Round

Round
Aug 18, 6:19 PM
Amputation stump - downstream pulse, warmth, infection

Acute thrombosis->antiplatelet therapy
Risk factor: smoking, DM, homocystinemia
5-10 min rest cure claudication walk 100 m; location of claudication -
Lerisch syndrome; sleep pain sit relieve
Subside slowly - venous claudication
Neuropathic most common in diabetes; calluses cause ischemia
Gangrene dry: bypass->amputation; wet: amputate->bypass
Skin and subcutaneous atrophy; Buerger test,angle = vascular angle;
drop->reactive hyperemia
Clinical diagnosis
Medial calcification
Velocity wave form
PVR 60 mmHg; TBI<0.7
Exercise therapy in claudication 30-60 min 3/wk 3 mo: better tolerance
CT angiography for revascularization
Anticoagulant->prevent obstruction, repeated surgery

<1cm telangiectasia (spider vein)
1-3 reticular vein
>3 varicose vein
Fix with aethoxysklerol not >5cm
Dilatation, tortuous, deformity
Sclerotherapy
Tight venous pain, chronic venous insufficiency

Fluid resuscitation for surgery: isotonic; urine SpG <1.02
Antibiotic prophylaxis: clean contaminated wound needs one.; vs
antibiotic therapeutic
Anaerobe: Bacteroides MTX
Set OR, define the skin to operate
Bowel preparation: exacerbate peritonitis, perforation; not in appendicitis
Post-op fluid NSS/2 for how long? + 5% dextrose just to maintain catabolic state
Morphine/pethidine for analgesia, naloxone antidote/on respirator; MO
0.05-0.1 mg/kg

Endothelial injury, stasis, hypercoagulable state; SCD sequential
compressive device; lifestyle; lupus, antiphospholipid syndrome; CA
lung; smoking; protein C,S deficiency; always check pulse
Acute compartment syndrome: sensory loss 1st dorsal web space
Sure DVT -> D-dimer, not sure -> Doppler, duplex, ascending
venography, CTA; Doppler normally like respiration, variable:
respiratory variation, augmentation; heparin keep APTT/PT loading 80
MT 18 cc/kg stimulate ATIII switch warfarin, pressurize leg; warfarin
cause prothrombotic state so start heparin first. Primary DVT 3-6 mo +
FU, secondary treat cause first or lifelong; late complication
alba->cerulea need surgery drip heparin + consult surgery

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Round

Round
Aug 17, 5:04 PM
Case AAA: pre-op; need stress test/Thallium scan; echo not suffice
Chronic limb ischemia: pulse may be 1+; segmental pressure - ABI, AP;
triphasic-biphasic-monophasic-flat line; ABI unreliable cuff 60 look
for dicrotic notch; CNO cannot occlude; see TP instead; some measure
TCOM; inflow, outflow/distal runoff; 5 steps; 4. CT angiogram 5.
Bypass/EVAR; control risk factor + good wound dressing; ABCDDEF
anti-platelet, BP, cholesterol, diet, don't smoke, exercise, foot care

PVR - pulse-volume recorder

Clexane before Heparin for DVT because faster
Triple Vessel Disease coronary
NG tube gastric content 80 OK
Stroke indication for surgery >50+symptomatic

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Round

Round
Aug 16, 7:59 PM
Groove of pressure ulcer - bedridden

1. 6p
2. Position
3. Severity
4. Source cause
5. General status
6. Choice of management

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Round

Round
Aug 15, 7:25 PM
Vascular
14 Expansile mass abdomen 5 cm; umbilicus - bifurcation, xiphoid -
renal artery - upper border of mass; >1.5x aortic aneurysm, 5 cm
rupture to peritoneum, retro-peritoneum, distal duodenum, IVC;
anatomical/extra-anatomical bypass; endovascular aortic aneurysmal
repair (EVA) + occlude common iliac artery

Aortoenteric fistula
3sbe
Triad of aortoiliac occlusive disease
Ischemic rest pain - night pain
Non-healed ulcer >2wk + lab ABI, ankle pressure, toe pressure
ABI<0.9 disease <0.5 severe
Ankle pressure <50, <70 in DM indication Tx
Segmental pressure
Error: hard artery; ABI>1.3; monophasic; toe pressure <30, <50
TCOM transcutaneous oximetry >40, <20 - enough oxygen to heal?; lift
leg 5 min decrease>10

AVF - rule of six
Carotid stenosis - Amalurosis fugax, check retina, TIA/stroke -
differentiate symptomatic or not, degree of stenosis; surgery
complication nerve injury ESP. 12,10,9,mandi7, hyperperfusion syndrome
of brain - edema, stroke

Chemical debridement
Wet dressing
1. AgZnSulfa
2. Non-adhesive
3. Hydration
4. Absorptive
5. Coverage
6. Immobilize

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OR

OR
Aug 10, 10:16 AM
Monday
Hypospadias repair
Removal of right renal mass

Wednesday
Big thread for stitching fat
IORT, think of penetration 0.5 cm
Rt breast mass -> myeloid sarcoma

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Round
Aug 8, 7:45 AM
เตียง 1 สส CA bladder, mild degree HN, PCN+volume+Lasix เลือดดีขึ้น,
hematuria เยอะ; เปิด p flow หักสาย foley ดูว่ามี leakage, clot ไหม
(ไม่มี)
เตียง 5 known case of CA cervix post-tx, history of radiation
cystitis, ครั้งนี้ปัสสาวะเป็นเลือด มีลิ่มเลือด, ต้องเช็คทั้ง upper,
lower tract; formalin - stricture need diversion
Radiation cystitis: immediate -ATB, acute, delayed; radiation dose =
?; grade 1-5 usu 3, 5=moribund; hyperbaric oxygen - optional Tx, must
be no tumor

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Skill Lab

Skill Lab
Aug 5, 1:15 PM
NG tube
45,55 cm
Test - suction, push air
Fix - beware pressure necrosis
Complication - sinusitis

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OR

OR
Aug 5, 10:52 AM
Paget's disease of breast
Pre-op, pre-incision (markings), find sentinel LN, TM (choice of
knives, retractors)
Lipoma at neck; discontinuous simple stitch lower layer + subcuticular
stitch upper, no drainage
Surgery big/small

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Round

Round
Aug 5, 8:01 AM
25 kcal/kg
Gastrostomy, esophagostomy - drip, not bolus - risk of aspiration;
jejunostomy ok
Debride wet necrosis
Oral cavity cancer
Facial nerve recover in 6 mo; F/U Fri 19 Aug; need chloramphenicol,
artificial tear left eye

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Round

Round
Aug 4, 6:46 PM
Chest wall, skin dimple T4c; inflammatory breast area>1/3; T3N1
locally advanced operable/inoperable; inflammatory breast also locally
advanced should not SLNB, op; LFT, ALP abnormal
Mammogram: person position exposure density (granular tissue 4 levels)
7 topics: symmetry, skin thickening (>5 mm), nodule, LN, abnormal
micro-calcification; fat hilum
U/S cyst,mass benign,malignant lobulation taller-than-wide,
complicated cyst, complex cyst
Breast Imaging Reporting And Data System 0123456
Contraindication to ?? 1st or 2nd trimester pregnancy

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OR

OR
Aug 4, 9:55 AM
Lobectomy; Joll retractor; 2 strap muscles

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Round

Round
Aug 3, 7:52 AM
- risk factors of breast cancer: late child, ever breast biopsied?
Breast mass PE head to toe
Fibrogranular
FNA 23-25 not very invasive
CNB 12
SNLB

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Round

Round
Aug 2, 7:53 AM
Needle localized incision
Hematoma = heavy bleeding + pain
Clean wound 1-4% infection ESP. Breast, hernia
Latissimus dorsi flap/ blood supply
Morphine bleeding orthostatus
Nipple discharge: milky, non-milky (clear, bloody) is it spontaneous?
ออกกี่จุด - 3S's; associated lesion = mass; imaging under nipple
Screening mammogram not for < 35 y/o
Intraductal papilloma - ??? into duct; usually not premalignant - Bx
for DDx malignant or benign; maybe foresign for papillary CA
Cystic bleeding
Do microdochectomy with excision
CNB less hematoma if malignant suspected
No discharge left, still mass - treat as mass
IPma-> w atypia --> IPmatosis -> DCIS
No need to stop bleeding

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Round

Round
Aug 1, 5:25 PM
Mammogram - density; macrocal 0.5 mm - should bx?
Ultrasound - cyst; U/S guided bx at calcification - malignant
Ectopic parathyroid at arm, AVF - easy CAPD, fluid thrill; post-op
hypocalcemia give Ca PO/IV 'Bone hungry syndrome'
Lipomatosis - pain at lying down
Post-op: win water wound walk
Vacuum drain