Large non-tender lymph nodes limited to the inguinal region suggest metastatic cancer (melanoma, anal, or genital cancer) (testicular cancer does not usually metastasize to the groin; it more commonly travels to the retroperitoneum)

one must consider syphilis, chancroid, and lymphogranuloma venereum.

metastatic cancer from a local source (melanoma, anal, or genital cancer).

abdominal wall defect, hernia sac which protrudes through the defect, and contents within the sac.

both ends of the bowel blocked and nowhere for fluid and gas to egress

indirect congenital. direct acquired.

patent processus vaginalis에서 bowel can pass through the patent processus vaginalis into the scrotum

Protrudes through the abdominal wall (Hesselbach’s triangle), medial to the inferior epigastric artery

Passes through the femoral canal, into empty space medial to femoral vein

Peritoneum

Patent processus vaginalis, peritoneum

peritoneum

둘레의 일부만 hernia sac에 갇힘. 이때 strangulation 일어나고 ischemia gangrene 모두 가능하지만 일부만 herniated 되어 있으므로 환자들은 bowel obstructionㅇ디 sign이나 symptom이 없다.

후복막장기가 sac의 뒷벽을 형성. hernia sac dividing 과정에서 장기가 다칠수있으므로 위험. indirect hernia sac은 항상 anterior하게 열려야 하는 이유.

Indirect inguinal hernias originate lateral to the inferior epigastric vessels, while direct inguinal hernias pass medial within Hesselbach’s triangle. Indirect inguinal hernias travel through the internal ring along with the spermatic cord.

strangulation 온걸 그냥 밀어넣으면 peritonitis 오고 sepsis 온다. OR에서 Bowel 안죽은거 확인하고 reduce 해야함

The small bowel distention stretches visceral peritoneum, resulting in autonomic stimulation with progressive nausea and emesis.

The intestine proximal to the site of obstruction becomes distended due to the accumulation of gastrointestinal secretions and gas. Stasis in the intestinal lumen results in bacterial overgrowth, which causes even more dilation due to bacterial fermentation. As the hydrostatic pressure within the intestinal lumen increases, fluid accumulates in the bowel wall, altering the Starling forces of capillary fluid exchange such that there is a net filtration of fluid, electrolytes, and protein into the bowel wall and lumen. This loss of fluid from the intravascular space is termed third spacing and contributes to volume depletion in both proximal and distal SBO.

volume depletion 있으므로 resuscitation 해주고 nasogasteic tube 줘서 air fluid level 제거하여 각종 증상 줄인다

Crepitus implies the presence of gas within the tissues, most likely due to the presence of gas-forming organisms.

cellulitis는 항생제만 주면 되지만 NSTI는 debridement 필요. low serumNa or very high WBC가 NSTI suggestive. LINEC score 중요.

healthy bleeding tissue가 보일 때까지 subcutaneous fat fascia msucle 다 뜯어내라. borderline도 다 뜯어내라. extensive muscle necrosis->amputatiob

Current recommendations are that a second-look operation should be scheduled 24 hours after the initial debridement to ensure that the infection has not reemerged. Patients may require multiple reoperations after the initial debridement.

surgical exploration. 이는 치료의 gold standard 이기도 하다.

Clostridium perfringens. 이때는 clindamycin을 broad spectrum IV anti에 추가로 준다.

hyperbaric oxygen. 이게 수술대신은 못한다.

클수록 benign. 작을수록 breast cancer

prominent necrosis in the center of the involved spaces

lumpectomy 통해 negative margin 나오게 절제. 안되면 재수술하거나 mastectomy

새로운 breast mass에 모두 시행. physical examination imaging tissue sampling

과잉, 과다

Hematoma, femoral aneurysm, or pseudoaneurysm

suggest a systemic process (infectious, malignant, or autoimmune) such as tuberculosis, lymphoma, leukemia, HIV, or sarcoidosis.

patent processus vaginalis에서 peritoneal fluid가 scrotum을 채움.

Indirect inguinal hernias traverse the deep ring and the superficial ring, while direct inguinal hernias only pass through the superficial ring.

This is typically done by placing the patient in slight Trendelenburg position, providing some sedation and analgesia, applying a cold compress, and then attempting gentle manual compression. The advantage of reduction is that it converts an emergent procedure into a semi-elective one and makes the operation easier as there will be less inflammation. If the hernia is not reducible, urgent surgical intervention is required.

Indications for surgery are persistence beyond age 4, hernia defect larger than 2 cm in diameter (unlikely to close spontaneously), strangulation, or progressive enlargement after 1–2 years of age.

severe abdominal pain and/or localized tenderness continuous abdominal pain fever leukcytosis tachcardia peritoneal sign acidosis absence of bowel sound

조영제 경로 있으면 conservative. (nonoerative). 없으면 early intervention. high osmotic한 특징이 early partial SBO에 도움된다는 말이 있음. (Bowel wall edema를 줄여서) 증거는 빈약하지만 adhesion에 의한 SBO에 a gastrografin이 좋을수 있다더라

increasing abdominal pain and tenderness on exam

presence of mydriasis, rhinorrhea, and diaphoresisin those presenting with opioid withdrawal.

Factors that depress immunity and/or decrease tissue perfusion increase the risk for NSTI including diabetes mellitus, malnutrition, intravenous (IV) drug abuse, obesity, chronic alcohol abuse, chronic lymphocytic leukemia, chronic steroid use, renal failure, peripheral arterial disease, and cirrhosis.

The presence of bullae implies partial tissue death within the layers of the skin that allows for the collection of fluid between tissue layers.

violaceous skin implies ischemia

NSTI can involve the skin and subcutaneous tissue (necrotizing cellulitis), the fascia (necrotizing fasciitis), and/or the muscle (necrotizing myositis). Another term used for necrotizing myositis is gas gangrene.

suspicious calcification. Without a clearly defined shape or form; small and hazy appearance

malignant epithelial cells within the mammary ductal system without invasion into the surrounding stroma

Lobular carcinoma in situ (LCIS) is characterized by malignant epithelial cells that arise from the lobules and terminal ducts of the breast.

LCIS, atypical ductal/lobular hyperplasia, flat epithelial atypia, radial scar ->excisional biopsy needed

Pleomorphic subtype of LCIS is considered an aggressive subtype. As such pleomorphic LCIS needs an excisional biopsy with negative margins but does not require additional treatment (such as radiation) unless an invasive component is found.

잘안한다. 다만 multifocal comedo type high grade 에서 Lymph node침범가능. 따라서 SNLNB 하는 경우는 However, for certain high-risk lesions such as extensive microcalcifications on mammogram >5 cm, or DCIS associated with a palpable mass, SLNB should be performed. It is also recommended if the patient chooses a mastectomy for treatment.

Peau d’orange is a French term meaning “skin like an orange peel.” It is caused by tumor cells invading local lymphatics, leading to lymphedema of the skin, expanding the interfollicular dermis and producing characteristic dimples which resemble the texture and appearance of orange peels. When deeper subcutaneous layers are involved, it can also cause pitting. This finding is most commonly seen in inflammatory carcinoma. A full-thickness, punch biopsy of the dermis is essential for definitive diagnosis and will demonstrate cancer cells. This is vital, as inflammatory breast cancer is managed differently

liver chemistry, alkaline phosphatase, plane x ray 다른 검사는 symptom 있거나 검사 결과 이상할 때 단 stage III 이상이면 CT 다찍어보고 bone scan도 한다.

ER PR HER-2

High-risk features of DCIS include comedo-type, highgrade, >5 cm, palpable, and multifocal lesions.

Relative contraindications are a history of collagen vascular disease and large tumors in a small breast in which adequate margins would result in a cosmetically undesired appearance.

There are four boundaries: axillary vein (superior), floor of the axilla (posterior), latissimus dorsi muscle (lateral), and pectoral minor muscle (medial).

Axillary lymph node levels are based on their location relative to the pectoralis minor muscle. Level I nodes are lateral to the muscle border, Level II nodes are located behind, and Level III nodes are medial. Rotter nodes are interpectoral (between pectoralis major and minor) and are technically Level II nodes.

blistering sunburns and overall sun exposure

Melanoma originates from melanocytes, which are derived from neural crest cells. It can arise from a preexisting nevus or de novo as a new pigmented lesion (although a small percentage can be amelanotic).

Further screening workup should include a chest X-ray, complete blood count, liver function tests, and serum lactate dehydrogenase (LDH) to rule out metastatic disease.

Thicker lesions, ulceration, location on trunk, and male gender

Lymph node dissection is reserved for patients with clinically palpable lymphadenopathy or those with a positive SLNB.

angina syncope CHF

Lymphadenopathy (reactive), mononucleosis (EBV), abscess, sarcoidosis, lymphogranuloma venereum

Lymphoma, lipoma, lymphadenopathy, metastatic cancer (anal, skin, genital)

In general, LBO causes gradually increasing abdominal pain, progressive distention, constipation, and occasionally feculent vomiting. There are longer intervals between episodes of cramping pain, and there is more pain in the suprapubic area with LBO than with SBO. 

crepitus skin necrosis bullae or gas on X-ray

Clostridium septicum infection can lead to gas gangrene and is associated with occult malignancies, most often colon cancer and hematologic malignancies.

High probability of malignancy Represent casts of the ducts (“casting” type) in which they lie; often associated with comedo subtype of intraductal carcinoma, typically high grade or poorly differentiated

Suspicious calcifications Irregular, conspicuous calcifications typically lager than 0.5 mm; associated with benign (e.g., fibroadenoma, fibrosis) and malignant conditions (e.g., DCIS)

High probability of malignancy. Classified as BI-RADS 5; typically associated with DCIS

Absolute contraindications are multiple primary tumors in two or more quadrants, diffuse malignant-appearing microcalcifications throughout the breast, previous history of chest wall radiation, positive surgical margins despite repeat excision, and early pregnancy

an autosomal dominant disorder characterized by multiple dysplastic nevi with increased risk for progression toward melanoma (10% risk). These patients have a family history of melanoma, 100 or more moles, and at least 2 large dysplastic nevi.