1. Injuries that warrant further exploration solely by mechanism of injury: 
-unprotected (i.e. pedestrian vs vehicle, bike/motorcycle accidents, assault/battery with object)
-high-impact: unrestrained driver, death at scene, fall > 15 feet, ejection from vehicle, etc.
-vulnerable populations: immunocompromised, elderly, chronically ill, many other medical conditions.
2. Evaluating the abdomen s/p blunt trauma (i.e. car accident): 
-Abdomen looks benign, flat, no evidence of injury: can observe unless one of #1 is true.
-Severe abdominal pain: indicates presence of blood or GI contents (both peritoneal irritants), emergency ex-lap
-Significant superficial markers of damage (lots of bruising, a tire mark): need imaging; DPL/FAST if unstable, CT if stable.
-Coma: need imaging, DPL/FAST unstable, CT stable
-CXR showing diaphragmatic hernia or free air: emergency ex-lap
-Unstable vital signs with flat, unchanged abdomen: DPL/FAST, then OR.
-Unstable vital signs with distending abdomen: emergency ex-lap
-Unstable vital signs with obvious pelvis injury: DPL/FAST to r/o abdominal injury (if you see one, emergency ex-lap). Otherwise go to the angiography suite to try to embolize the bleed, also external fixation would be good.
3. Spleen/Liver injury: 
-Spleen/liver injury with perisplenic fluid and unstable vitals: go to OR.
-Grade III or less injury, stable- manage medically.
-Grade IV or higher injury, stable- manage operatively or with angiogram/embolization.
4. Injuries to root of the mesentery often require large forces, such that they are often accompanied by bowel injury. If you see suspicion of such injuries on CT, go to the OR.
5. Neuro trauma:
-LOC < 5 mins buys you observation in the ED for several hours (+/- CT scan, depending on attending)
-LOC >5 mins buys you CT scan, 24 hours obs
6. Coagulopathy in trauma can be due to: 
-Hypothermia-- leads to platelet and coag factor dysfunction. (Hypothermia can also lead to poor tissue perfusion and acidosis)
-Thrombocytopenia from DIC, sepsis, transfusion reaction. Transfuse to > 60

1. Melanoma margins based on Breslow's depth: 

-Melanoma in situ: 0.5-cm margins

-Melanoma with Breslow's thickness <2 mm: 1.0-cm margins

-Melanoma with Breslow's thickness ≥2.0 mm: 2.0-cm margins

2. Sentinel node biopsy based on Breslow's depth: If the Breslow depth is <0.75 mm (or 1mm by some more liberal guidelines), sentinel node biopsy is not necessary as the risk of spread is very low. 

3. The sun should never set on a complete bowel obstruction. If they are partially obstructed, you can NPO/NG/IVF wait it out, but if it's entirely obstructed (obstipation) with a mechanical cause, you should go to the OR. 

4. Very high (>104) fever within 24 hours postop-- must rule out gas-forming would infection. Within first 12 hours, most likely to be C. perfrigens or group A strep. Atelectasis unlikely to cause this high of a fever unless its very extensive. 

5. Postoperative hemoptysis: likely due to PE, other causes: bronchitis, pneumonia, TB, cancer. If the hemoptysis is long-standing, it's most likely to be due to malignancy (or some sort of vasculitis), if the first episode is postop, likely PE. 

6. Postoperative acute hypotension and hypoxia: big PE, MI, tension pneumothorax. ABCs, auscultation should r/o the pneumothorax. Enzymes, EKG, D-dimer.
7. Elective surgery in someone with pulmonary disease:
-If they smoke, they should quit; 6-8 weeks of abstinence is necessary before statistically significant differences in postop pulmonary outcomes.
-Green sputum: rule out pneumonia by getting CXR, listening to lungs. If those are OK, then its' likely just a bronchiits. Give antibiotics, do surgery after the abx are done and the disease resolves. If it seems more like pneumonia (decreased breath sounds on exam, consolidation on CXR, vital sign changes-- tachypnea, tachycardia, decreased sats) then work up and treat the pneumonia before proceeding with surgery.
-Open > Lap surgery in CO2 retainers, as lap surgery adds more CO2 to blood.
-Hemoptysis: rule out cancer. CT +/- bronchoscopy.
-ABGs are good to determine the extent of pulmonary disease; pCO2 > 45 associated with increased perioperative mortality
8. Emergency surgery in someone with pulmonary disease: 
-If someone looks pretty sick and could have pneumonia, get a CXR
-preoperative bronchodilators, limited time on anesthesia, aggressive early postoperative ambulation, IS use, postop pulmonary preventative care.
9. Predictors of cardiac complications after vascular surgery: 
-Q waves on EKG (indicates transmural MI-- non-q-wave MIs are more likely subendothelial, and may progress to transmural during surgery. Workup with thallium stress test to see areas of ischemia, may need revascularization before surgery)
-Ventricular ectopy bad enough to need treatment (>5 PVCs/minute associated with increased perioperative mortality)
-Angina
-Diabetes needing medications
-Age > 70
10. Prophylactic antiobiotics: not necessary in clean wounds, necessary in clean-contaminated and contaminated wounds.

1. Cardiac workup in someone who has suspected ischemic heart disease (i.e. has peripheral arterial disease and other risk factors) in high-risk surgery
-EKG
-Persantine Thallium stress test or dobutamine stress echo (in someone who can't walk on a treadmill for the persantine thallium)
-If reversible ischemia is found, do preoperative revascularization
2. Elective surgery in a patient with liver failure
-Child's A is ok, Child's C is a no-go, Child's B could go either way
-Optimize medically before surgery: k sparing diuretics for ascites, monitor electrolyte status, treat coagulopathy with vitamin K, optimize nutritional status, make them stop drinking.
-Be wary of hemorrhoid surgery in these patients, as portal hypertension can lead to uncontrollable bleeding
2. Elective surgery in a patient with kidney failure:
-If they have a transplant and are in the midst of rejection, surgery will accelerate the process. If the organ is salvageable, salvage it first; if not, go on dialysis and wait until everything (electrolytes, creatinine, hydration/fluids, etc) are stable before proceeding.
-Bleeding intraop: may be due to uremia-induced platelet dysfunction. Desmopressin may help, as will FFP. Platelet transfusion will not help.
-Hypotension intraop without sign of beeding: May be due to adrenal dysfunction from a long history of steroid use. Give stress dose steroids: 25mg intraop, 100 mg in the next 24 hrs.
3. Surgery in someone with mitral valve stenosis:
-If compensated, 5% perioperative mortality. Avoid anything to increase pulmonary hypertension (hypoxia, hypercapnia, acidosis), avoid tachycardia as it decreases diastolic filling, and you'll want endocarditis prophylaxis (ie. abx). Intraop, a-line to monitor pressures, TEE to monitor LV filling. Keep their fluids up enough to get cardiac output, not so high for pulmonary edema.
-Workup: look for a-fib, R heart failure with echo. If they have a-fib, b-blockers for rate control and warfarin for anticoagulation.
4. Surgery in someone with bad heart disease such as MVS + CHF (risk of death is 20%). Critical AS, cardiomyopathy, etc. Do a more extensive cardiology workup, do extensive intraop monitoring.
5. Types of gastric ulcers: 

6. Management of type 1 ulcers: due to mucosal erosion, not to overproduction of acid. During EGD, biopsy to rule out cancer. If its benign, try medical management first: stop all NSAIDs, take PPIs, test for H.Pylori (if positive, treat with PPIs and flagyl+clarithromycin or amox). If medical treatment succeeds, follow up clinical symptoms. If medical treatment fails after 12-18 weeks, consider surgery: distal gastrectomy with some re-anastomosis: billroth I/II or roux en y. NO vagotomy, because theres is no acid overproduction

7. Management of type IV ulcers: also not due to acid overproduction, but erosion. Same medical management, with biopsies. If surgery is needed, you'll need to do close to a total gastrectomy: can connect remaining stomach to jejunum, or just do roux-en-y with esophagus-jejunum anastomosis. 

8. Management of type II ulcers; Usually due to acid overproduction. In addition to the abovementioned medical treatment modalities, consider testing blood gastrin levels to r/o zollinger ellison. Surgery would be highly selective vagotomy plus antrectomy. 

9. Management of type III ulcers; same as type II, also due to acid overproduction. Surgery would be vagotomy & pyloroplasty.

10. Gastric cancer:

-You need a 6cm margin, so if its at the G-E junction you may need to resect the entire esophagus (intrathoracic anastamoses spare more esophagus, but are a disaster if they leak, whereas neck anastomotic leaks are more easily managed) with an interposition graft.

-Comes in 2 types: intestinal and diffuse; Intestinal is glandular and presents like an ulcer, diffuse is signet ring cells that at their worst cause linitis plastica, which is a poor prognostic indicator, and cure is rare even with a total gastrectomy/japanese D2 nodal dissection (incl spleen) 

1. Surgical management of perforated ulcer: primary closure with graham patch
-If there is a history of ulcers through medical treatment (PPIs etc), or a medical need for daily NSAID use, consider doing a highly selective vagotomy procedure at the same time.
-If the patient starts to look septic, or the ulcer looks like its been perforated for a while (>12 hours), then just do the primary repair and get out ASAP.
2. ICU patient that starts to get coffee ground emesis or coffee ground drainage from NG: think ulcer. Treat empirically. If the blood turns bright red, resuscitate with IVF, type & cross, then endoscopy.
3. Endoscopic findings:
-duodenal ulcer with white base: hasn't bled recently, unlikely to bleed. Treat with PPIs/H2 blockers to keep pH>5
-duodenal ulcer with adherent clot: has bled, 10-15% chance of rebleed soon. Mange with endoscopic methods-- injecting epi or sclerosing agents, argon or laser coagulation, suturing.
-duodenal ulcer on top of giant artery: local control endoscopically, go to the OR for definitive repair (i.e. oversewing vessel) within next 24-48 hours.
-duodenal ulcer in ESRD: coagulopathy 2/2 uremia treat with DDAVP or FFP, ESLD: coagulopathy 2/2 platelet sequestration (transfuse, or DDAVP), defect in coagulation factors (FFP/cryo), portal hypertension.
-Gastric ulcer: biopsy to r/o cancer once the bleeding is under control (i.e. within 2 weeks)
4. Gastritis: erosions without ulcers, common in ICU, burns, sepsis, increased ICP, vent patients, trauma, renal failure, etc. Keep pH>5. If that doesn't work, and it still bleeds, you will need to cut out whatever stomach is bleeding-- endoscopic or partial surgery doesn't work.
5. Acute management of bleeding from esophageal varix:
-First: IVF/blood resuscitation, FFP/cryo, platelets (if they are thrombocytopenic), B-blocker, IV octreotide (or vasopressin but that causes coronary vasoconstriction and is CI in people that are old or have a cardiac history), GI banding/ligation
-If that doesn't work: re-scope, band/ligate/sclerose again.
-If that doesn't work: tamponade balloon such as Minnesota (can cause esoph/stomach necrosis, can increase aspiration risk so only can do in people who are intubated, only works while inflated), TIPS, go to OR for portosystemic shunt (50% mortality in emergent cases of people who have bad ESLD)
6. Prevention of future bleeding after successful control of acute variceal bleed:
-In people who have good synthetic liver function and good overall health, TIPS or portosystemic shunt can offset the need for transplant for 5-10 years
-In people who don't have good synthetic liver function, a shunt procedure can be devastating, list them for transplant.
7. Gastric lymphoma:
-Staging: CT C/A/P with IV and PO contrast to look for other tumor, biopsy enlarged nodes, check waldeyer's ring.
-If it's MALToma, eradicate H.Pylori usually cures it.
-If it's stage I or II, surgery, III or IV, chemoradiation.
8. GB: 
-Asymptomatic gallstones: <10% of patients will develop symptoms requiring surgery over 5 years, no surgery unless they are high risk (immunocompromised and can't tolerate sepsis, people with porcelain GB or stones > 3cm since they are assoc with GB cancer development)
-RUQ pain, no fever, doesn't look toxic, mild leukocytosis (<15), mild jaundice: likely biliary colic, schedule surgery. NO antibiotics.
-RUQ pain, fever, thickened GB wall and stones: acute cholecystitis. Usually GNR and anaerobes (e.coli, enterobacter, kelb, enterococcus), treat with 2nd gen cephalosporins with anaerobic coverage (cefotetan, cefoxime). IVF, NPO, NG tube if they are vomiting or nauseous. Lap chole within 2-3 days.
-RUQ pain, fever, stones + elevated LFTs and very elevated bili: probably CBD stone. See other post for determining risk of CBD stone (in brief: Tbili>4 or seeing a stone in CBD on u/s: ERCP for stone removal; if the CBD > 6mm and Tbili 2-3, MRCP then ERCP if its positive). If there's a stone, ERCP then lap chole, or lap chole with intraop cholangiogram.
-GB cancer: open chole + wide resection of liver, with 2-3 cm margins around GB.
-Polyp: excise if >2cm in size because of 7-10% risk of developing adenocarcinoma.
-Porcelain GB: 50% risk of developing adenocarcinoma.
9. Hepatic masses:
-cyst with no internal echoes: simple cyst, leave it alone or if there are symptoms, drain and inject w sclerosing agent
-cyst with internal echoes: likely echinococcal cyst, inject w sclerosing agent
-cyst + signs of systemic infection: bacterial/amebic abscess. Serologies to r/o amebic abscess. Drain bact abscess + abx, flagyl for amebic abscess.
-hepatic adenoma: assoc with OCP use, resect if it's big because there's a greater chance of rupture (esp during pregnancy)
-solid mass: r/o hemangioma (w tagged RBC scan), then biopsy. Check afp, cea.
10. Resectable HCC:
-1 cm  margins attainable
-not invading vessels
-<5cm in size
-solitary
-noncirrhotic liver
-NO METS (look at hepatic hilar nodes, celiac nodes, diaphragm, local structures). CT C/A/P to look for mets.

1. The two most effective chemotherapy regimens for advanced pancreatic cancer are gemcitabine-abraxane and FOLFIRINOX (folate, 5-FU, irinotecan, oxaliplatin). Gem-abraxane is less toxic, but less effective; if the person is relatively young and healthy, go for folfirinox; gem-abraxane if they can't take it.
2. Most common presenting symptom of cholecysto-duodenal fistula: gallstone ileus (the enlarged stone pressing upon the small bowel is thought to lead to erosion and fistula formation). Most common presenting symptom of cholecysto-colonic fistula: bile in the stool (bypasses absorption in terminal small bowel)
3. Subcostal vs vertical incision: subcostals offer better lateral access (distal panc, splenectomy, liver) but cutting the rectus muscles leads to more pain, and later on there can be problems with muscle pooching during engagement of the abdominal muscles. Studies focusing on the effect of subcostal incisions (theorized effects on wound healing, incidence of respiratory complications post-op) have not found conclusive evidence.
4. Fecal elastase < 200 indicates pancreatic insufficiency, <50 will lead to steatorrhea.
5. Neuroendocrine tumors: definitive classification requires positive staining with chromogranin and synaptophysin. These tumors are clinically sub-categorized-- i.e. gastrinoma is defined by elevated levels of blood gastrin, not histological staining for gastrin. These tumors are often hypervascular on CT, rendering them easily confused for vessels. They are often slow growing.
6. PNET tumors: Ki67 expression is associated with worse outcomes: >20% is associated with significantly increased mortality (i.e. poor 5-year survival) relative to <5% (excellent 5-year survival). The liver is a common site of metastasis/recurrence after resection; visible lesions can be resected, however dissemination is often widespread. These tumors grow slowly, but invariably. Tumors <2cm with no radiographic evidence of spread and no symptoms can be watched at 6-mo screening intervals. Larger ones should be resected-- enucleation to manage symptoms in benign masses, oncologic resection with margins for more malignant tumors. For patients with small tumors who request surgery out of nervousness; consider the fact that the point of surgery is to either manage symptoms or prevent recurrence. If they do not have symptoms (i.e. non secreting tumor), they will gain no benefit if you do not attempt a full oncologic resection with an attempt to get negative margins (i.e. whipple); a compromise in the form of an enucleation still subjects them to surgical risk with no proven benefit.
7. You can treat unresectable liver metastases with isolated hepatic perfusion: cannulate GDA to IVC above liver, clamp common hepatic artery to prevent back-flow, run high-dose chemotherapy through circuit. Percutaneous veno-veno bypass IVC below liver to subclavian to maintain preload, clamp portal vein. This has morbidity, including possibility of liver failure-- screen patients well before for pre-existing liver pathology. Liver transplant is a possible treatment for pancreatic neuroendocrine tumors with liver mets.
8. Clavicle fractures: do angiogram and neuro exam on extremity to r/o neurovascular damage (brachial plexus, subclavian). Middle clavicle fractures- closed reduction, figure of 8 brace. Distal clavicle may need ORIF.
9. Ankle-brachial index (compare dorsalis pedis or posterior tibial to brachial aa, leg/arm systolic pressure): normal is 1-1.3, <0.9 is sensitive and specific for >50% occlusion of artery, <0.4 is c/w limb ischemia. Measure with a sphingomanometer and doppler distal: instead of listening, you use the doppler. Inflate cuff, when you see the signal first return that is the systolic pressure.
10. Post-cholecystectomy jaundice ddx: 
-Retained stone in CBD
-Stricture
-Bile leak
-Cholestasis 2/2 other disease process (i.e. sepsis)
-Cut the CBD instead of cystic.

1. Generally, in a surgical abdomen, pain precedes nausea/vomiting, while the reverse is true of a medical abdomen.
2. In clinically obvious appendicitis (pain started in umbilicus, moved to RLQ, severe pain, anorexia, rebound, guarding, rigid abdomen, +psoas sign, +Rovsing's sign, elevated WBC, fever) no CT scan is necessary, just go to the OR. Sensitivity of H&P is >95%. Groups where there's a higher false-negative (ie. negative ex-lap) rate: women of childbearing age, elderly people. For them, CT is indicated.
3. In a patient with trauma to both abdomen and pelvis, with an inconclusive FAST exam, do a DPL before you go to the OR.
4. Risk factors for gastric cancer: 
-H.Pylori infection
-History of atrophic gastritis
-Diet: high-salt (damages mucosa), nitrosamines (smoked foods)
-Lifestyle: Obesity, Smoking (NOT alcohol)
-History of gastric cancer (billroth II > billroth I, 2/2 alkaline reflux)
-Genetic: type A blood, hereditary diffuse gastric cancer (e-cadherin truncation mutation, also predisposes to lobar breast cancer)
5. Workup/staging for gastric cancer: 
-CT C/A/P with IV and PO contrast-- to look for mets
-EGD to find the exact location, EUS for depth of invasion and nodes.
-Laparoscopy
The first of these will inform you about the role of preoperative chemotherapy, and whether you should operate at all.
6. PET scans have no role in the workup of gastric cancer-- only 2/3 of these cancers are PET sensitive, false negative and positive reactions are common. Cancers for which PET scans are shown to be beneficial in diagnosis: melanoma, RCC, lymphoma. Cancers for which PET is not shown to be beneficial: gastric, pancreatic.
7. Treatment regimens for gastric cancer: 
-Mcdonald's protocol, SW oncology group trial 0116: surgery followed by chemotherapy and radiation
-Cunningham trial: chemotherapy first, then surgery, then more chemotherapy
-If you do a total gastrectomy, reconstruct with roux-en-y: more physiologic than billroth II.
8. Surgical management of ulcerative colitis: 
-proctocolectomy with end-ileostomy: pros- one surgery; cons- permanent ostomy
-ileal pouch anal anastomosis: pros- no ostomy; cons- risk of pouchitis (up to 50% incidence), frequent BM ranging from 4-12 times a day, anastomotic leak, may take up to 3 surgeries (end ileostomy, pouch creation and anastomosis with diverting ileostomy, ileostomy takedown)
9. Risk of PSC with UC decreases with colonic resection-- thought to be due to less formation of memory neutrophils. Risk of re-developing PSC in a transplanted liver thought to be up to 50%
10. Diagnosis of UC does not require imaging, it is a clinical diagnosis. However there are imaging modalities that can be used:
-CXR to see toxic megacolon
-CT to see nonspecific wall thickening and fluid
-Barium enema: can see psuedopolyps, lead pipe sign, ulcers
-Colonscopy: full circumferential involvement (no skip lesions)

1. Contraindications to whipple:
-Mets: this is an absolute CI. Mets to liver, pancreas, omentum, extra-abdominal sites, celiac LN and other LN not removed by surgery. If you see these on laparoscopy, close and go home.
-Involvement of SMA, IVC, aorta, celiac aa, hepatic aa
-Encasement (>50%) of portal vein-SMV confluence
2. Infections/inflammation can cause ileus: pneumonia, UTIs, nephrolithiasis, appendicits, pancreatitis, sepsis, etc. Someone with a spinal cord injury with distention and obstipation is a UTI until proven otherwise.
3. The incidence of UTI is much higher among people with spinal cord injuries-- the neurogenic bladder leads to urine stasis and frequent caths, which introduces bacteria into the urine. In fact, most of these patients' urine is always colonized with bacteria, rendering the diagnosis of acute UTI difficult. Current diagnosis are >100 cfu/mL; >50 wbc/hpf indicates severe pyuria.
4. Microbiology of UTIs in spinal cord injury: usually polymicrobial, often the bugs form dense biofilms that are difficult to treat: proteus, klebsiella, pseudomonas, serratia, providentia, plus staph and enterococci. There's some data that intentionally colonizing the bladder with less virulent organisms (e.coli) decreases morbidity. Empiric treatment is with fluroquinolones, watch out for the side effects. In-hospital management options; amp/gent, imipen/cilastatin, b-lact/b-lactamase inh, 3g cephalosporin, aminoglycosides. Treat for 7-14 days (as short as 4-5 in those with more clinically benign presentation). If it doesn't get better in that time-frame, evaluate further for stones or aberrant anatomy, re-culture to look for resistant bugs.
5. Prophylaxis and management of asymptomatic bacteriuria in SCI: Because so many are colonized, the threshold to treat is high to avoid overtreatment: some advocate treating >10,000 cfu/mL plus >8-10 wbc/hpf. Prophylactic bactrim reduces incidence of UTI, but may increase resistance. Some advocate alternating methenamine (turns into formic acid which is bacteriostatic) TID with nitrofurantonin BID, alternating q2 mos.
6. Lesions above T6 can result in autonomic dysreflexia to noxious stimuli (such as an over-distended bladder), whereby spinal levels below the injury have uninhibited sympathetic output, resulting in severe vasoconstriction and reflex bradycardia; treat with alpha-blockers.
7. Septic thrombophlebitis: palpable cord on skin, with overlying erythema or pus: incise and pop it out. Ice, elevation, NSAIDs.
8. The small bowel does not tolerate radiation: radiation enteritis occurs in nearly 50% of those irradiated. Radiation causes damage to mucosa (erosion/ulceration, ischemia, fibrosis) which can lead to lifelong symptoms of pain, diarrhea, malabsorption, hematochezia, even obstuction/perforation. A significant portion (20%?) of those who get radiation to the rectum end up incontinent.
9. Hypokalemia worsens ileus
10. In someone who has been vomiting, they lose H+Cl through vomiting, there is also a contraction alkalosis (via aldosterone? lose K and H in urine). Treat with fluids-- NS, to replenish Na-Cl and volume.

1. AAA: more pain = increased likelihood of rupture = more emergent
2. Subclavian steal can happen with vertebral aa; someone who experiences arm claudication and neurological symptoms at the same time needs a doppler of their subclavian artery.
3. In evaluating peripheral arterial disease, look for a gradient on doppler; the presence of one indicates stenosis, and thus ability to be resolved with bypass graft. No gradient means the problem is in the smaller vessels, which will not be fixed with surgery. Do an angiogram to find the stenosis and a good distal vessel; smaller blocks can be stented, bigger ones need grafts. Do not do prophylactic grafts, wait until the symptoms interfere significantly with normal life (until then, lifestyle changes and cilastazol). When evaluating perfusion with the doppler, if they don't have symptoms at rest, you may need to induce exercise in order to get good findings.
4. Skin cancers: diagnose with full-thickness punch biopsy at margin including normal skin.
-Basal cell, ulcer or raised waxy lesion, favor face above mid-lip line, do not metastasize, 1mm margins.
-Squamous cell, ulcerated lesion, favor below mid-lip line, can metastasize, need up to 2 mm margins, LN dissection if margins+
-Melanoma: <1mm invasion good prognosis, 1-4 do aggressive resection and LN dissection, >4 bad prognosis. Mets to weird places, unpredictable course
5. Optho: 
-Strabismus in a kid that develops later in infancy may be due to refraction error; glasses will correct immediately.
-Glaucoma: frequently presents as pain and seeing halos around lights after a long session of dilated pupils (movies/TV at night). Physical exam, eye is hard, cornea is greenish, pupil is mid-dilated and non-reactive. Next step: refer to optho, in the meantime treat with diamox (carbonic anhydrase inhibitor) or mannitol, topical b-blockers, a2-agonists, or pilocarpine.
-Orbital cellulitis: key is pupil is dilated and non-reactive, no extraocular movements. Next step: emergency CT and drainage
-Retinal detachment signs: flashes of light + floaters (more floaters= worse outcome). Bad signs: see snowstorm in eye, curtain coming down.
-Emboli to opthalmic artery: sudden loss of vision. Breathe into paper bag and have someone press and release on their eye: the idea is to vasodilate and propel clot further downstream so a smaller part of the retina is lost to ischemia.
-Every new DM diagnosis needs to have a retinal evaluation, since it may have been undiagnosed for years.
6. Peds ortho diagnosis & management: 
-DDH: dx with ortolani and barlow, tx abduction splinting with pavlik harness for 6 mos
-Legg-Calve-Perthes: dx with AP and lateral xrays, treat with casting and crutches
-SCFE: sole of affected foot points towards other foot; when you flex the hip, the thigh will not internally rotate; AP x-rays. Tx: surgery to pin the femoral head into place.
-Septic hip: toddlers who hold their hip flexed, abducted, and externally rotated, resistant to motion. Aspirate joint fluid to r/o transient synovitis (also: Kocher criteria, fever>101.5, ESR>40, WBC>12, non-weight-bearing, >2 criteria = >40% chance of septic hip), open drainage if the aspirate is pus. Antibiotics to cover gram-pos.
-Osteomyelitis: bone scan, antibiotics
-Genu varum: no treatment until age 3, at which point it's blount disease (medial growth plate overgrowth), surgery to shave it down.
-Genu valgus normal between age 4-8.
-Osgood Schlatter: TTP at tibial tuberosity or with quad flexion. Treat by putting knee in extension cast for 4-6 weeks
-Club foot (plantarflexion, inversion, adduction of forefoot). Serial casts to correct first adduction, then  inversion, then plantarflexion. 50% are corrected this way, the other half require surgery after 6-8 mos but before 1-2 years.
-Supracondylar fractures (along with growth plate fractures, are worrisome in kids): 2/2 hyperextension of elbow from fall on extended arm. Volkmann contracture can occur-- from damage to brachial artery either directly or via compartment syndrome, leading to ischemia, and later fibrosis of muscles of the arm. All muscles are affected, but the flexors are more numerous and stronger than extensors, so there are more flexor than extensor features; both are engaged, so it is painful to attempt to straighten the fingers. Treat these fractures with normal casting, but watch out for the development of these contractures
-Growth plate fractures: closed reduction if the growth plate is in one piece and it's laterally displaced from metaphysis, ORIF if its any more complex.
-Osteosarcoma: ages 10-25, around knee, sunburst. Ewing's 5-15, diaphysis of long bones, onion skinning.
7. Adult ortho
-Bone pain, suspect mets: bone scan first, then x-ray, because bone scan is more sensitive but less specific and x-ray is vice-versa.
-Old man with anemia, bone pain, protinuria, hypercalcemia: think multiple myeloma. Tx with chemo, or thalidomide if chemo fails.
-Sarcomas metastasize to lungs, not LN.
-Closed reduction: fractures that are not badly displaced/angulated that can be easily reduced.
-Clavicle fracture: figure of 8 device for 4-6 weeks
-Shoulder dislocation: anterior (arm is adducted and externally rotated, may have some deltoid numbness from axillary nerve stretch), posterior (adducted and internally rotated)- rare, occurs after massive muscle contraction (seizure, electrical burn), may go undetected for a long time; need axillary or scapular lateral x-rays.
8. Ortho specific fractures: 
-Colles fracture: fall on extended wrist, radius displaced dorsally, "dinner fork" wrist. Tx: closed reduction, cast.
-Monteggia fracture: blocking a nightstick. Fracture of proximal ulna, anterior displacement of radial head (part closer to elbow)
-Galeazzi fracture: fracture of distal radius, displacement of distal ulnar posterior.
-Scaphoid fracture: fall on extended wrist, fracture of scaphoid, TTP over anatomical snuffbox. Tx with thumb spica cast even if x-rays are negative (i.e based on history/physical); these are notorious for non-union.
-Metacarpal neck fractures: usually 4th/5th, from punching with a closed fist; closed reduction and unlar splint if its mild, ORIF for bad.
-Hip fractures: femoral neck (esp displaced) need total hip replacement since it's likely to damage vascular/nerve structures; intertrochanteric needs an ORIF with pins, diaphyseal can treat with intramedullary rod fixation.
-Complex bone fractures: if they are open need OR fixing within 6 hours, comminuted can lose a lot of blood, watch out for shock; if they are multiple watch out for fat emboli
-Collateral ligament: knee swelling, TTP on affected side; knee flexed 30 degrees, passive ab/adduction wil make pain. Tx with hinged cast, surgery if there are multiple injuries
-ACL: anterior drawer. Surgery if its someone whos going to be active, can immobilize and do rehab if its a relatively immobile person.
-Meniscal tears: hard to dx on physical, show up great on MRI. Protracted pain and swelling, knee catches and "clicks" upon extension.
-Tibial stress fractures (shin splints): TTP over specific point, x-rays will be normal at first. Treat with cast/crutches, re-x-ray in 2 weeks.
-Achilles injury: popping sound. Cast in equinus position.
9. Ortho emergencies: 
-Pain under a cast is never OK to be watched-- always take off the cast and look at the limb. Forearm and lower leg most likely to develop compartment syndrome.
-Posterior hip dislocation: patient holds leg adducted, flexed, internally rotated. emergency reduction to avoid fem head ischemia.
-Gangrene: looks toxic, treat with high dose IV Penicillin, debridement, hyperbaric oxygen.
-Radial nerve injury: from upper humerus oblique fractures. Weakness of hand extension. If it doesn't get better with closed reduction, the nerve is caught, go to surgery.
-Posterior knee injury: watch out for pop artery damage (get pulses). If you missed it for a while, do prophylactic fasciotomy.
10. Ortho, arm and hand and feet: 
-Anterior arm dislocation, worry about axillary nerve damage.
-Humerus fracture, worry about radial nerve damage.
-De Quervain's tendonsynovitis: hand flexion and thumb extension, pain in tendons of anatomical snuffbox, worsened by flexing thumb and ulnar-devation of wrist
-Trigger finger: finger acutely flexed,  tendon caught on tendon sheath, treat with steroid injections
-Depuytren's contracture: finger contracture, palmar nodule, treat with surgery
-Gamekeeper thumb: ulnar collateral ligament of thumb injury, caused by hyperextension, treat with casting
-Morton's neuroma: mass or tender point between 3rd and 4th metatarsals. Inflamm of common digital nerve.