; ►Unstable; ligate ►Stable; primary repair □Neck injury, conscious and alert with oxygen saturation of 82%; endotracheal intubation Vessel injury; □Left subclavian injury incision; left anterior lateral thoracotomy □Most common site of aortic injury (in general); aortic isthmus □Most common site of aortic injury in blunt trauma; ligamentum arteriosum □Most common site of thoracic injury; distal to the left subclavian artery □Cervical emphysema, decrease air entry and pnumomediastinum; Trachobroncial injury □Trachea shifted, lung expansion and wide mediastinum; thoracic aorta rupture, if not there; rupture esophagus Rectal injury: ►If Extra peritoneal injury; diverting colostomy, ►If Intra peritoneal; primary repair Burn; □Black spots over nostrils, 40% carboxyhemoglobin, ►Initial; intubation and 100% oxygen ventilation ►Definitive; hyperbaric oxygen □Carbonaceous sputum (after fire); inhalation injury HIGH YIELD SMLE NOTES □Biopsy show 10^4 staph; proceed to graft, if 10^5 or more; antibiotics □Chemical burn in back; powder sweeping □Depth of burn wound; biopsy □ Indicate good resuscitation: ►In Burn; urine output, ►Others; lactic acid □Chemical mediator in burns; Prostaglandin □Oil dissolvent injury, Tx; surgical drainage □In burn, all electrolytes are; Low Shock: □25% blood loss, what decrease; pulse pressure (1st indicator of hemorrhagic shock) □Class of shock: Class 3; if heart rate: not more than 140, AND BP: not less than 90. □Type of shock: ►If high cardiac output (CO); septic shock ►if low CO, check PCWP; if high PCWP; cardiogenic shock if low PCWP; hypovolemic shock □If high central venous pressure (CVP); give diuretic (Normal CVP; 8-10) □Post RTA with massive bleeding in the nose and mouth, can take his breath, low BP; IV fluid □Massive bleeding, Unstable after fluid resuscitation, what's the cause; brain hypoxia □Hypotension after 6 L of fluid; ►What to give; norepinephrine ► If refractory to norepinephrine; give arginine vasopressin HIGH YIELD SMLE NOTES □Hemoglobin level at which blood transfusion is indicated; less than 7 (in sickle patient: less than 5) □Compensated shock if; cold and pale peripheries Chest Trauma : □Tension pneumothorax, needle thoracostomy (even if confused), ►(if with GCS ≤8 or LOC); intubation □Stony dullness; plural effusion or hemothorax; chest tube ►(If still dyspnea after chest tube; second chest tube) □Loculated hemothorax; decortication □Sucking wound; open pneumothorax; Initial; three side dressing, then; Chest tube □Simple pneumothorax Mx; ►If Spontaneous (no underlying lung disease or malignancy): if unstable or recurrent; chest tube, if stable and mild symp/size 3cm and less; oxygen and observe, if stable and sever symp or size more than 3cm; aspiration or chest tube ►If 2ndry; If 2cm and more or symptomatic: plain X ray then chest tube otherwise; oxygen and observe □Air leak through chest tube, how to diagnose; Fiber optic bronchoscopy □Chest tube and needle decompression; in 5th intercostal space (if child; 2nd), □Thoracocentesis; in 9th intercostal space □Flail chest; ►Tx; ventilation or fluid and analgesia ►If with basilar atelectasis, dx; pulmonary contusion. HIGH YIELD SMLE NOTES □ Sternal fracture, chest bruises, pounding pulse; cardiac contusion. Next; Troponin+ ECG □ Pericardial fluid: ►if stable; subxiphoid window, ►if not stable: low blood pressure, distension of the jugular veins, and muffled or diminished heart sounds on cardiac auscultation (beck triad): First; precardiocentesis Best; sternotomy □Child with chest trauma and decompensated shock; Thoracotomy □Stab in left chest, vital stable, imaging negative; diagnostic laparoscopy Blunt vs. penetrating trauma; □Right chest gunshot no pulse and hypotension; left thoracotomy □Hematoma of 3rd part of duodenum; NGT, TPN □Abdominal stab wound; ►if Unstable or evisceration or peritonitis; Operation room (laparotomy) ►If stable; initial; wound inspection then wound exploration then CT to see if fascia Penetrated or not; ♦ If Violation of anterior facial; laparotomy, ♦ if No violation; discharge □Blunt trauma : ►If stable; CT ►If unstable; FAST, Positive FAST; ♦ if stable; CT ♦ if Unstable; laparotomy Negative FAST; DPL □ Laparotomy indications; ♦ Omentum is out (evisceration) ♦ Mesh exposed ♦ Air under diaphragm ♦ Intraperitoneal air HIGH YIELD SMLE NOTES Abdominal Trauma: □CT in trauma for; retroperitoneal injury □Free fluid in abdomen and thoracic aorta rupture, What to do first; laparotomy (call general surgeon) □Seat belt injury, dx by; CT, □Type of injury: ►If with chance fracture; duodenal injury, ►If without chance fracture; Jejunal injury □RTA, stable, with tenderness and ecchymosis in the left hypochondrium, next; CT abdomen □Child fall of bicycle 18 days ago, bruises in RUQ; CT (traumatic pancreatitis) □Rectus sheath hematoma, dx; CT with contrast, Tx; analgesia and rest □RTA, unstable and diffuse tenderness and rigidity, next step; FAST, (if stable; CT) □1 cm laceration above umbilical, and patient is stable; wound exploration □Any grade liver injury, and patient is stable; observation □Spleen injury; ►If Stable; non operative (ICU observation) ►If unstable; splenectomy ►If Blush in CT and stable; angiography and embolization □After splenectomy vaccine; pneumococcal, meningococcal, H. Influenza □Give vaccine after; 2 weeks of the surgery □After splenectomy (or any surgery), What will be low; insulin Head trauma : □Appropriate type of feeding; either gag reflex present or absent; ►Initial- for short period; NGT ►Long period-2weeks; with basal ganglia; gastrostomy HIGH YIELD SMLE NOTES □Temporal fracture; epidural (extradural) hematoma; lucid interval (the period of time between regaining consciousness after a short period of unconsciousness); affect middle meningeal artery VS. □Subdural hematoma; concave toward the brain and unlimited by suture lines □Hematoma with signs of lateralization or decrease level of consciousness, Next or Definitive Mx; craniotomy. Perforation: □Boerhaave syndrome (esophageal perforation); chest pain, vomiting, emphysema (Mackler triad) □Oesophageal perforation Mx: ►Stable; stent ►Unstable (WBC;21000); oesophagectomy or surgical drainage and anastomoses □Emphysema after ERCP; duodenal perforation □Anterior duodenal; perforation, Mx; omental patch (graham) □Posterior duodenal; bleeding, Mx; suturing □Duodenal perforation; ►if contained; NPO, IVF ►if not contained; Minor; simple repair Major; surgical bypass □Patient on TPN developed: ►Weakness and convulsion; hypophosphatemia, ►If Weakness only; hypomagnesemia Inflammatory response: □SIRS; 2 of these criteria are met: Body temperature ≥38 or ≤36 degrees Celsius. Heart rate ≥90 beats/minute. Respiratory rate ≥20 breaths/minute or partial pressure of CO2 ≤32 mmHg, WBC ≥12K or ≤4K /uL If SIRS + documented infection; sepsis if the labs indicate an organ failure; Severe sepsis If maintained on vasopressor or low base excess; septic shock. HIGH YIELD SMLE NOTES Vascular Surgery: □Unilateral leg erythema increase in dependent position; Arterial insufficiency □Leriche syndrome; triad of claudication, erectile dysfunction, and decreased distal pulses, Tx; aortobifemoral bypass □Limb ischemia: □ABI < 0.3 and, CTA show artery occlusion more than 3 cm; amputation (Acute on top of chronic) □Intermittent claudication, Mx; smoking cessation, what improve walking distance; supervised exercise program □Chronic limb ischemia/Critical limb ischemia: ►Next; Aspirin ►dx; initial; ABI then doppler US ►imaging; CTA ► Gold standard (best, most diagnostic test); conventional angiography □Acute limb ischemia: ►Next; heparin ►Then; US Doppler duplex ►Gold standard; CTA ►Mx; Grade 1; No motor or sensory loss; heparin and observe Grade (2A); Only sensory, no motor involvement; catheter thrombolytic (not systemic) Grade (2B); Mild to moderate motor involvement (4 hours ago with absent popliteal); embolectomy (definitive) Grade 3; Anesthetic + paralysis; Amputation □Lower limb ischemia: ►Prevent cardiac event; aspirin ►Prevent systemic emboli; warfarin □Poorly controlled DM comes with ulcers on tip of three of his toes, diminished dorsalis pedis bilaterally, ►Next; lower limb duplex scan or CTA ►initial Mx; Diet modification and lifestyle changes, if not there; debridement HIGH YIELD SMLE NOTES □Lymphedema (non-pitting edema), ►Include in history; family history ►Next step; Duplex US, ►Management; exercise then compression then message □Spider nevus; clinical dx □Varicose veins, investigation before Tx; duplex US □Varicose lesion Tx; ►if Therapeutic; endovascular/thermal ablation ►if Cosmetic; sclerotherapy □Vascular malformation in leg, indication of surgery; congestive heart failure □ Cord like swelling, dx; thrombophlebitis, Tx; NSAID □AV fistula; radial artery cephalic vein. □Young with weight loss and abdominal pain relieved by squatting; SMA syndrome □Abdominal aortic aneurysm (AAA): □Risk factor for AAA rupture; Smoking (strongest), COPD, age, HTN, Female 65 y.o smoker, screen for; AAA □AAA investigation; serum amylase (can cause ischemic pancreatitis) + (low Mg) After AAA, increase distended abdomen; sigmoidoscopy (ischemic colitis) □AAA, ►if stable and symptomatic; CTA ►stable and asymptomatic; US ►if unstable and known case of AAA; laparotomy ►if Unstable and not known case of AAA; US Vs. □Aortic dissection (tearing, radiating to back, wide mediastinum in CXR), ►If stable; CTA ►if unstable; TEE HIGH YIELD SMLE NOTES □Foot ulcer: ►lateral ulcer; Arterial (no pulse), ►medial ulcer; venous (with pulse) □Cause of venous ulcer; venous HTN. If not there; age ►Ex. Ulcer in lateral malleus; ♦ if Pulse intact; venous duplex ♦ if No pulse; arterial duplex Gallbladder Diseases: □Post laproscopic cholecystectomy: ►Dilated CBD (no Collection) and jaundice; retained CBD stones ►Dilated CBD and fluid around the gallbladder or large/ collection and tenderness); CBD injury, next; ERCP ►Sub hepatic biloma 10cm; CT guided drainage ►Vague abdominal pain, large collection in subhepatic; CT guided drainage ►Bleeding; Angiography (hemobilia) ►Pain in angel of mouth; antibiotic □Small bowel obstruction signs + stones +Air in biliary tree (Pnumobila); gallbladder ileus, Dx by; CT abdomen, Mx; laparotomy □Gallstones and dilated CBD; ERCP, if pt did Roux en Y; PTC tube (NOT ERCP) □RUQ pain, jaundice, fever; cholangitis; IV antibiotics, next: US, best; ERCP Vs. □RUQ pain, jaundice, ascites; budd-chiary syndrome; heparin □Elective lap cholecystectomy after PCI, ►If bare metal stent; after 6 weeks VS. ►If drug-Eluting stent; after 6 months □Open or laparoscopic cholecystectomy ? ►if he has hear faliure or low Ejection fracture (below 50%); open cholecystectomy ►if only MI; laparoscopic cholecystectomy □Accidentally transects CBD; hepaticojejunostomy HIGH YIELD SMLE NOTES □Type of stone: ►Sickle cell disease; pigmented stone (black) Vs. ►Sickle cell trait; mixed stones Vs. ►Obese; cholesterol □Painful enlargement of gall bladder, stones impacted in the Hartmann's pouch; Mirizzi's syndrome, Mx; open cholecystectomy and CBD exploration □Shrunken gall bladder, intrahepatic duct dilation with normal CBD; klatskin tumor; lap cholecystectomy □Calcified gallbladder; cholecystectomy □Intramural gas of gallbladder; emphysematous gallbladder □Morphine; sphincter of oddi dysfunction □Acute Cholecystitis, Mx; ►Less than 3 days; early surgery ►More than 3 days; Antibiotics and interval surgery (after 6 weeks) ►Elderly pt. admitted to ICU/burn unit, has RUQ pain and tenderness. Mx; us guided cholecystostomy drainage □Post lap cholecystectomy with abdominal pain and fever and fullness; US Vs. □Post sleeve gastrectomy with abdominal pain and fever and fullness; Stable; CT with contrast Unstable; laparotomy □ Gallbladder polyp: If asymptomatic; serial US follow up (if not there; surgical consultation) If symptomatic or >1 cm or increase in size or more than 50 y.o or presence of stones; lap cholecystectomy □Adenocarcinoma of gallbladder limited to muscular layer; no treatment HIGH YIELD SMLE NOTES □Typical symptoms of recurrent biliary pain, US shows no stones; HIDA scan (biliary dyskinesia) □High ALP, MRCP shows multiple foci of stricture and dilatation; Primary sclerosing cholangitis; colonoscopy (to exclude ulcerative colitis) Bariatric Surgery: □Most common cause of obstruction; ► Post laparoscopic Roux-en-Y Gastric Bypass; internal hernia ► Post sleeve gasterctomy; Adhesion □Post sleeve gasterctomy (vomiting, bloating, irritable); reassure □GERD post gastric sleeve; 30% □Obese and hiatus hernia for bariatric surgery: ►Test before; endoscopy ►Type of surgery; Roux-en-Y Appendix: □Appendicular mass: ►Intra-operative finding; proceed with surgery ►pre-operative finding; conservative then; if young; interval appendectomy in 6-8 weeks if old; colonoscopy in 6-8 weeks Vs. □Appendicular abscess; IV Antibiotics, percutaneous drainage and interval appendectomy □Normal Appendix (Appendectomy vs. keep appendix?): ►In operation room (either laparoscopic or open), no etiology; appendectomy ►If there is other etiology for appendicitis; If Open: treat the cause then appendectomy If Laparoscopic; treat the cause and keep appendix HIGH YIELD SMLE NOTES □Fecal material from wound: ►Few days post appendectomy; if unstable or peritonitis ; antibiotics and laparotomy, if stable; conservative and CT Vs. ►in incisional strangulated hernia with ulcer; laparotomy □Adenocarcinoma of appendix, next; colonoscopy and CT chest, Tx; resection regardless of size and location (right hemicollectomy) □Carcinoid Appendix; ►If more than 2 Cm or mesoappendiceal invasion, or base or lymph node involvement; right hemicollectomy ►None of the above: Appendectomy is enough □Press on Left side , pain on Right side; Rovsing’s sign □Post appendectomy 3 collections; laparoscopic surgery □Large cystic appearing appendiceal mass; psuedomyxoma peritonei □Perforated appendix; delayed primary closure. □Appendicitis, Mx: ►If high Alvarado; 7 and more; laparoscopy ►If low Alvarado; less than 7; CT scan ►If pregnant or child; US ►If young female; B-hcg and transvaginal US □Appendicitis antibiotics; 30 minutes pre op (Abx cover; negative aerobes and anaerobes) Anorectal conditions: □Anal hematoma (thrombosed pile); swelling and painful, but vitally stable, □Anal abscess: swelling, painful, high WBC, fever HIGH YIELD SMLE NOTES □Anal fissure; painful, and a crack □Itching present with; hemorrhoid Mx of Hemorrhoid: □External; ►Symptomatic thrombosed external piles: if within 72 hours; Hemorrhoidectomy or lateral sphinctotomy. If more than 72 hours; conservative Mx □Internal: 1st and 2nd degree hemorrhoid; start with conservative. If it fails, go with rubber band ligation (definitive) 3rd degree: start with conservative. If fails; hemorrhoidectomy. ( if there’s bleeding; rubber band ligation) 4th degree: hemorrhoidectomy Internal hemorrhoids; sclerotherapy ►If More than 40 years old with hemorrhoids; COLONOSCOPY □Anal fistula: ►Anal fistula 7 o’clock internal opening; Medline posterior (Most common site of fistula) ►Multiple perianal abscess/fistula 3,5 o’clock; if known case of crohns; MRI, If not known case of crohns; colonoscopy □Patient with Crhons disease: ►with pus from anus; IV antibiotics then pelvic MRI ►with boggy swelling anteriorly; drainage □Patient presented with pain, discharge, opening (anal fistula): ►If 1st time; F/U in clinic ►If 3rd time; pelvic CT HIGH YIELD SMLE NOTES □Management of fistula; surgery (fistulotomy); if simple, inter-sphincteric, low lying MRI then seton; if complex (IBD), recurrent, high, multiple, rectovaginal or with fecal incontinence In crhons; infliximab or adalimumab □Low back; pilonidal sinus; excision □2*2 peri rectal abscess; incision and drainage □Gluteal abscess; secondary intention (open and dressing) UGI surgery: □Esophageal cancer; ►Strongest risk factor; Barrett’s esophagus ►Most common; SCC □Multiple ulcers in Antrum; partial gasterostomy (anterctomy) □Gastric ulcer not improved with medical; Endoscopic biopsy □Post endoscopy, sternal pain, next; X-ray, Best; esophagoram □Corrosive esophageal injury; do esophagogram with water soluble contrast (gastrografin). □ Staging of: ►Oesophageal or Gastric cancer by; Endoscopic ultrasound (EUS) ►Colon cancer by; CT chest, abdomen and pelvis □ Type of Fluid: ►duodenal and above; (ex. Gastric cancer or gastric outlet obstruction); normal saline, ►below Duodenum; (ex. Pancreatic fistula); ringer lactate (also in burns and sweating) HIGH YIELD SMLE NOTES □Succession splash; Metabolic alkalosis Vs. □Chronic vomiting; compensated metabolic alkalosis □ Gastrointestinal stromal tumor (GIST) Mx; ►Less than 2cm; observe - conservative ►More than 2cm, volcano sign; WLE, R0-R1 margin ►With metastasis; Imatinib (tyrosine kinase inhibitor) Pancreas: □Pancreatitis diagnosed by 2 out of 3; pain characteristic, high amylase, CT (if typical pain but normal amylase, next step; CT) □Determine severity of Pancreatitis; serum C-reactive protein (CRP) □Poor prognosis of pancreatitis; hematocrit and hypoxia □Nutrition support for severe pancreatitis; Nasogastric feeding □Chronic pancreatitis for pain; NSAID then celiac plexus block □Pancreatic psudocycts, dx by; CT □Mx; ►Less than 6cm and 4w; observe ►More than 6cm or 4w; depend; If not infected; endoscopic drainage (not laparoscopic), If Infected; percutaneous drainage □ Pancreatic cancer; (Ca 19-9) ►Painless jaundice, weight loss and painless enlarged gallbladder (courvoisier sign), dilatation of intrahepatic and extrahepaic ducts (CBD); dx by; CT abdomen then stage by; CT chest □ Biliary pancreatitis; urgent ERCP within 24 hrs followed by cholecystectomy □Laparoscopic cholecystectomy after pancreatitis: ►if Mild; same admission ►if Sever; after 6w HIGH YIELD SMLE NOTES □One of surgery indication; Necrotizing pancreatitis; increase lipolysis or decrease glycogenlysis Liver lesions; □To diagnose any liver lesions, first; US then triphasic CT ►If triphasic CT shows hypervascular; either Benign liver lesions: □ Liver adenoma; OCP, rupture mass, obese, shock; tx; more than 4cm; resection, if less; stop OCP □Hemangioma; peripheral enhancement w/ progressive filling, CT shows centripetal; observation (avoid heavy exercise/contact sport, if not there; then avoid OCP). □Focal nodular hyperplasia (FNH); central stellate; observation Or Malignant liver lesions: □HCC (high AFP) or breast (mammography) ►If shows hypovascular; 2dry to GI (colonoscopy) or 1ry colangiocarcioma (Dx of exclusion) □ HCC: ►If there is identifiable cause (hepatitis B (the most common)); CT abdomen then biopsy, ►If there is no identifiable cause; colonoscopy □ Hydatic liver cyst; ►Less than 5cm; Albendazole ►5-10cm; Albendazole (initial) and PAIR (definitive) ►More than 10cm or complicated or daughter cysts or failed PAIR; initial; albendazole definitive; surgical deroofing □Risk factor for pyogenic liver abscess; History of biliary tract disease □Multiple densities in liver, bubbles with SMV; portal pyemia □Diarrhea, pain, fever, travel to India/Mexico, anchovy sauce, CT shows double target; amebic liver abscess; serology; metronidazole HIGH YIELD SMLE NOTES Colorectal Surgery: □Screening for colon cancer ; ►If one relative more than 60; every 10 years ►If relative less than 60 or more than 1 relatives; every 5 Y □Screen colon cancer for healthy individual with no risk factor; from age of 50 by; ► Colonoscopy every 10 Y ►Or Sigmoidoscopy every 5 Y ►Or FOBT annually □Left adrenal vein drain to; left renal vein □Sacral ulcer, Mx; debridement and Vacuum-assisted closure (VAC) □Bed sores with exposed necrotic skin and subcutaneous tissue; debridement & dressing with secondary closure □Subcutaneous fat is lost, but Vasculature is exposed; debridement and graft later (don’t use VAC). □Most common adrenal mass discovered accidentally; nonfunctional adenoma □Post resection of terminal ileum; Anemia; vitamin b12, Diarrhea; bile acids, Tx; Cholestyramine □Old pt with symp of LBO, X-ray showed Y shape ( inverted U shape ), Dx; sigmoid volvulus, next; sigmoidoscopy, if not there; colonoscopy □Mx of Sigmoid volvulus (coffee bean sign); ►If Stable; endoscopic decompression ►If Unstable; Hartmann □Mx of Diverticulitis; conservative, oral Abx, colonoscopy after 6 weeks, if with intraperitoneal air; laparotomy □Recurrent attacks of painless rectal bleeding, next step; angiography or RBC scan to look for angiodysplasia □Angiodysplasia; Endoscopy (laser, cauthery, argon plasma) Then angio/embolization Then resection HIGH YIELD SMLE NOTES □Schistosomiasis; dx by; ova in stool, associated with; pulmonary HTN □Multiparous with midline abdominal bulge increase with leaning forwards, cough negative; rectus muscle diverticulum; no need for surgery □Intestinal obstruction and perforations, which is contraindicated; nitric oxide □Massive LGIB, next; endoscopy (NGT aspiration) then; colonoscopy Vs. □Non massive LGIB, 1st; colonoscopy, if normal, then; Technetium 99 □Small bowel obstruction signs, next; Examine the groin, Anal examination □Old patient with retroprotineal mass; liposarcoma □Kidney investigation always CT, with contrast for; renal cell cancer, no contrast for; renal stone Bowel obstruction: □Most common cause of small bowel obstruction: ►if Virgin abdomen (no prior surgery); hernia ►if there is previous surgery; adhesion □Abdominal pain and exaggerated bowel sound and high amylase; small bowel obstruction □Hx of appendectomy years ago, present with sudden abdominal pain x ray shows multiple air fluid level and dilated loop in certain point, next; CT abdomen □Best diagnostic tool for small bowel obstruction; CT, if CT shows multiple dilated loops of small bowel with transition point in the distal small bowel, with fat stranding, Next; conservative HIGH YIELD SMLE NOTES □Elderly with SBO Symptoms, first; X Ray, then; CT abdomen if CT shows obstructed cecal mass; right hemicolectomy □Minimal intravesical pressure indicate abdominal decompression; 35 mm hg Surgical Oncology: □Sclerotic lesion in distal femur; osteosarcoma □Old patient schedule for chemo, osophagectomy on TPN, concern initially; hypophosphatemia □15 Y.O his father 37 y.o died of colon cancer and has multiple comorbidities. Typical example of; duodenal cancer (familial adenomatous polyposis - FAP) □Lung cancer screening; low dose CT □lung cancer with pleural effusion 1500ml bloody with exudate effusion. Next; CT with IV contrast □Rapidly growing painless mass in the right upper leg, healthy; MRI (sarcoma) □Sarcoma metastasis to lung, Dx; Core Needle Biopsy, excisional if ≤ 5cm, Staging; MRI preferred over CT Scan □Most common primary origin of metastatic brain tumor; Lung tumor □Most common malignant brain tumor in pediatric; medulloblastoma □Polyps: ►high risk to transfer to Malignancy; Villous ►Every 10 years: if low-risk polyp (