Date post: | 06-Jul-2018 |
Category: |
Documents |
Upload: | kenyandoctor28 |
View: | 1,079 times |
Download: | 615 times |
of 285
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
1/285
!!"#$ &'("$)(* +
,( -&.) /012
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
2/285
#
!"#$%#$ '()%
$%& '()*+ ,-.+ $/01+2
! '2-/0- 34/*)(567+8(-*()9: ;772%-8< =
;>?-@8+> '2-/0- A(B+ 6/77%2) ;*.%2() F@)2-?-E8/*-2 I%-./*-)(%@ 3HFI: – ;8/)+
;1>%0(@-* '2-/0-
I-2>(%) 1-E+ L +*+8)2%*9)+E C @/)2()(%@ – 2+5B++>(@. E9@>2%0+N +@)+2-* -@>
7-2+@)+2-* @/)2()(%@
,+2(%7+2-)(?+ I-2+ – an anaesthetist’s perspective
,%E)5K7+2-)(?+ I%07*(8-)(%@E
6/2?(?(@. 6+7E(E
# ;8/)+ ;1>%0(@-* ,-(@ =O (**+,-./ $, (.012 (34,526
I*-EE(8-* 6(.@E F@ ,-)(+@)E P()< ;1>%0(@-* ,-(@
A(B+5'%0(@-* 68-2E
I*(@(8-* QBB+8)E %B '/0%/2
U K+E%7(@.
,+7)(8 Z*8+2 H(E+-E+
X-E)2(8 I-@8+2
[ I%*%2+8)-* H(E+-E+E \U
(**+,-./ $, I%@>()(%@E
H(?+2)(8/*-2 H(E+-E+
Meckel’s Diverticulum
F@B*-00-)%29 D%T+* H(E+-E+ C Crohn’s Disease C Z*8+2-)(?+ I%*()(E
W ;@-* L ,+2(-@-* H(E%2>+2E !!O
R-+0%22E
;@-* ](E)/*-
;@-* ](EE/2+E
;@%2+8)-* ;1E8+EE
\ 6/2.(8-* H(E+-E+E KB '+2
I
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
3/285
=
!# R+-> ;@> $+8J ![W
$+8J 4-EE+E
I-/E+E KB 4(>*(@+ 4-EE
I-/E+E KB ;@)+2(%2 '2(-@.*+ 4-EE
I-/E+E KB ,%E)+2(%2 '2(-@.*+ 4-EE
I+2?(8-* A907+@%7-) 6T+**(@.E !WU
6-*(?-29 X*-@> '/0%/2
I%07*(8-)(%@E %B ,-2%)(>+8)%09
6(-*%*() !W_
(**+,-./ $, $/8+,;4 '+,3=259
R(E)%29 '-J(@. ^ ,(>90-* I9E)
'+E)(8/*-2 '%2E(%@ 36/2.(8-* Q0+2.+@89:
M-2(8%8+*+
682%)-* ;1E8+EE
]%/2@(+2 [email protected]+@+
#! ;77+@>(S #U\
A/07E L D/07E
6/2.(8-* F@E)2/0+@)E L ,2%8+>/2+E
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
4/285
U
$G(>I( JI>@$?KH'%!?(@?$LM (''G"(!D
(7N(#!%7 $G(>I( @?O% H>''"G$ (@)"G?$DI
$G(>I( 7%($DH J$G?I"7(@ 7?H$G?$?"#MP
- F00+>(-)+ >+-)< %88/22(@. -) )(0+ %B (@G/29 – (&+& >/+ )% >+?-E)-)(@. T%/@>E^*-8+2-)(%@E
- Q-2*9 >+-)< %88/22(@. T()-9E ^ T++JE -B)+2 (@()(-* (@G/29 – (&+& #O 8%07*(8-)(%@E – E+7E(EN ;YH6N 6FY6N 4K]
I(?# 'G?#!?'@%HP
- '2+-) .2+-)+E) )(-.@%E(E (E *+EE (07%2)-@)
- '(0+ (E (07%2)-@) – the “golden hour” after trauma is when 30% of trauma deaths occur, and
-2+ 72+?+@)-1*+ 19 ;'A6
(''G"(!D J?#?$?(@ (HH%HHI%#$M
!&
,2+7-2-)(%@ -@> '2(-.+
#&
,2(0-29 E/2?+9 3;DIHQ: -@> Y+E/E8()-)(%@ %B M()-* ]/@8)(%@E
=&
Y+5+?-*/-)(%@ %B ) )-J(@. - R(E)%29 %B )-29 E/2?+9 35)%5)%+ +?-*/-)(%@:
V& ,%E)52+E/E8()-)(%@ 0%@()%2(@. -@> 2+5+?-*/-)(%@
[&
K7)(0(E+ B%2 )2-@EB+2 -@> >+B(@()(?+ 8-2+
'G?I(GL H>GN%L J(H!?$($?"#
QR (?GS(L (HH%HHI%#$ S?$D !%GN?!(@ H'?#% !"#$G"@
- ;E8+2)-(@ 7-)(+EN 3#: ]-8(-*^4-@>(1/*-2 aN 3 =: A-29@.+-*^'2-8 7%)+@)(-* B%2 %1E8/2(@. ) 7-2-*9)(8 -.+@)
->0(@(E)+2+> (00+>(-)+*9 -B)+2 )-)(?+ 3E/88(@9*8 ) ->+c/-89 %B ?+@)(*-)(%@ (E
-EE+EE+>
1&
$++>*+ I2(8%)+8)%09 T()< G+) (@E/BB*-)(%@ %B )*(@+ 8+2?(8-*: )+@>+2@+EE8&
,-)(+@) (E (*+2) -@> %2(+@)-)+> )% )(0+ ̂ 7*-8+ ̂ 7+2E%@
>& $% +?(>+@8+ %B ?@)%S(8-)(%@
+&
$% 7-(@B/* 7(E)2-8)(@. (@G/2(+E 3(&+& *%@. 1%@+ B2-8)/2+:
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
5/285
V
#&
#)HM
- ;EE+EE0+@) %B 12+-)+7)< %B 2+E7(2-)(%@
F@E7+8) -@> 7-*7-)+ ) 8
1(*-)+2-* 8 -@9 E(.@E %B (@G/29 3(&+& B*-(*
8E – 7+28/EE )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
6/285
[
U&
7?H(
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
7/285
W
- ;1>%0+@ 32^% (@)2-5-1>%0(@-* (@G/29 2-)E
;EE+EE ,+*?(E E)-1(*()9 37-*7-)+ (*(-8 T(@.E:
7;-:6,91;. %B-=0-1;,69P O(H$\ 7'@\ !$ 9.-6
- ,+2(@+-*N Y+8)-* L M-.(@-* QS-0(@-)(%@
'2+;6205` 8%@)/E(%@N +2@+EE
Z77+2 -@> A%T+2 A(01E – 2^% 72+E+@8+ %B E%B)5)(EE/+N ?-E8/*-2N %2)(8 %2
@+/2%*%.(8-* (@G/2(+E
! F@E7+8) – .2%EE >+B%20()9N -8)(?+ 1*++>(@.N %7+@ T%/@>EN +S7-@>(@.
Q-2*9 @+/2%E/2.(8-* 8%@E/*)-)(%@
)%#%G(@
- R-?+ - +S %B E/E7(8(%@ B%2 (@G/2(+E )% -?%(> 0(EE(@. )*9 2+8%.@(E+ T+)+2(%2-)(@. 38%@)(@/%/E 0%@()%2(@.:
- ;@9 2-7(> >+8%07+@E-)(@. 19 )E 0/E) 1+ -88%/@)+> B%2
- FM -@-*.+E(- -E -772%72(-)+ B%2 7-(@ 0-@-.+0+@)
G#H ?#C>GL I(#()%I%#$
Minor: ≤15% TBSA, Moderate: 15 525% TBSA, Severe: ≥25% TBSA
G0=2 ,V ]P 3->/*): – _dN 1-8J !\dN 80(@(E)+2 #5U0* ^ J. ^ dD6; 1/2@ (@ #U $%
69E)+0(8 72%8+EE(@. 72%>/8(@. 1%)< )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
8/285
\
(H%7 (HH%HHI%#$ S?$D H"#")G('DL ?# $G(>I( JO(H$M
- Y-7(>N 2+72%>/8(1*+N 7%2)-1*+ -@> @%@5(@?-E(?+ 1+>E(>+ )+E) )% >+)+8) B*/(> (@ )%0+@ %2
7+2(8-2>(/0 (≥ 100ml and more typically 500ml of peritoneal fluid, sensitivity: 605_Vd:
- ]-(*E )% (>+@)(B9 (@G/29 )% )% 2+*(-1*9 +S8*/>+ (@G/29 (@ 7+@+)2-)(@. )2-/0-
- Z*)2-E%@%.2-7%TE`
!&
6/1S(7` ,+2(8-2>(/0
#& YZo` Perihepatic Space (aka. Morrison’s Pouch or %T:
V& 3+];6': – ->> 1^* -@)+2(%2 )(-7+B+8)E %2
1%T+* (@G/29
I%072%0(E+> (@ /@8%%7+2-)(?+N -.()-)+> 7-)(+@)N %1+E()9N E/1E)-@)(-* 1%T+* .-EN
E/18/)-@+%/E -(2
A+EE E+@E()(?+N 0%2+ %7+2-)%25>+7+@>+@) ) 8-@@%) >(E)(@./(E< 1*%%> B2%0 -E8()+E
F@)+20+>(-)+ 2+E/*)E 2+c/(2+ B%**%T5/7 -))+07)E %2 -*)+2@-)(?+ >(-.@%E)(8 )+E)E
!$ H!(#
- K@*9 E/()-1*+ B%2 E)-1*+ 7-)(+@) -E c/()+ *%@. )(0+ (@?%*?+> (@ (0-.(@. T()< %@*9 7-)(+@) (@ ) >+8%07+@E-)(%@
- (4B-61-:29
;1*+ )% 72+8(E+*9 *%8-)+ (@)2-5-1>%0(@-* *+E(%@E 72+%7+2-)(?+*9
;1*+ )% +?-*/-)+ 2+)2%7+2()%@+-* (@G/2(+E
;1*+ )% (>+@)(B9 (@G/2(+E ) @%@5%7+2-)(?+*9
$%) (@?-E(?+
- 7;9-4B-61-:29
QS7+@E(?+N )(0+ 2+c/(2+> )% )2-@E7%2) 7-)(+@)N /E+ %B 8%@)2-E)
7?()#"H$?! '%G?$"#%(@ @(N()% J7'@M – G(G%@L 7"#%
- 6+@E()(?()9 %B _W5_\d T()< - !d 8%07*(8-)(%@ 2-)+
-
ZE+B/* (@ (@. (@)2-5-1>%0(@-* 1*++>(@.
- F@?%*?+E -@ (@8(E(%@ (@ )*(@+N 1+*%T /01(*(8/EN >(EE+8)(%@ >%T@ )% 7+2()%@+/0 -
8-) -@> - *()2+ %B $^6 (E 2/@ (@)% ) -**%T+> )% B(**
- ;** 7-)(+@)E /@>+2.%(@. H,A 2+c/(2+ 72(%2 +?-8/-)(%@ %B )2-(@-.+ %B 1*->>+2 19 (@>T+**(@. 8-)(8-)(%@ B%2 *-7-2%)%09 -*2+->9 +S(E)E
- F@?%*?+E 0-J(@. - 8/) (@ ) (@E+2)(@. - 8-) 37+@+)2-)(@. )2-/0-:
]2-@J 1*%%> 3i!O0*: %2 -@9 +@)+2(8 8%@)+@)E
YDI i!OONOOO 7+2 00= 37+@+)2-)(@.` i !ONOOO YDI:
PDI iVOO 7+2 00= 37+@+)2-)(@.̀ i VO PDI:
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
9/285
_
!(G7?"$D"G(!?! $G(>I(
'/2+E -2+ *(B+E-?(@.` 8-2>(-8 )-07%@->+N -(2T-9%1E)2/8)(%@N B*-(* 8 *(01 *+->E %2r!O00 (@ 72+8%2>(-* *+->E
(?GS(L"!$?"#
H/+ )% *-29@.+-*(@G/29 %2
7%E)+2(%2^B2-8)/2+>(E*%8-)(%@ %B 6Ib
7;-:6,91;. !=029 JV,+ =-+86:2-= 1+-05-M R%-2E+@+EE
6/18/)-@+%/E Q07%S(8-* 0%?+0+@) %B )+2*9(@. 7/*0%@-29 8%@)/E(%@N 8%@)2(1/)+> )%
19 7-(@ T()< 2+E)2(8)+> 8+@8+ %B 8+c/-)+ %S9.+@-)(%@ -@> ?+@)(*-)(%@m G/>(8(%/E B*/(> ) B*/(>%?+2*%->:m ->+c/-)+ (@)2-?+@%/E -@-*.+E(-
I%@E(>+2 0+8 i!VOO0*E %2%@5.%(@.
8%22+8)(%@ %B 8%-./*%7-)+@ 8+EE-)(%@ %B 82-(@-.+ -E ) /1+ 8-@ .+) 1*%8J+> 19 8*%) 0-EE(?+ (-* )% E8-7/*-
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
10/285
!O
'#%>I"$D"G(TJ$%#H?"#E "'%#M
$269;,6 *6205,1/,+-F p >+?+*%7E T (@ )+2 7%E()(?+72+EE/2+N >(E7*-8(@. 0+>(-E)(@-* E)2/8)/2+E -@> 8%072%0(E(@. 8-2>(%7/*0%@-29 B/@8)(%@ F) (E - 8*(@(8-* >(-.@%E(E 3IfY T(** %@*9 >+*-9 )2+-)0+@)N -@> 0-9 8-/E+ >+-) ?+@%/E 2+)/2@ 8-/E+> 19 8%072+EE(%@ %B ) >2-7+>& A; (E(@B(*)2-)+> (@)% ) >%T@ )% )+ (@ V )+2T-)+2E+-* 3)/2(@. +S7(2-)(%@N 1/) @% -(2 )% +@)+2 %@ (@E7(2-)(%@:& Q@E/2+ )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
11/285
!!
#%>G"H>G)?!(@ $G(>I(
(?IP 72+?+@)(%@ %B E+8%@>-29 12-(@ (@G/29 3B2%0 +-)<(E (22+?+2E(1*+&
'($D"@")?%H
!,6.099;,6
,9EB/@8)(%@ T()(%*%.(8-* -1@%20-*()9 379EB/@8)(%@ (E )E 8+** >+-))< %2 +E2-7(> >+)+2(%2-)(%@
#Od %B 7-)(+@)E T()< QHR -2+ -*+2) -@> T+**m 12-(@ (E0(@(0-**9 >-0-.+>N )2-(@-.+ .(?+E .%%> 2+E/*)E
6/1>/2-* ^%2 E+(e/2+E
FB E907)%0-)(8 p E)%7 -@)(8%-./*-@)E ^ -@)(7*-)+*+)EN 2+?+2E++BB+8) 19 ],,N ,' 8%07*+SN B-8)%2 M((N 7*-)+*+) )2-@EB/E(%@N
%1E+2?+ -@> 0%@()%2N %@8+ 2+E%*?+ p 1/2252-(@-.+ kE/1>/2-* >2-(@ 7*-8+0+@)
'2-/0-)(8 E/1-2-8+82+-E+E (@82+-E+> (@)2-8+**/*-2 E%>(/0 8+**/*-2 ET+**(@.
I%@?+@)(%@-**9 ) -1E%27)(%@ %B I6] (@82+-E+E (@ )2-@E+7+@>90-* I6] B*%T -8/)+
2%8+7 ->0(@(E)2-)(%@N -@> ()E 2+E7%@E+ )% %E0%)+1-)-1*+
M-E%.+@(8
D2+-J>%T@ %B 1*%%>512-(@ 1-22(+2 72%)+(@E +@)+2 (@)+2E)()(-* E7-8+ %+>+0- 6++@ (@ 'DFN @+%7*-E0EN -@> (@B*-00-)%29 8%@>()(%@E '+0- E/1)97+ (E 2+E7%@E(?+ )% 1%)< E)+2%(> ->0( @(E)2-)(%@ -@> %E0%)
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
12/285
!#
'($D"'DLH?"@")L
I,6+,2K^2==;24,.1+;62
': -2+ +@8*%E+> (@ - 2(.(> E7-8+ TE )% 2+0-(@ 8%@E)-@) (@82+-E+ (@ ) >+82+-E+ ) FI, T(** (072%?+ 8+2+12-* 7+2B/E(%@
O;F24 4;=-124 *0*;=
Q-2*9 .2->/-* >(*-)(%@N E*/..(E< 2+E7%@E+ )% *(. @%@52+-8)(?+ )% *(.(*-)-)(%@ -@> B(S-)(%@
I%@E)2(8)%2 B(12+E )% ) ?-E%8%@E)2(8)(%@ – (@82+-E+> )%)-* 7+2(7 31: (@82+-E+ 8-2>(-8 %/)7/) (@82+-E+> D,m 38: (@82+-E+E D,
D-2%2+8+7)%2E >+)+8) -1@%20-**9 2-(E+> D, -@> )29 )% >+82+-E+ () 19 )2(..+2(@. -7-2-E907-)(E)%2)(%@ %B ?-./E @+2?+ >/+ )%2-(E+> FI, ^%2 (@82+-E+> 72+EE/2+ %B 12-(@E)+0 38%@)2%*E (@?%*/@)-29 12+-)G)?!(@ %N(!>@($?"#- $+/2%*%.(8 E907)%0E #O 0-EE *+E(%@N 0(>*(@+ E FI, 2+B2-8)%29 )% 0+>(8-* 0-@-.+0+@)
I(#()%I%#$(992995261= (07%2)-@) 7-2-0+)+2E` ;DIEN XI6N 7/7(* E(e+
I;6,+ /2-4 ;6[0+83XI6 i!=:
4%E) 8%00%@ F@>(8-)(%@E B%2 ->0(EE(%@` ,+2E(E)+@) -8^%2 ?%0()(@.
I6] *+-J$+/2%*%.(8-* >+B(8()6J/** B2-8)/2+R(E)%29 %B *%EE %B 8%@E8(%/E@+EE;0@+E(-
F@ T-2>` $D4N FM >2(7 3@% >+S)2%E+ E-*(@+s:N @% E+>-)(%@N 0%@()%2 XI6 FB 7) >+)+2(%2-)+E I' E8-@
QS8*/>+ 0+)-1%*(8 8-/E+E 3+&.& + E+7E(E:
I,4R /2-4 ;6[0+83XI6 \ 5 !=:
;** T(** 1+ I'5E8-@@+> -) QH $Q6 T(** %7+2-)+ (B -@9 (@>(8-)(%@ )% >% E%
F@ T-2>` -E 7+2 0(*> (@G/29
H2B2+2 /2-4 ;6[0+8
4/E) E8-@ )% *%%J B%2 2+?+2E(1*+ 8-/E+E %B 2-(E+> F I, 1/) E)-1(*(E+ 7-)(+@) B(2E)
682++@ B%2 %)+0- I24;.-= – %E0%E(E >(/2+E(EN *%%7 >(/2+)(8E $K' E)+2%(>E H0+:;.-= – I6] >(?+2E(%@N >+8%072+EE(%@N 2+0%?-* %B 0 -EE +BB+8)
G-;92 /2-4 ,V 324 3(072%?+E ?+@%/E >2-(@-.+ 1/) 8%/*> D, )% ) 8%@E)2(8)(%@ %B 1*%%> ?+EE+*E *(0()E 1*%%>
B*%T )% ) )% @%20-* )%% c/(8J*9:
?N 5-66;1,=` 82+-)+ - (@. (@)% -1>%0(@-* 8-?()9
;DX )% >+)+8) -8(>%E(E j++7 0%@()%2(@. 7-)(+@) -@> 2+5(@?+E)(.-)+ T !+-6;2.1,58 3(&+& 1%@+ B*-7 @%) 2+7*-8+>: %2 .+-6;,1,58 31%@+ B*-7 2+7*-8+> -B)+2
1*%%> +?-8/-)+>: gD/22 2-(@ -@ -8/)+ 1*++>h Q?-8/-)+ 8*%) F@E+2) +@>%5?+@)2(8/*-2 >2-(@ 3QMH: (B )/2-:
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
13/285
!=
I>H!>@"H^%@%$(@ $G(>I(
)%#%G(@ '"?#$H QS)2+0()9 )2-/0- )+@>E @%) )% 1+ *(B+5) *%EE 8-@ %88/2 (@ *-2.+ ?%*/0+ – (&+& 7+*?(8 a 3/7 )% =A:N B+0%2-* E )% %?#C>G?%H
$8*29
K7+@` *-8+2-)(%@N -12-E(%@ I2/E I*%E+>
S,064 .-+2 6T-1E %B )E B%2 8/*)/2+ -@> E+@E()(?()9 FM -@)(1(%)(8 72%7+12(>+0+@)N (22(.-)(%@ 3T()(@. %@ X/E)(*%8*-EE(B(8-)(%@:
A+-?+ T%/@> K,Q$
I(#()%I%#$ "OOG(!$>G%H
Y+8%.@(E+ B2-8)/2+ -@>^%2 >(E*%8-)(%@ I%07*+)+ @+/2%?-E8/*-2 +S-0(@-)(%@ %B ) 1+B%2+ 2+>/8)(%@ ;772%72(-)+ f52-9E 3-) *+-E) # 7*-@+E: ;@-*.+E(- I%22+8)(%@ %B >+B%20()9 '+07%2-29 (00%1(*(E-)(%@ – 1-8JE*-1N 0-**+-1*+ E7*(@) $+/2%?-E8/*-2 +S-0(@-)(%@m +S-0(@+ B%2 8%07-2)0+@) E9@>2%0+ I(28/*-)(%@ 8
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
14/285
!U
HD"!^
- H+B(@()(%@` (@->+c/-)+ )(EE/+ -@> %2.-@ 7+2B/E(%@ )% 0++) 0+)-1%*(8 >+0-@>E *+->(@. )%+?+@)/-* .*%1-* 8+**/*-2 8%@)2-8)(*()9&
G%!")#?$?"# "O HD"!^- F@->+c/-)+ )(EE/+ 7+2B/E(%@
(&
6J(@ – 8%*>N 7-*+N >+82+-E+> 8-7(**-29 2+B(**((& Y+@-* – >+82+-E+> /2(@+ %/)7/) 3rO&V0*^J.^+82+-E+
72+*%-> 72+>%0(@-@)*9 (@82+-E+E )(-E)%*(8 D, 2+E/*)(@. (@ -@ %?+2-** >+82+-E+ (@ 7/*E+ 72+EE/2+YY $-22%T+> 7/*E+ 72+EE/2+ p *+EE ) 19 (@82+-E+> E9E)+0(8 ?-E8/*-2 2+E(E)-@8+
6)-.+ #` ↑HRN 7%E)/2-* 19 (@82+-E+> 6MY
6)-.+ =` 69E)%*(8 D, r!OO 00R.N ↑HRN ↑ RRN -*)+2+> 0+@)-* E)-)+ 38%@B/E(%@:
6)-.+ U` M+29 *%T D,N ↓ HRN T+-J 7/*E+ 72+EE/2+N >+72+EE+> 0+@)-* E)-)+N /2(@+ %/)7/) @+.*(.(1*+
%#7'"?#$ "O G%H>H!?$($?"#Hd - $%20-*(e-)(%@ %B D,N RYN Z2(@+ K/)7/) 0%E) 7-)(+@) 3VO585%) still in “compensated” shock- 6+2/0 0-2J+2E – =-.1-12 3r# 00%*^A:N 3-92 42V;.;1 31+)T++@ 5# -@> k#: L :-91+;. 50.,9- *D 3W&=O
– W&=V: -2+ 0%2+ -772%72(-)+ +@>57%(@)E -(0 B%2 @%20-*(e-)(%@ T() I*-009 6J(@
↑HR
↑peri vas Ω
↓JVP
]DI
Z^Q^I2
I-2>(-8 Q@e90+E
,'^,''
Xf4
;DX
Z,'
!-+4;,:26;.
F@)2(@E(8 8-2>(-8 B-(*/2+
D*/@) I-2>(-8 F@G/29
;4F
K)+82+-E+> 8-2>(-8 %/)7/)
↑JVP H5>(0+2
#20+,:26;.
3>(E)2(1/)(?+:
A%EE %B E907& )%@+q
67(@-* (@G/29
q *-8J %B E907-)+82+-E+> 6MY
7%%*(@. %B 1*%%> (@ +S)2+0()(+E (E)2(1/)(?+:
D()+E ^ 6)(@.E
;**+2.+@E – H2/.E ^ ]%%>
]+?+2N 2(.%2E
P-20 7+2(7+0-N12%@8
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
15/285
!V
I(#()%I%#$
- (;5P +@E/2+ ->+c/-)+ >+*(?+29 %B %S9.+@ )% )(-8 K/)7/)
(&
6-O# – 0-S(0(e+> (@ -8/)+ E+))(@.N 8A
(((&
IK – RY -@> 6M 3+E)(0-)+> (@>(2+8)*9 B2%0 QIX )2-8(@.:
)262+-= I-6-:25261
G2.,:6;e2
2-+=8 V2-10+29
,V 9/,.W
$-22%T+> ,/*E+ ,2+EE/2+N ,%E)/2-* R97%)+@E(%@
'-8(-
R97%)+@E(%@ 6D, r_O00R %2 4;, r60mmHg or ↓ in SBP >30mmHg from 1-E+*(@+
;EE+EE (%.+@(8 E+ – 6)-2) FM B*/(> 1%*/E T()< VOO0* $^6 -@>^%2 FM >%7-0(@+ (@B/E(%@
V /.^J.^0(@ -@> 72+7-2+ B%2 7+2(8-2>(%8+@)+E(E
F>+@)(B9
Z@>+2*9(@.
I-/E+E
R(E)%29 – 8/22+@) E907)%0E 3)2-/0-N (@B+8)(?+:N 7-E) 0+>(8-* (8-)(%@E:
QS-0(@-)(%@ – ?()-*EN /2(@+ %/)7/)N E9E)+0(8 2+?(+TN ,Y +S-0
F@?+E)(.-)(%@E 3-E (@>(8-)+>: – ]DIN Xf4N ,'^,''N Z^Q^I2N I-2>(-8 682++@ 3+@e90+E k
QIX:N ;DXN IfYN 6+7)(8 P%2J5/7 3D*%%> I/*)/2+N F@B*-00-)%29 4-2J+2E – (&+& IY,:
Y?6V,+5 H26;,+ %-+=8Y
D8*,B,=25;. H/,.W
F@?+E)(.-)(%@E
]DI 3 (@ -8/)+ -*8%(/2+)(8 +BB+8)
%B -*8% 8 12+-)T+**(@. /2(@-29 8-)%0+@ B%2 -@9 7/*E-)(*+ ;;;
IM, *(@+ (@E+2)(%@ )% ./(>+ B*/(> 2+E/E8()-)(%@
]*/(> YS
! A 829E)-**%(> B-E) (@B/E(%@ T()(-8
+@e90+E
4-@-.+ -88%2>(@.*9 – 2+B+2 -8/)+ 8%2%@-29 E9@>2%0+ L ;IA6 @%)+E
"391+0.1;B2 H/,.W
'+@E(%@
,@+/0%)(8(@+ D*-8J D%%J
Clinical Likelihood of PE (Well’s Score)
I*(@(8-* 6907)%0E %B HM' – >9E7@+- %B E/>>+@ %@E+)N
)-8+2 >S (0-.(@.
≤ U – jFM H5>(0+2
K)+
,/*0%@-29
Q01%*(E0
#20+,:26;. H/,.W
DFE'%
'2-/0- – E()+N 0+8%8/0+@) (@()(-* @+/2%*%.(8-* >+B(8()E
'2(-> %B 98-2>(- -@> 2+E/E8()-)+ T()< /2(@+ %/)7/)
?-E%72+EE%2E (B D, >%+E @%) 2+E7%@> )% B*/(> 8(8-)(%@E – @%@57+@+)2-)(@. E7(@-* 8%2> (@G/29 L T^(@ \ (8-)(%@E
! r!=vK
! ,2+.@-@89
! i \ +2^1%T+* 7-2-*9E(E @%)+>& '
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
16/285
![
H2*1;. H/,.W J92B2+2 92*9;9 h +2V+-.1,+8 /8*,1269;,6M
6FY6 p # %B )T+**(@. 8-)>+2 >eN 7+2()%@()(EN 7@+/0%@(-N
-77+@>(8()(EN (00/@%8%072%0(E+> E)-)+
F@?+E)(.-)(%@E
O(0+2
(BB+2+@) E()+E:
!-*;==-+8 3=,,4 :=0.,92
;DX
!TGP 7@+/0%@(-N ;YH6
QIX
Z2(@+ >(7E)(8J – Z'F
>+;62 !EH
]*/(> YS Y-7(> (@B/E(%@ !5#A 829E)-**%(>E
IM, *(@+ (@E+2)(%@
F@%)2%7(8
E/77%2)
(B @% 2+E7%@E+ )% B*/(> YS
$%2->2+@-*(@+ 3>2/. %B 8 .+@ 8+7
T^% %1?(%/E E%/28+
;@)(57E+/>%0%@-* ;1S 3?N .2V1-e;4;52 Q:: KY
i0;6,=,62
,AZ6 -0(@%.*98%E(>+ 3)261-5;.;6 jX5::
X2-057%E()(?+31/2@EN ]D ^ *(@+E 72+E+@):
?N .2V-e,=;6 d:
?N B-6.,58.;6 Q: (B T+**(@. 8-)%N 1(*(-29N B+0-*+ .+@()-*
)2-8)N -E7(2-)(%@ 7@+/0%@(-:
?N 521+,6;4-e,=2 fXX5: h .2V1+;-F,62 Q: h ?N
:261-5;.;6 jX5:
,2%.@%E(E
! %2.-@ – WOd E/2?(?-*
# %2.-@E – VOd E/2?(?-*
U %2.-@E – 0%2)-*()9 -772%-8+0-)%/E L 72/2()(8 7*-c/+E T 7-*+ 8+@)+2 L 2-(E+> +>.+E
;@.(%+>+0- – +>+0- %B >++7+2 *-9+2E %B )(2+8)
B%2 72(%2 E+@E()(e-)(%@
I%00%@ 8-/E+E
H2/.E – 7+@(8(**(@ L $6;FH6 8%00%@+E)N -E7(2(@N 'I4N E/*72/.E
]%%> – E+
X-E)2(8 *-?-.+ L -8)(?-)+> 82/. T-E ( @.+E)+>
;(2T-9
,2+7-2+ B%2 (@)/1-)(%@ %2 82(8%)%)%09 – Q$'^;@+E) YS 2L Hartman’s or N/S bolus
H2/. YS
(4+26-=;62 $%20%)+@E(?+ – XRXQ5=EW: J5-F XRf5=M QPQXXX 4;=01;,6 H!E?I
R97%)+@E(?+ – XRQ5=EW: J5-F f5=M QPQX\XXX 4;=01;,6 ?N %?+2 V 0(@E
)=0.-:,6
F@>(8-)(%@E` B-(*/2+ %B ->2+@-*(@+ YS KY (B ->2+@-*(@+ (E
8%@)2-(@>(8-)+> +&.& FRHN E+?+2+ R,'N 72+.@-@89N 51*%8J+2 /E+ XRfKQRX5: ?NE?I& I-@ 1+ 2+7+-)+> %@8+ -B)+2 =O0(@E
(61;/;91-5;629
H(7
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
17/285
!W
'%G?"'%G($?N% !(G%
?#'>$ E ">$'>$
#,+5-= 4-;=8 ;61-W2 #,+5-= 4-;=8 ,01*01
S-12+
7;21P dUXX 5=I21-3,=;95P dXX5=
Z2(@+ !UOO0* 30(@ %1*(.-)%29 ?%*/0+ p UOO0*:6J(@ *%EEq VOO0* 3%1*(.-)%29 >(BB/E(%@ L ?-7%2(E-)(%@:A/@. *%EE VOO0* 3%1*(.-)%29:]-+8-* *%EE !OO0*
q 6T+-)(@. (@ 792+S(- ^ -9
H,4;05
7;21P QfX 55,=E4-832-@.+ VO – =OO 00%*:
6)%%* V 00%*^>-96J(@ )2-@E7(2-)(%@ V 00%*^>-9 3(@ -1E+@8+ %B ET+-)(@.:Z2(@+ !UO 00%*^>-9 38-@ B-** )% !V 00%*^>-9:
',1-99;05
7;21P QXX 55,=E4-832-@.+ VO – #OO 00%*:
6)%%* !O 00%*^>-9 3%1*(.-)%29:6J(@ r V 00%*^>-9Z2(@+ \V 00%*^>-9 32-2+*9 B-**E 1+*%T [O 00%*^>-9:
7(?@L )(H$G"?#$%H$?#(@ (?G%I%#$H#OOO – #VOO J8-*^>-9
!(@"G?! !"#$%#$H
X*/8%E+` U J8-*^.
,2%)+(@ U J8-*^.
]-)E` _ J8-*^.
;*8%]2%0 *%EE %B (E%)%@(8 +S)2-8+**/*-2 B*/(> 3XF':` ! 7%(@) p VOO 0* *%EE %B B*/(>]2%0 *%EE %B 7/2+ T-)+2 3+?-7%2-)(%@ B2%0 */@.E:` @% 8 Q>()(%@:
'-+2612+-= H,=01;,69
I29E)-**%(>E
$%20-* 6-*(@+
- H+B(@+> -E E%*/)(%@E %B +*+8)2%*9)+E -@> T-)+2 )% )%)-* 1%>9 E%>(/0%?+2*%-> -@> 2+E/E8()-)(%@q((& ]%**%T(@. 8%22+8)(%@ %B >+B(8()N *+EE 8%@8+@)2-)+> E-*(@+ -2+ 0 %2+
-772%72(-)+ )% 2+7*-8+ %@5.%(@. B*/(> *%EE+E- O&UVd^O&==d^Od $^6 ]*/(>E -2+
(@B/E(%@ 8-@ 2+E/*) (@ G+S)2%E+ (E ->>+> )%(@82+-E+ )%@(8()9
- =d $^6 – (/0 >+B(8() (@7-)(+@)E T()< E907)%0-)(8 Y(@.+2(Hartmann’s
E%*/)(%@:
- ZE+> )% 2+7*-8+ B*/(> T()< ) *%EEN%+>+0- B*/(>N E0-** 1%T+* *%EE+E:
- F>+-* B%2 2+7*-8+0+@) %B +S(E)(@. B*/(> >+B(8() T+> /E+ -@> (@ 7-)(+@)E T()< (07-(2+>2+@-* B/@8)(%@
Vd H+S)2%E+3HVP:
- ]/@8)(%@ – 3!: ?%*/0+ +S7-@>+2 -@> 3#: 0+-@E %B 7-2+@)+2-* @/)2()(%@
- X*/8%E+ (E 2-7(>*9 0+)-1%*(e+> 19 *(?+2 -@> 2+0-(@(@. T-)+2 T(** >(E)2(1/)+()E+*B -82%EE -** 8%07%@+@)E T()< *())*+ B*/(> 2+0-(@(@. T() E7-8+ @%) B%2 B*/(> 2+E/E8()-)(%@ss
- QS8+EE Vd >+S)2%E+ T-)+2 2(EJ %B E
R+)-E)-28<H+S)2-@
- D+@+B() %B 72%0%)(@. 2+)+@)(%@ %B B*/(>E ( @ ) %B2+>/8(@. +S8+EE (@)+2E)()(-* B*/(> 3%+>+0-:
;*1/0(@3Vd^!Od^#Od:
- F@82+-E+ 7*-E0- %@8%)(8 72+EE/2+ 2+)-2>(@. 0%?+0+@) %B T-)+2 (@)%(@)+2E)()(-* E7-8+ 3%+>+0-: – DON’T USE IN ALL PATIENTS PX WITH EDEMA
(& Vd 8%0+E (@ #OO0* 8%@)-(@E !O. %B -*1/0(@
((& !Od 8%0+E (@ !OO0* 8%@)-(@E !O. %B -*1/0(@
(((& #Od 8%0+E (@ VO0* 8%@)-(@E !O. %B -*1/0(@
- I-/)(%@ (@ 7-)(+@)E T()(%@ 3(&+& ;YH6N 1/2@EN E+7E(E: (E E+8%@>-29)% 5;.+,KB-9.0=-+ -36,+5-=;1;29 +S%.+@%/E*9 ->0(@(E)+2+> 72%)+(@E (@8%**%(> E%*/)(%@ 8-@ +S)2-?-E-)+ (@)% ) (@)+@E(B9(@)+2E)()(-* %+>+0-
X+*-)(@- X+*%B/E(@ 3/2+-5*(@J+>:- R-+0-88+* 3E/88(@-)+5*(@J+>:- Y(EJE – -**+2.(8 2+-8)(%@EN 2+@-* (07-(20+@)
qO&_d $^6 3(E%)%@(8: – >%+E @%) 2+0-(@ T()(*/)+ QI] 2+*-)(?+ )% FI] -@> T-)+2 T%/*> 1+ +c/-**9 >(E)2(1/)+> )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
18/285
!\
O@>?7H E I(?#$%#(#!%' 0-@-.+0+@) (E )-@8+ %B E+c/-)+ +@>5%2.-@ 7+2B/E(%@ -E 7%%27+2B/E(%@ 0-9 *+-> )% (22+?+2E(1*+ +@>5%2.-@ >-0-.+
D%>9 8%07%E()(%@U
'%)-* 1%>9 T-)+2 p [Od 1%>9 T+(./*) 0-*+Eq!
F@)2-8+**/*-2 ]*/(> p #^= %B 'DP!
QS)2-8+**/*-2 ]*/(> p !^= %B 'DP 3%2 -1%/) #Od %B 1%>9 T+(.+B(8() p 'DP S 3>+E(2+> E+2/0 $- – -8)/-* E+2/0 $-:=&
Δ serum Na 7+2 A (@B/E-)+ p g3(@B/E-)+ $- – E+2/0 $-: ^ 3'DP k !:h
Y HK $K' 8%22+8) 0%2+ )-9 2(EJ %B %E0%)(8 >+09+*(@-)(@. E9@>2%0+ 3*%8J5(@ E9@>2%0+:
?5*,+1-61 %Z0-1;,6 J*-1;2619 A;1/ /8*2+6-1+25;-M!&
P-)+2 >+B(8() 3(@ A: p 'DP S g3-8)/-* E+2/0 $- ^ !UO: – !h
G-12 ,V O=0;4 (45;6;91+-1;,6- ]*/(> 1%*/E 3(B 7-)(+@) (@ 2+7*-8+0+@) n (@ B(2E) \ 19 n %?+2 )+S)2%E+
-@> O&== $-IA: =d $^6 X+*-)(@
$-k !VU0Qc^A !VU0Qc^A WW0Qc^A !=O0Qc^A V[0Qc^A V!=0Qc^A !VU0Qc^A
I*5 !VU0Qc^A !VU0Qc^A WW0Qc^A !O_0Qc^A W[0Qc^A V!=0Qc^A !#O0Qc^A
jk U0Qc^A #O0Qc^A
I-#k #&W0Qc^A
K)+S)2%E+
#V.^A
>+S)2%E+
A-8)-)+
#\0+c^A
VO.^A
>+S)2%E+
UO.^A
.+*-)(@
6)+2(*+ P-)+2 p >% @%) ->0(@(E)+2 T()+S)2%E+ FM -E 8-@ 8-/E+ (-1+)+E (@E(7(>/E 3 T()< $- k 3(&+&O&_d $^6: T(** *+-> )%2+)+@)(%@ %B $-k T()< 2+)+@)(%@ %B T-)+2 72+>(E7%E(@. ) %?+2*%->+> E)-)+& F@E)+->N B2++ T-)+2 8-@ 1+ 2+7*-8+>T()< /E(@. Vd H^P 3Vd >+S)2%E+ (@ T-)+2: %2 O&UVd $^6
A-8)-)+> Y(@.+2 7E – 3/E+ T()< 8-2+ (@ 7-)(+@)E T()< 2+@-* 72%1*+0E:
=d $^6 /E+> T+> j (E @%) /E/-**9 2+c/(2+> (@ ) B2%0 >-0-.+> 8+**E
!-92 H.26-+;, [O92 0-@N WOJ.N 72+E+@)(@. 8^% ?%0()(@. -@> -1>%0(@-* 7-(@N $%)+> )% -1%/) #A& F@)
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
19/285
!_
!(@!>@($?#) '%G?"'%G($?N% O@>?7 G%i>?G%I%#$Hf
V ;@+E)+@) 6/2?(?-* X/(>+ 38 ?%*/0+ E)-)/E TE -2+ ->0(@(E)+2+> >/2(@. E -) - 2-)+ )(-8 %/)7/) %7)(0-*:
Ohm’s Law:
= −
× 80
N%#$?@($?"#M+@)(*-)%2 E+))(@.E
'(>-* M%*/0+ p ?%* %B -(2 (@ +-8< 12+-)< 3\5!# 80= ^J.:
Y-)+ p @% %B 12+-)+*(?+2+> 7+2 0( @ ](K# p -0) %B K# >+*(?+2+> 3$ p UOdm )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
20/285
#O
(!?7
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
21/285
#!
#>$G?$?"#
$/)2()(%@-* E/77%2) 0-9 E/77*+0+@) @%20-* B++>(@.N %2 8%07*+)+*9 2+7*-8+ @%20-* B++>(@.
D+@+B()E %B @/)2()(%@-* E/77%2)
,2+E+2?-)(%@ %B @/)2()(%@-* E)-)/E
,2+?+@)(%@ %B 8%07*(8-)(%@E %B 72%)+(@ 0-*@/)2()(%@
H+82+-E+ 7%E)5%7+2-)(?+ 8%07*(8-)(%@E – (&+& >+*-9+> T%/@> +2+> B%2` ,-)(+@)E -*2+->9 T()< 0-*@/)2()(%@ E/2.+29 ̂ )2-/0- ̂ E+7E(E ,-)(+@)E -) 2(EJ %B 0-*@/)2()(%@
!
H+7*+)+> 2+E+2?+E!
,%%2 %2-* (@)-J+ B%2 i V >-9E!
F07-(2+> 1%T+* B/@8)(%@! I2()(8-* (**@+EE
!
$++> B%2 72%*%@.+> 1%T+* 2+E)
$/)2()(%@-* E/77%2) E 1+ 8%@E(>+2+> B%2`
D4F r !\&V
Z@(@)+@)(%@-* T+(.
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
22/285
##
G%O%%7?#) HL#7G"I%b ; 7%)+@)(-**9 B-)-* 0+>(8-* 8%@>()(%@ T -@> +*+8)2%*9)+ E/2(@.@/)2()(%@-* 2+(/0 (@82+-E+E 3 E+8%@>-29 )% (@E/*(@: B*/(> 2+)+@)(%@
I*(@(8-* 4-@(B+E)-)(%@!
Q*+8)2%*9)+ H+B(8(+@8(+E 8%@)2-8)(*()9N 09-*.(-N )+)-@9N 2%09%*9E(E!
$+/2%*%.(8-* )2+0%2N 7-2-+E)+*(2(/0N E+(e/2+E
Y(EJ B-8)%2E! G240.24 ?61-W2 – ;R2R *+,=,6:24 V-91;6: ,+ =,A 262+:8 4;21 E I-+-9509
H9E7-9E ;@%2+S(- @+2?%E-N H+72+EE(%@N I+72+EE+> 6' E+.0+@)
R97+2J-*-+0(-!
6/>>+@ 8-2>(-8 -22 ' T-?+E 72%*%@.+> ,Y (@)+2?-* *%EE %B , T-?+E T(>+@+> oY6 E(@+ T-?+ 7-))+2@
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
23/285
#=
%#$%G(@ O%%7?#),2%?(E(%@ %B @/)2()(%@-* 2+c/(2+0+@)E ?(- @%@5(@?-E(?+ %2 (@?-E(?+ 0+)E T()< E)-@>-2>B%20/*-)(%@ %2 >(E+-E+ E7+8(B(8 B%20/*-)(%@E
I(@. 2+.(0+@
I%@)(@/%/E
- ;**%T *%T+E) 7%EE(1*+ (@. 2-)+ 1+))+2 XF )%*+2-@8+
- D+))+2 8%@)2%* %B 1*%%> .*/8%E+ >/+ )% 8%@)(@/%/E IDR (@7/)
- P(@. (E 2+c/(2+>N 8%@)(@/%/E B++>(@. (E %B)+@ 1+))+2 )%*+2-)+>
)E 0-9 2+>/8+ -E7(2-)(%@ 2(EJ (B () (E >(BB(8/*) )% 0-(@)-(@ =O>+. +*+?-)(%@
%?+2@(.(@.:
D%*/E- ,-)(+@) 0/E) +c/-)+%2-* >(+):
6)(0/*-)(%@ %B E+82+)%29 B/@8)(%@ >%+E @%) T%2E+@ )()(%@ 1+(@. )2+-)+> 3+&.& E0-**1%T+* B(E)/*-:
I%@)2-(@>(8-)(%@E` I%07*+)+ E0-** 1%T+* %1E)2/8)(%@ F*+/E
F@->+c/-)+*9 )2+-)+> E >%T@ /77+2
XF'N B%**%T(@.
@%20-* -@-)%09
- $-E%.-E)2(8 '/1+E
- K2%.-E)2(8 '/1+E
- $-E%5>/%>+@-* '/1+E T%E8%7(8 .-E)2%E)%09 3,QX: /E+> B%2 B++>(@.N >2-(@-.+
-@>^%2 72+?+@)(%@ %B ?%*?/*/E 32-2+N B(S E)%0-8< )% -1>%0(@-* T-**:
((& K7+@ X-E)2%E)%09
- b+G/@%E)%09 '/1+E
'97+E %B K2-* ]++>E`
Q@E/2+ 372%)+(@ _ .0 ̂ E+2?(@.:
Q@E/2+ ,*/E 3(B(+> B-):
,/*0%8-2+ 3B%2 IK,H 7-)(+@)E (@. 3!#d %?+2-** 8%07*(8-)(%@ 2-)+E:`
X-E)2%(@)+E)(@-*
- H(E)+@)(%@
- $-/E+- L M%0()(@.
- H(-22 8-)
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
24/285
#U
'(G%#$%G(@ #>$G?$?"#
,2%?(E(%@ %B -** @/)2()(%@-* 2+c/(2+0+@)E 19 )?-@)-.+E ̂ H(E->?-@)-.+E` ;**%T .2+-)+2 8-*%2(8 (@)-J+ DZ'
!
4%2+ +S7+@E(?+! 4%2+ 8%07*(8-)(%@EN @++>(@. 0%2+ )+8 ?+@%/E -88+EE )% - *-2.+ 8+@)2-* *(@+ 2(EJ %B ) >+S)2%E+ 8%@)+@) (B .(?+@ )9 T+(.> %@5.%(@. *%EE+E 1-E+> %@ F^K 8> (@E+@E(1*+ B*/(> *%EE+E ->> !Od B%2 +?+29 !>+. 2(E+ (@ )+07+2-)/2+
H+)+20(@+ $%@5$I-*%2(8 $++>E
>+)+20(@+ ()/2+ 3'QQ:- Y+E)(@. Q@+2.9 QS7+@>()/2+ 3YQQ: #V )% =OJ8-*^J.^>-9 3E8 +c/-)(%@:- $%% _ G%% h H1+299 O-.1,+ h (.1;B;18 O-.1,+- ]-)E 3#V5=Od %B 8-*%2(+E: -@> I-21%2-)+E 3WO5W Vd %B 8-*%2(+E:
H+)+20(@+ '+,12;6 Y+c/(2+0+@)E
- 1-E+> %@ 8-*%2(+` @()2%.+@ 2-)(% @%20-* !VO8-* ` !. @()2%.+@- 1-E+> %@ >+.2++ %B E)2+EE -@> 1%>9 T+(. E)2+EE !&O5!. ^ J. ^ >-9(((& 0%>+2-)+ E)2+EE !&=5!&WV.^J.^>-9;BR 92B2+2 91+299 dKdRf:EW:E4-8
- 1-E+> %@ @()2%.+@ 1-*-@8+ -(0 B%2 7%E()(?+ 1-*-@8+ %B !&V5#.^J.^>-9
H+)+20(@+Q*+8)2%*9)+ -@> '2-8+
+*+0+@)2+c/(2+0+@)E
Q*+8)2%*9)+ Y+c/(2+0+@)E- #-h QKd55,=EW:E4-8 3%2 [O5!#O 0+c^>-9:- ^h XRfKQ 55,=EW:E4-8 3%2 =O5[O0+c^>-9:- I:dh XRUfKXRgf 52ZEW:E4-8 3%2 !O5#O0+c^>-9:- !-dh XRdKXRU 52ZEWZE4-8 3%2 !O5!V0+c^>-9:- '"g
dK dXKUX55,=E4-8
'2-8+ Q*+0+@)E- I%00+28(-* 72+7-2-)(%@E +S(E) )% 72%?(>+ YH;- z@ #5U0.^>-9 - I2 !O5!V/.^>-9 - I/ O&=5O&V0.^>-9- 4@ O&U5O&\ 0.^>-9
H+)+20(@+ @++> B%2->>()(?+E
- M()-0(@E .(?+ #5=S ) (8-)(%@ B%2 ',$
;1@%20-* ./)
B/@8)(%@
- K1E)2/8)(%@ %B XF'` 72%S(0-* E0-** 1%T+* %1E)2/8)(%@ @%) (00+>(-)+*9 2+*(+?+>
- H/,+1 3,A2= 9864+,52`
(& '+07%2-29 31+B%2+ ->-7)-)(%@: (@ r =0 %B B/@8)(%@-* E0-** (@)+E)(@+
((&
,+20-@+@) (@ r !0 %B B/@8)(%@-* E0-** (@)+E)(@+
- ,2%S(0-* (@)+E)(@-* B(E)/*- 3(&+& (@ 7-)(+@)E T()< E0-** 1%T+* %1E)2/8)(%@ – (&+& E+8%@>-29
)% 8-28(@%0-)%E(E 7+2()%@+(: ` B-8(*()-)+ B(E)/*- 8*%E/2+
- Y+B2-8)%29 (@B*-00-)%29 1%T+* disease of the GIT (e.g. Crohn’s, UC)
K)+c/-)+ -0%/@)E %B @/)2(+@)E ?(- +@)+2-* B++>(@. – F@-1(*()9 )% /E+
)
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
25/285
#V
'%G?"'%G($?N% !(G% – (# (#(%H$D%$?H$’H '%GH'%!$?N%
- ]-E)(@.` 0(@(0/0 [ B%%>N # E- r VO92 T()< @(* ,4RS p @% (@?+E)(.-)(%@N- i VO92 p >% ]DIN Y,N QIX k (@>(8-)+> (@?+E)(.-)(%@EN Xf4 (B +S7+8)+> 1*%%> *%EE %2 *%T R1N- F@ ) B%2 =^!#N QIX [^!# -@> IfY !92
'G%K(#(%H$D%$?! (HH%HHI%#$Y
K2.-@ 69E)+0 67+8(B(8 ,%(@)+2E
X+@+2-*
- R+(.(%?-E8/*-2- D*%%> ,2+EE/2+ -@> R+-2) Y-)+- 682++@ B%2 R'$N FRHN I-2>(-8 4 /20/2EN ;22
Y+E7(2-)%29
- 60%J(@. RS – E0%J+2E [S (@82+-E+> 2(EJ %B 2+E7(2-)%29 8%07*(8-)(%@E – ->?(E+ )% E)%7E0%J(@. [ T++JE 72(%2 )% E/2.+29
- ;EE+EE0+@) %B 8(E+-E+ – (&+& -E)
K) 7-)(+@) )% 0-(@)-(@ ^ (072%?+ B()@+EE 72(%2 )% E/2.+29- ;>?(E+ )% 8/) >%T@ %@ -*8%!?(@ I%7?!($?"# D?H$"GL
'97+E %B H2/.E 67+8(B(8 ,%(@)+2E
H2/. ;**+2.9 - H%8/0+@) )97+ %B -**+2.(8 2+-8)(%@ – 2-E(8-)(%@ B%2 -@)(7*-)+*+)- ;@)(57*-)+*+) -.+@)E @++>E )% 1+ >(E8%@)(@/+> B%2 !5#T++JE 1+B%2+ E/2.+29 B%2 B/**
2+E)%2-)(%@ %B 7*-)+*+) B/@8)(%@ 3(&+& -E7(2(@ ^ 8*%7(>%.2+* p E)%7 W >-9EN >(792(>-0%*+p E)%7 !O >-9EN )(8*%7(>(@+ p E)%7 ! U >-9E:
;@)(58%-./*-@)E32+8%00+@>-)(%@
?-2(+E B2%0 (8-)(%@ B%2 -@)(8%-./*-)(%@- @,A G;9W ,V 1/+,53,253,=;9-1;,6 3(&+& @%@5?-*?/*-2 ;] T^% (E8%@)(@/+> B%2 !5#T++JE 1+B%2+ E/2.+29 – (@ 8-E+E %B
(@)+2-8)(%@ T()< 8%-./*-)(%@ -@> -@-+E) E%%@ -B)+2 E/2.+29
'#H4 %@ KRX;
- I%@)(@/+ KRX; )(** 0%2@(@. %B E/2.+29 )(@. E8-*+
u %BB 0+)B%20(@ (@ 7-)(+@) T()< E/E7+8)+> 2+@-* (@E/BB(8(+@89N %E+ -@> /75)()2-)+
F@E/*(@5>+7+@>+@)H4
- ;>G/E) 1-E-* (@E/*(@ >%E-.+ -@> E)%7 72-@>(-* (@E/*(@ 3E++ 1+*%T:qq- 6)-2) %@ >+S)2%E+ >2(7 3(&+& HVP %2 n H^6: -) VO5WV0* ^
0+)-1%*(8 8 .*/8%E+ 2+./*-2*9 - FB 8-@ +-) 7%E)5%7 )()2-)+ 1-8J )% /E/-* (@E/*(@ 2+.(0+@
K)
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
26/285
#[
'"H$K"'%G($?N% !"I'@?!($?"#H
?II%7?($%3r! (@. E)2/8)/2+E
,2(0-29 0-9 2+c/(2+ 2 +)/2@ )% )
69E)+0(8 D-E-* -)+*+8)-E(E 38%**-7E+ %B -*?+%*(:`
12%@8%+E @%) 12+-)++7*9 >/+ )% 7-(@'S` 8 2+7*-8+0+@) 7+2(5%7+2-)(?+*9 ;4FN 7/*0%@-29 +01%*(E0
%(G@L3B(2E) #U5U\ @+EEN ET+**(@.N >(E8/+ )% EJ(@ E)-7 %2 -@-E)%0%)(8 >+-)+Y]` (@B+8)(%@N 7%%2 1*%%> E/77*9N 0 -*@/)2()(%@N E)+2%(>E'S` ;@-*.+E(-N E)+2(*+ T%/@> >2+EE(@.N B*/(> 2+E/E&N 2+5E/)/2+ /@>+2 X; (@ K'4%2)-*()9 /7 )% =Od
F@8(E(%@-* %0(@-* T%/@>EZE/-**9 -E907)%0-)(8N 1/) (B 7-(@B/*N 8%@E(>+2 E)2-@./*-)(%@ 3/@8%00%@ >/+)% T(>+ @+8J:Y]` K1+E()9N 7%%2 0/E8*+ )%@+ 3%*> -.+:N 3(@82+-E+> (@)2-5-1>%0(@-* 72+EE/2+38+2 1*%%> X(?+ 72%)-0(@+ E/*B-)+ 3!0. 7+2 !OO/@()E %B /+ )% (@B+8)(%@ *+->(@. )% +2%E(%@ %B ?+EE+*E -) ) >(-222/. 2+-8)(%@c Q 5,61/J42=-824M
6/2.(8-* 6()+ F@B+8)(%@
F@B+8)(?+ Q@>%8-2>()(E
,K6'5K, ,KKY ZYF$Q KZ,Z'
'+2KG26-= Y+@-* R97%57+2B/E(%@ ^ R+-2) ]-(*/2+G26-= ;8/)+ '/1/*-2 $+82%E(E
',91KG26-=
K1E)2/8)(%@ 3(&+& 1*%8J+> 8-)#7 ?#O%!$?"#
S,064 !=-99 %F-5*=29 %F*2.124 ?6V2.1;,6 G-129QX
I*+-@ R+2@(- Y+7-(2N D2+-E) 6/2.+29N M-2(8%E+ M+(@ 6/2.+29 r #dI*+-@ I%@)-0(@-)+> I,+@+)2-)(@. ;1>%0(@-* F@G/29N K7+@ aN ;@(0-* %2
R/0-@ D()+EN Q@)+2%)%09 >/2(@. 1%T+* %1E)2/8)(%@y !Vd
H(2)9 ,+2B%2-)+> H(?+2)(8/*()(EN ]-+8-* ,+2()%@()(E i #Vd
!O from “revision guide for surgical trainees” (2@> Q>()(%@:
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
27/285
#W
7N$E'%;BB+8)E #V5VOd %B E/2.(8-* 7-)(+@)EHM' (@ >++7 8-*B ?+(@E` V5!Od 2(EJ %B ,QHM' (@ (*(%B+0%2-* ?+(@E` VO5[Od 2(EJ %B ,Q
G;9W O-.1,+9gVirchow’s Triadh
!&
6)-E(E 1+> 2+E)N (@-8)(?()9N IR]N IM; T()` _Vd E+@E()(?()9 -@> E7+8(B(8()9 B%2 E907)%0-)(8 HM'
H5H(0+2` rVOO ` [\d:! 6(@/E )-8(-! ;] 2(E7%E+ )% )%E+5+BB+8) 2+*-)(%@E-9EN .%-* F$Y #5=:! M()-0(@ j -@)-.%@(E)N (@ Y] = 0%@) DVT or PE ≥ 3 months (reassess if low bleed risk) *(B+*%@. #@> HM' ^ ,Q *(B+*%@.
6/2.(8-* FMI B(*)+2 37+20-@+@) %2 )+07&` 2+0%?+ -B)+2 # T++JE %B -@)(58%-./*-)(%@: F@>(8-)(%@E`
! R(E)%29 %B 2+8/22+@) HM'^,Q!
]2++ B*%-)(@. )/7*+S E8-@!
;@)(8%-./*-)(%@ 8%@)2-(@>(8-)+>
$+2-15261 ,V N$% 6/77*+0+@)-* %S9.+@N (@)/1-)(%@N 0+8 7+2B%20 8%072+EE(%@ Z ^6Low Probability ≤0 – H5>(0+2 )+E)
!=;6;.-= V2-10+2 H.,+2;8)(?+ 8-@8+2 3)2+-)0+@) %@5.%(@. %2 T()+2@+EE -*%@. )(E)2(1/)(%@ %B )++7 ?+@%/E E9E)+0 !Q@)(2+ *+. ET%**+@ !I-*B ET+**(@. i = 80 8%07-2+> )% ) 1+*%T )(1(-* )/1+2%E()9: !,())(@. %+>+0- 3.2+-)+2 (@ )(-.@%E(E -E *(J+*9 %2 0%2+ *(J+*9 )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
28/285
#\
H>GN?N?#) H%'H?HQd
6+7E(E (B - E9E)+0(8N >+*+)+2(%/E (@. )% E+?+2+ E+7E(E -@> E+7)(8 E/8+> )(EE/+ 9EB/@8)(%@
! 6+7E(E5(@>/8+> A:
[ D(*(2/1(@ i =U/0%*^A 3#0.^>A:
W ,*-)+*+) r !OONOOO/A
\ I%-./*%7-)& #O!= ]+1mU!3#:`V\O5[=W
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
29/285
#_
I(#()%I%#$ "O H%N%G% H%'H?H – (O$%G (
F@()(-* Y+E/E8()-)(%@ L F@B+8)(%@ FEE/+E
YQIK44Q$H;'FK$ 'RF$X6 'K HK
F@()(-* Y+E/E8()-)(%@
3.%*>+@ [ (2+8)+>
)5E7+8)2/0
;1 3=5V >-9E 0-S:
- (&+& E+?+2+ (@B+8)(%@ -^T 2+E7( B-(*/2+ -@>E+7)(8 E+> E7+8)2/0 1+)-5
*-8)-0E k -0(@%.*98%E(>+ -@>^%2
B*/2%c/(@%*%@+ 3B%2 ,;Q 1-8)+2-+0(-:
- 1+)-5*-8)-0 k 0-82%*(>+ B%2 7-)(+@)E T()<
E+7)(8 E/+ )% E)2+7 7@+/0%@(-
- (&+& -@)(?(2-* ) (@B+8)(?+ E%/28+ T() %/) – (B 7-)(+@) (E E+?+2+*9 E+7)(8
(@)+2?+@+ T()< *+-E) 7+0-28-)(%@ %B ?(-1*+ -@> @%@5?(-1*+
)(EE/+
- I9@-0(8 E/77%2) -@> ->G/@8)(?+ )
- DON’T USE hydroxyethyl starches (HES) –
-1E+@8+ %B 8*+-2 1+@+B() T()< 8%**%(>E
- ]*/(> 8/8+> )(EE/+
M-E%72+EE%2
- '-2.+) 4;, %B [V00R.
- H%7-0(@+ (E -*)+2@-)(?+ ?-E%72+EE%2 )%
@%2+7(@+7%7-0(@+ B%2
2+@-* 72%)+8)(%@
- $%2+7(@+7
- M-E%72+EE(@ 3/7 )% O&O=/^0(@: 8-@ 1+
/E+> -E T+**
- F@E+2) -2)+2(-* 8-)0(@(E)+2+> %2 ->>+> )% ?-E%72+EE%2
I%2)(8%E)+2%(>E
- FB ->+c/-)+ B*/(> 2+E/E8()-)(%@ – @% 2%*+ B%28%2)(8%E)+2%(>E
- FB B*/(> 2+E/E8()-)(%@ @%) ->+c/-)+ – jFM FM
2%8%2)(E%@+ #OO0. ^ >-9
- I%2)(8%E)+2%(> @%) 1+ ->0(@(E)+2+> B%2
)2+-)0+@) %B E+7E(E (@ -1E+@8+ %B EE -2+ /E+> – .(?+ 8%@)(@/%/EB*%T
6/77%2)(?+ )A (@ ->/*)E
- ;>0(@(E)+2 7*-)+*+)E (B 8%/@)E r!ONOOO^00=
%2 (B 7-)(+@) -) 2(EJ %B 1*++>(@. -@> 8%/@)E
r#ONOOO00=
- Don’t use FFP to correct clotting
-1@%20-*()(+E (@ -1E+@8+ %B 1*++>(@.
- ]/** 1*%%> 8%/@)
- YDI )2-@EB/E(%@ (B R1 rW&O
- jFM 7*-)+*+) )2-@EB/E(%@
X*/8%E+ I%@)2%*- Target upper blood glucose of ≤ 10mmol/L - jFM E)-2) (@E/*(@ T .*/8%E+ i!O00%*^A
$/)2()(%@
- K2-* %2 +@)+2-* B++>(@. -E )%*+2-)+> 2-)
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
30/285
=O
(!>$% (>+@ %@E+) %B E+?+2+ -1>%0(@-* 7-(@ 3@+T 7-(@ %2 -@ (@82+-E+ (@ 8@$HQg
!& '2+V,+-124 N;9.09 J;R2R *2+V,+-124 *2*1;. 0=.2+ 5,91 .,55,6M
,-)(+@) )+@>E )% 1+ (@ )-9E -B)+2 %@E+) %B +7(.-E)2(8 7-(@
!
6/E7+8)+> (@ (@>(?(>/-*E T()< T+?+*%7 E/>>+@ %@E+)
%B E+?+2+N >(BB/E+ -1>%0(@-* 7-(@
K)+E`
! ,+2B%2-)+> %+E%7 1%T+* 3(E8(?+2)(8/*()(E:
!
,+2B%2-)+> -77+@>(S
dR G0*10+24 (34,5;6-= -,+1;. -620+895 J(((M
Y(EJ ]-8)%2E` ->?-@8+> -.+ 3i[O 9+-2E:& IK,HN 7/*0%@-29 >(E+-E+N ,MHN R'$N E0%J(@.
-@> B-0(*9 +SE-@./(@-)(@.
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
31/285
=!
D?H$"GL $(^?#)
Patient’s Bio5>-)-
,2+E+@)(@. I%07*-(@
R(E)%29 %B ,2+E+@)(@. I%07*-(@
- 6()+ %B ,-(@ 3E++ 1+*%T >(BB+2+@)(-* >(-.@%E(E %B -1>%0(@-* 7-(@:
- K@E+) -@> H/2-)(%@ %B ,-(@
P()E
3!: F@B-28)(%@ 34F ^ 4+E+@)+2(8 K88*/E(%@:N
3#:
Y/7)/2+ 3Y/7)/2+> ;;;:N
3=: ,+2B%2-)(%@ 3,+2B%2-)+> ,+7)(8 /*8+2:
P()(8()(EN ,-@82+-)()(EN H(?+2)(8/*()(E:
3#: I%*(8 3D(*(-29 8%*(8N Z2+)+2-* 8%*(8N 60-** D%T+* K1E)2/8)(%@:
3=: FE8(8()(EN I D%T+* K1E)2/8)(%@N Z2(@-29 Y+)+@)(%@:
3=: 4+8+@/0
R+0-)+0+E(E – E/..+E) 7+7)(8 /*8+2 %2 .-E)2()(E
]+?+2 %2 8
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
32/285
=#
'DLH?!(@ %T(I?#($?"#
X+@+2-* ;77+-2-@8+
- A9(@. 0%)(%@*+EE 3;8/)+ ;77+@>(8()(EN H(BB/E+ ,+2()%@()(E:- Y+E)*+EEN T2()(@. ]%2T-2> 3,-@82+-)()(E:
M()-* 6(.@E k ,+2(79@-0(8 F@E)-1(*()9 – 2^% *(B+ )+ ]+?+2 – E/..+E)E -1E8+EEN 8(@.N 1%-2>5*(J+ 2(.(>()9
;@9 7-*7-1*+ 0-EE+E
R+2@(-E – (@8(E(%@-*N ?+@)2-*N /01(*(8-*N (@./(@-*N B+0%2-*
,-(@ %/) %B 72%7%2)(%@ )% ,Q B(@>(@.E – E/..+E) 0+E+@)+2(8 (E8>+2 – -8/)+ 2+)+@)(%@ %B /2(@+
'907-@(8 E%/@>E %?+2 >(E)+@>+> 1%T+* – (@)+E)(@-* %1E)2/8)(%@
- ;/E8/*)-)(%@ ;1E+@8+ %B 1%T+* E%/@>E – 7%EE(1*9 (*+/E B2%0 >(BB/E+ 7+2()%@()(E
R(.E – E/..+E)(?+ %B %1E)2/8)(%@
- Y+8)-* QS-0(@-)(%@- ,+*?(8 QS-0(@-)(%@ – ,M k 1(0-@/-* +S-0(@-)(%@- '+E)(8/*-2 -@> 682%)-* QS-0(@-)(%@
I-2>(%2+E7(2-)%29 QS-0(@-)(%@
- ;@9 E(.@E %B 7*+/2(E9N ;4FN 1-E-* 7@+/0%@(-
K)
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
33/285
==
7?OO%G%#$?(@ 7?()#"H?H "O (
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
34/285
=U
7?OO%G%#$?(@ 7?()#"H?H "O '(@'(
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
35/285
=V
?#$%H$?#(@ "!$?"#
F@)+E)(@-* %1E)2/8)(%@ %88/2E T& F) 8-@ 1+8*-EE(B(+> 7-)9@-0(8:
I*-EE(B(8-)(%@;& ,-)9@-0(8 ?E& ->9@-0(8D&
;@-)%0(8-* E0-** 1%T+* 3E -@> -> ^ 8+8/0 30%2+ 8%00%@*9 E(.0%(>:
- F@)/EE/E8+7)(%@
- A907< $%>+ I%072+EE(%@
- 6/7+2(%2 4+E+@)+2(8 ;2)+29 69@>2%0+
]/@8)(%@-* – -1E+@8+ %B 7+2(E)-*E(E T()2%0+qq
I% K1E)2/8)(%@
!& R(2E8(-)+> – E0-** 8+** A/@. I;
=&
F@B+8)(%@ – I (E 72%B/E+ T()< 2-7( > >+2-)(%@
- H(E)+@)(%@ (E 0(@(0-*
A%T- ,-(@ (E 72+>%0(@-@) T()< 8+@)2-* >(E)+@)(%@
- 4/*)(7*+ 8+@)2-* B*/(> *+?+* E++@ %@ ;fY
A-2.+ D%T+*
K1E)2/8)(%@
- H(E)+@)(%@ (E +-2*9 -@> 72%@%/@8+>
- ,-(@ (E 0(*> -@> ?%0()(@. -@> >+2-)(%@ -2+ *-)+
- ,2%S(0-* 8%*%@ L 8+8/0 >(E)+@>+> 38%07+)+@) ( *+%8+8-* ?-*?+:
!@?#?!(@ !@(HH?O?!($?"#
;8/)+- ZE/-**9 (@ E0-** 1%T+* T()< E/>>+@ %@E+) %B 8%*(8J9 8+@)2-* -1>%0(@-* 7-(@ -@> >(E)+@)(%@
-@> +-2*9 ?%0()(@. -@> 8%@E)(7-)(%@
I%0(@-* 8%*(8 -@> %1E)(7-)(%@
B%**%T+> 19 >(E)+@)(%@
;8/)+ %@
I2%7 %B 7-(@ -@> 8%@E)(7-)(%@
6/15-8/)+- F@8%07*+)+ %1E)2/8)(%@
- Y+8/22+@) -))-8JE %B 8%*(8 2+*(+?+> 19 7-EE(@. B*-)/E %2 B-+8+E
“Small bowel obstruction is more common than *-2.+ 1%T+*& '
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
36/285
=[
!(>H%H "O '(G(@L$?! ?@%>H
,%E)5%7+2-)(?+
30%E) 8%00%@:
- , 0%)(*()9 2+)/2@E )%
@%20-*N /E/-**9 E+*B5*(0()(@.
- $%20-* 2+E/07)(%@ %B 1%T+* -8)(?()9 -B)+2 -1>%0(@-* E/2.+29 B%**%TE - 72+>(8)-1*+
7-))+2@` H< K A;1/;6 /,0+9l 91,5-./ K QKd 4-89l .,=,6 K UKf 4-89
- I*(@(8-**9 E(.@(B(8-@) (B`
F*+/E )(E)+@)(%@ 1+8%0+E 0%2+ 0-2J+> -@> )907-@(8
,-(@ (E @%) - B+-)/2+
F@B+8)(%@
- 6+7E(E 30-9 .(?+ 2(E+ )% *%8-*(E+> %2 .+@+2-*(E+> (*+/E:
Y+E/*)-@) -> E+@E%2(/0N )-8(-N B+?+2N 7%E)/2-* %0(@-* >(E)+@)(%@ -@> )+@>+2@+EE t *%8-*(e+> %2 .+@+2-*(E+> 7+2()%@()(E
7;-:6,91;. !+;12+;-Qo - Y->(%*%.(8-* +?(>+@8+ %B 8%*%@(8 >(E)+@)(%@ PLUS (≥ 3 of the followings)
]+?+2 i =\>+.
RY i !#O170
$+/)2%7(E)/21-@8+N V>& (*-)-)(%@ %B ) 2(./2-* -@-*.+E(8EN -@)(58
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
37/285
=W
'($D"'DLH?"@")LI )% %?+28%0+ %1E)2/8)(%@
- FB %1E)2/8)(%@ @%) 2+*(+?+> >(*-)-)(%@ %88/2E T()< -1E+@) 7+2(E)-*E(E
X-E ;88/0/*-)(%@ E(.@(B(8-@) %?+2.2%T)< %B 1%)< -+2%1(8 -@> -@-+2%1(8
%2.-@(E0E L B2%0 ET-**%T+> -(2
3.-E 8%07%E()(%@ – K# N IK# N R#6 L $#:
]*/(> ;88/0/*-)(%@ (07-(2+> -1E%27)(%@ B2%0 ./) *+->(@. )% E+c/+E)2-)(%@ %B
B*/(> (@ )+2-)(%@ -@> +*+8)2%*9)+ (01-*-@8+:
6)2-@./*-)(%@
- I%072%0(E+> ?+@%/E 2+)/2@ >/+ )% >(*-)+> 1%T+*
- F@82+-E+> 8-7(**-29 72+EE/2+
- A%8-* 0/2-* >(E)+@)(%@ >/+ )% B*/(> -@> 8+**/*-2 +S/>-)(%@
- I%072%0(E+> -2)+29 E/77*9
- D(%I"GGD()?! ?#O(G!$?"#
- Y(EJ %B )2-@E*%8-)(%@ %B (@)+E)(@-* 1-8)+2(-* -@> )%S(@E ( @)% 7+2()%@+-* 8-?()9
-
'%G?$"#?$?H (#7 H%'$?!%I?(- PN E+c/+E)2-)(%@ %B 1*%%> %88/2E (@ ) E+.0+@)
- DL'"N(@%I?! HD"!^ Y
I*(@(8-* ]S` 1*%%> E/77*9 8%072%0(E+>N E 0%2+ 8%@E)-@) *%8-*(E+> 7-(@N 7+2()%@(E0 (E
)(@-* E(.@& 4-9 PII -@> E(.@E %B 0+E+@)+2(8 (E8
A%%7
K1E)2/8)(%@
- 6(07*+` %@+ %1E)2/8)(?+ 7%(@)N @% ?-E8/*-2 8%072%0(E+
- I*%E+>5*%%7` %1E)2/8) -) # 7%(@)E B%20(@. - *%%7 %B .2%EE*9 >(E)+@>+> 1%T+* – -) 2(EJ B%2
7+2B%2-)(%@N 3)+@>+2@+EE -@> 7+2B%2-)(%@ /E/-**9 -) 8-+8/0: i!O 80 2+c/(2+E /2.+@)
>+8%072+EE(%@
I*(@(8-* ]S` I%@E)-@) YF] 7-(@N ./-2>(@.N )+@>+2@+EEN -1E+@8+ %B >(*-)+> E0-** 1%T+*E
'-1/,*/89;,=,:8P E)2-@./*-)(%@ *+-> )% ?+@%/E 8%072%0(E+ *+-> )% +>+0- *+-> )%
-2)+2(-* 8%072%0(E+> 8-/E(@. [email protected]+@+ -@> 7%)+@)(-* B%2 7+2B%2-)(%@
!-0929P
! M%*?/*/E
! R+2@(-)(%@ %B 1%T+*
! '(.+2-)(%@: )262+-= ;69*2.1;,6` ;1>%0(@-* >(E)+@E(%@l I-8E` F@()(-**9
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
38/285
=\
?#N%H$?)($?"#H
H(-.@%E)(8-)+
- ;fY 3+2+8) ;fY @% *%@.+2 2%/)(@+*9 %2>+2+>N 2->(%*%.(8-* >S 1-E+> %@ - E/7(@+ ;fY:
!& Q2+8) ;fY` -(2 B*/(> *+?+*E
In general ≥ 5 fluid levels are diagnostic of intestinal obstruction
F@ ) *+?+*E (E >(2+8)*9 72%7%2)(%@-* )% )+.2++ %B %1E)2/8)(%@ -@> )% ()E E()+ 30%2+ @/01+2 p >(E)-* *+E(%@:
#& H0*;62 (TGP *%%J B%2 E0-** %2 *-2.+ 1%T+* >(*-)-)(%@ %@ 2->(%.2-7<H/%>+@/0 - I5E
b+G/@/0
- H(*-)+> E0-** 1%T+* i=80 (E 8%@E(>+2+> -1@%20-*- I+@)2-**9 *%8-)+> 0/*)(7*+ >(*-)+> .-E B(**+> 1%T+*- 6)-8J %B 8%(@E -77+-2-@8+ 37*(8-+ 8(28/*-2+E ^ ?-*?/*-+ 8%@@(?+@)+E:
– 8%07*+)+*9 7-EE -82%EE T(>)< %B )- $% .-E (E E++@ (@ )% @%) 82%EE T(-0+)+2 %B )+2-)(%@E
M%*?/*/E
6(.0%(> M%*?/*/E 0-EE(?+ 8%*%@(8 >(E)+@)(%@ T()< >(*-)+> *%%7 %B1%T+* 2/@@(@. >(-.%@-**9 -82%EE )%0+@ B2%0 2(. (*+/0 -@> t >(E)+@>+> 8-+8/0 – @%*%@.+2 (@ YF] 31-2(/0 +@+0- E+@8+ %B 1%T+* T-** %+>+0- T()< {) 7E+/>%57%*97E %2 {0/8%E-* (E*-@>E{
X-**E)%@+ F*+/EA%%J B%2 -+2%1(*(- 3%88/2E (@ 8/%>+@-* B(E)/*-: L %7-8()9@+-2 )E )% )
- I%*%@%E8%79 >%@+ T() -*E% 8%@)2-(@>(8-)+>N (@ FK:
- I' 8%*%@%.2-7+2-)(%@ >/+ )% 3%2 -8/)+ 2+@-* B-(*/2+ B2%0 >+2-)(%@:
F@)2-*/0(@-* =2> 67-8+ A%EE 3>-0-.+> +@)+2%89)+E /@-1*+ )% 2+-1E%21:
M%0()(@. 3-*E% -EE+EE jk *%EE` 8-@ 7+27+)/-)+ 7-2-*9)(8 (* +/E:
- ;DX
;8(>%E(E B2%0 1%T+* (E8/+ )% ?%0()(@. 30%2+ B%2 79*%2(8 E)+@%E(E (@ 82+@:
- A-8)-)+ 3>% )2+@>(@.:
$%@5E7+8(B(8 E/22%.-)+ 0+-E/2+0+@) B%2 -@-+2%1(8 2+E7(2-)(%@
I%22+*-)+ T()< 8*(@(8-* E(.@E 3(&+& -1>%0(@-* 7-(@: (B E/E7+8)(@. (E8+2 >(-7(8-)+E 7@+/0%7+2()%@+/0& $/053K*+;61 9;:6
E *6205-1,9;9 ;61291;6-=;9 (E8
- ,'^,''
- QIX ^ I-2>(-8 Q@e90+E
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
39/285
=_
TKG(L O?#7?#)H
Rigler’s Sign = double wall sign (obvious bowel wall due to 2F1+-K=05;6-= -;+M- D*/+ -22%TE p B-*8(B%20 *(.-0+@)N 0->+ ?(E(1*+ 19 - B2++ -(2 (@ )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
40/285
UO
(!>$% I(#()%I%#$
Y/*+ %/) E/2.(8-* +0+2.+@8(+E (B E/E7+8)+>N (00+>(-)+ 8%@E/*) T()< X6 Y+.QR
?9./-25;. 3,A2= A;1/ 3,A2= 62.+,9;9 – *6205-1,9;9 ;61291;6-=;9#&
,+2B%2-)(%@^7+2()%@()(E=&
K1E)2/8)+> -@> E)2-@./*-)+> -1>%0(@-* N 8-+8-*N E)%0-85*%%7 %1E)2/8)(%@ 38%07+)+@) (*+%8+8-* ?-*?+:
“]+?+2N )-8(-N % E+7)(8 T%2J/7 3?(E8+2-* 7-(@ (@ 7-2-/01(*(8-*2+.(%@ 72%.2+EE(@. )% *%8-*(E(@. 7-(@ E/..+E) (07+@>(@. 7+2B%2-)(%@ – 8%@E(>+2 E/2.(8-* (@)ervention)”
!& ;DIE
4%E) (07%2)-@) 12+-) 67O# – 0-9 1+ -BB+8)+> >/+ )% E7*(@)(@. %B )(-7 >+8%072+EE(%@=&
$X )/1+ E/8)(%@
A-2.+ 1%2+ $X )/1+ 3E0-** >(-0+)+2 +-E9 )% .+) 1*%8J+> /7:
Q() %@ B2++ >2-(@-.+ T()< U5 2+2-)(%@ – E(@8+ T-)+2 -@> +*+8)2%*9)+E 3jk -@> I*5: -2+ >+7*+)+>
V&
Z2(@-29 8-) 8(@. 0%2+ (07) )(?(>/-* 72+EE/2+ 0+-E/2+0+@)E )% -EE+EE ?%*/0+ E)-)/E
_&
6/2.(8-* >+8%072+EE(%@ 3(B 1%T+* (E8 0+8 8%@E(>+2 7/))(@. /7 IM, *(@+ )% +@E/2+ 7-)(+@) (E ->+c/-)+*9 7+2B/E+> – (B IM, (E )%% *%T 8%@E(>+28%**%(>E 3+S8+7)(%@` E+7E(E: – T()< *+-J9 8-7(**-2(+E ?+EE+*EN (@B/E(%@ %B *-2.+ 0%*+8/*+E 8-@ T%2E+@ (@)2-?-E8/*-2*%EE -E *-2.+ 0%*+8/*+E (B >2-T@ %/) (@)% (@)+2E)()(-* E7-8+ >2-TE more fluid out.”
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
41/285
U!
7%O?#?$?N% I(#()%I%#$ 3H+7+@>E %@ 8-/E+:
QR ',91K,* *-+-=81;. ;=209 3i= >-9E 7%E)5%7:
6/77%2)(?+ 0-@-.+0+@)` >2(7 L E/8JN T-() B%2 7+2(E)-*E(E )% 2+E)-2)
K2-* .-E)2%.2-B(@` +
dR H;:5,;4 B,=B0=09
$%@5E/2.(8-*^ 8%@E+2?-)(?+
[&
Ryle’s tube decompression:
- X%T@ /7
- Put end of Ryle’s tube in a bottle submerged in water
- Insert lubricated Ryle’s tube into anus
#& ]*+S(1*+ E(.0%(>%E8%7(8 >+8%072+EE(%@ 32+8/2 (@ -E 0/8< -E VOd& Q*+8)(?+ *-7-2%E8%7(8 E(.0%(>
2+E+8)(%@ -@> 2(.+8%072+EE(%@ (E (@82+-E(@.*9 1+(@.
>+E82(1+> -@> 7+2B%20+> )% )2+-) 7-)(+@)E T()< ?%*?/*/E& ' (@)+2?-* 1+)T++@+@>%E8%7(8 >+8%072+EE(%@ -@> >+B(@()(?+ E/2.(8-* (@)+2?+@)(%@ (E U\5W# 8%*+8)%09 T()< 72(0-29 -@-E)%0%E(E` ,2(0-29 -@-E)%0%E(E (E 7+2B%20+> (B )(?(>+>
1%T+* +@>E -2+ ?(-1*+N 7+2()%@+-* 8%@)-0(@-)(%@ (E @%) +?(>+@)N -@> ) (@ =5[^!# – >+7+@>E %@ %?+2-**
8*(@(8-* 8%@>()(%@ -@> -1(*()9 )% T() -@%) 8%*+8)%09 L B%20-)(%@ %B >%/1*+ 1-22+* 8%*%E)%09 3'-0=KI;W0=;.e *+,.240+2: T()<
B/)/2+ 2+5-@-E)%0%E(E
>&
6(.0%(>%7+S9` B(S E(.0%(> )% 7%E)+2(%2 -1>%0(@-* T-** 32-2+*9 >%@+ -E +B/@8)(%@(@. 8%*%E)%09
Hartmann’s/Paul54(J/*(8e 72%8+>/2+ (B 1%T+* (E )%% (@B*-0+>^%+>+0-)%/E )%
-@-E)%0%E+ 3
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
42/285
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
43/285
U=
(!>$% (''%#7?!?$?H
?#$G"7>!$?"#- I*-EE(8-**9 W&V80 )% !O80- M+20(B%20 -77+@>(S (8()(E (E )%0+@- Q-2*9 -@> -88/2-)+ 72+5%7+2-)(?+ >(-.@%E(E 2+0-(@E -@ +@(.0-)(8 8 2+0(@>+2 %B
)(-.@%E(E
(#($"IL- D*(@> 0/E8/*-2 )/1+ T()< 0/8%E-*N E/150/8%E-*N 0/E8/*-2 -@> E+2%E- *-9+2E- ;77+@>(S *%8-)(%@
! G21+,.-2.-= *,9;1;,6 JofkM!
,+*?(8 3#!d:N 6/18-+8-* 3!&Vd:N ,-2-8-+8-* 3#d:!
I%@E)-@) 1-E+ %B -77+@>(S – -) 8%@B*/+@8+ %B = )-+@(-+ 8%*(N B/E+ )% B%20 %/)+2*%@.()/>(@-* 0/E8*+ 8%-) %B )(S
- 4+E%5-77+@>(S 8%@)+@)E!
;77+@>(8/*-2 -2)+29 312-@8< %B ) -2)+29
'E )% [email protected]+@%/E -77+@>(8()(E! A907/*)E – *->+@ T()< B-)EN 82+@ – )2-@E7-2+@)
(%$?"@")L5 H+82+-E+> >(+)-29 B(12+ -@> (@82+-E+> 2+B(@+> 8-21%2-)+E5
K1E)2/8)(%@ %B -77+@>(8+-* */0+@!
]+8-*()+12(E 8%**+8) -2%/@> @(>/E %B B-+8-* 0-)+2(-* T()(S
!
A907 (E8%0B%2) 37%%2*9 *%8-*(E+>N 0(>5./): (@ 2+E7%@E+ )% -77+@>(8+-* (@B*-00-)(%@
-@> %1E)2/8)(%@
1&
6%0-)(8 7-(@ 3(@)+@E+N 8%@E)-@)N *%8-*(E+>: (@ 2+E7%@E+ )% 72%.2+EE(?+ (@B*-00-)(%@ -@>
(22()-)(%@ %B 7-2(+)-* 7+2()%@+/0 (@ YF]
#&
$-/E+- -@> M%0()(@.
-&
;*0%E) -*T-9E %88/2 -B)+2 7-(@
1&
FB () 72+8+>+E 7-(@ 3l F@)+E)(@-* %1E)2/8)(%@:
=& ]+?+2
-&
](2E) [ 8%@E)-@) 8*(@(8-* B+-)/2+ +E7+8(-**9 (@ 82+@
V&
K)+2@+EE %@ 7+28/EE(%@N 2+1%/@> )+@>+2@+EEN 2(.(>()9 L ./-2>(@.
6(.@E )% +*(8()
- I%/.< E(.@` YF] 7-(@ %@ 8%/. 7+2()%@()(E:
- G,B9;6: 9;:6` YF] 7-(@ T()< >++7 7-*7-)(%@ %B )+@()(E,+2B%2-)+> ,+7)(8 Z*8+2
H(E+-E+Q8)%7(8 ,2+.@-@89 F@)+E)(@-* K1E)2/8)(%@
Meckel’s Diverticulum '+E)(8/*-2 '%2E(%@ ,+*?(8 F@B*-00-)%29 H(E+-E+ I%*%@(8 I-28(@%0-
A%1-2 ,@+/0%@(- Q7(>(>90()(E K28 K?-2(-@ I9E)F@)/EE/E8+7)(%@
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
44/285
UU
?#N%H$?)($?"#HF T%/*> *(J+ )% >% (@?+E)(.-)(%@E )% 3!: -EE(E) 09 8*(@(8-* E/E7(8(%@ %B -8/)+ -77+@>(8()(E& '+8)%09 2-)+ (E !V5=Od (B 1-E+> E%*+*9 %@ 8*(@(8-* E/E7(8(%@& F T%/*> )% 3#: 72+5%7+2-)(?+ (@?+E)(.-)(%@ )%2/*+ %/) >(BB+2+@)(-* 8-/E+E -@> *%%J B%2 8%07*(8-)(%@E %B )(E+-E+& ](@-**9N F T%/*> 7+2B%20 %)% ≤ 3 = no imaging, unlikely appendicitis- ;*?-2->% U5[ p 2+8%00+@> I' E8-@- Alvarado ≥ 7 = surgical consultation
q'% E8%2+E W %2 )^%2 M%0()(@. ! 7%(@)
6(.@E
$+@>+2@+EE 3YF]: # 7%(@)E
G+1%/@> '+@>+2@+EE ! 7%(@)↑ '+07+2-)/2+ 3i =W&=wI: ! 7%(@)
A-1%2-)%29@+/8%89)%E(E i !ONOOO # 7%(@)E
A+B) H/;V1 %B $+/)2%7%+E @%) 2^% -77+@>(8()(E
- ;1>%0(@-* /^E %2 8%@)2-E)5+@+2 >(-7 (@B*-0+> -77+@>(S 2+E/*)(@. (@ *%8-*(E+> (@B*-00-)%29 72%8+EE 37?+2)+@) E/2.+29 (E >(BB(8/*) -@> >-@.+2%/E 3 )% B(@> -77+@>(S:
Careful recording of the patient’s condition noting (1) pulse rate, (2) extent of the mass and (3) spread
%B -1>%0(@-* 7-(@
6907)%0-)(8 )2+-)0+@) -E T+** -E -@)(1(%)(8EN >% 8%@)2-E) +@ I'
P (@ E(e+N 7-)(+@) (E E)-1*+N >% E/2.+29 3*+EE (@B*-00-)(%@` +-E(+2:
QS8+7)(%@E` ?+29 9%/@. %2 ?+29 %*> 7-)(+@)EN %2 7-)(+@)E T()< E/E7+8)+> -77+@>(8/*-2 -1E8+EE 3>2-(@+>2->(%*%.(8-**9:N 8*(@(8-* >+)+2(%2-)(%@ 3+?(>+@8+ %B 7+2()%@()(E:
H+*-9+> >(-.@%E(E -@> )2+-)0+@) -88%/@) B%2 0/8< %B ) 0%21(>()9 -EE%8(-)+> T()<
-77+@>(8()(E&
'+*-9+>
>(-.@%E(E -2+ 8%00%@&
I%07*(8-)(%@E %88/2 (@ !5Vd %B 7-)(+@)E T()< -77+@>(8()(EN -@> 7%E)%7+2-)(?+ T%/@> (@B+8)(%@E
-88%/@) B%2 -*0%E) %@+ ) %B ) 0%21(>()9&
I%07*(8-)(%@E B2%0 -77+@>+8)%09
5
A%8-* 3E)/07: 2+)-(@+> B+8-*()(8()(EN *+-JN B(E)/*-
5
R-+0%22%0(@-*N -1>%0(@-* T-** N -77+@>(8+-* E)/07N 7+*?(8N E82%)-*:
5
,-2-*9)(8 F*+/E
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
45/285
UV
H>G)?!(@ (#($"IL
(#($"IL "O (%0(@-* T-**
5 6J(@
5
6/18/)-@+%/E '(EE/+
5 ]-E8(-
Camper’s fasciaq – E/7+2B(8(-* B-))9 *-9+2
Scarpa’s fasciaqq – >++7 B(12%/E *-9+2
5 4/E8*+
Y+8)/E ;1>%0(@(E
QS)+2@-* K1*(c/+ 4/E8*+ F@)+2@-* K1*(c/+ 4/E8*+
'2-@E?+2E+ ;1>%0(@-* 4/E8*+
5 '2-@E?+2E-*(E ]-E8(-
5 QS)2-57+2()%@+-* ]-)
5
,-2(+)-* ,+2()%@+/0
5 6J(@
5
6/18/)-@+%/E '(EE/+
5 ]-E8(-
Camper’s fascia – E/7+2B(8(-* B-))9 *-9+2
Scarpa’s fascia – >++7 B(12%/E *-9+2
5 A(@+- ;*1- – -7%@+/2%E+E %B )+> – 7
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
46/285
U[
(I">G
I*-EE(B(8-)(%@
A%8-*
D*++>(@. >/+ )% /*8+2-)(%@` R-+0-)+0+E(E ^ R-+0-)/2(-
,-(@
K1E)2/8)(%@ A-2.+ 1%T+* %1E)2/8)(%@ T()< 8-28(@%0-
F22()-)(%@ I%/.< >/+ )% 12%@8 ?+EE+*EN 1(*+ >/8)E 3 (&+& 8-@8+2 %B %B 7-@82+-E -@>
%1E)2/8)(?+ G-/@>(8+:
69E)+0(8
A907< $%>+E 4-9 1+ >(E82+)+ ^ ^ (22+./*-2 ^ 0+)+>
R+7-)(8R+7-)%0+.-*9 – 72(0-29 (@ E)%0-8+E (@ 7%2)- 7+7)(>+
5 I-28(@%(> E9@>2%0+ T()< *(?+2 0+)-E)-E+E B2%0 - 8-28(@%(> )/0 %/2>/+ )% VR'
F00/@%*%.(8-*
3-/)%(00/@+:
5 H+20-)%09%E()(E >/+ )% /@>+2*9(@. 0-*(.@-@89
5
4+012-@%/E X*%0+2/*%@+7 19 /@>+2*9(@.
0-*(.@-@89
4+)-1%*(8
' '+@%0-
;>2+@-* Cushing’s syndrome from ->2+@-* 8%2)(8-* ->+@%0-
,-2-) R97+27-2-)(E0 B2%0 7-2-) ->+@%0-
,-@82+-E F@E/*(@ B2%0 -@ (@E/*(@%0-
I%@E)()/)(%@-*I-8
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
47/285
UW
"%H"'D()%(@ 7?H%(H%H
(#($"IL "O $D% "%H"'D()>H
- K+E%7*+ !^= (E 0(S+>
- H0350.,9- – 8%@)-(@E E/10/8%E-* 7*+S/E 3Meissner’s ,*+S/E:
- I0.,9- – E)2-)(B(+> Ec/-0%/E @%@5J+2-)(@(E(@. +7()>*+ !^= A%T+2 !^=
4/E8/*-2(E ,2%72(- E)2(-)+> 0/E8*+ E)2(-)+> -@> E0%%)< 0/E8*+ E0%%)< 0/E8*+
D*%%> 6/77*9F@B+2(%2 )
-2)+29
K+E%7+E
q - 7%2)%5E9E)+0(8 -@-E)%0%E(E +S(E)E -) )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
48/285
U\
(''G"(!D $" 7LH'D()?(
!(>H%H "O 7LH'D()?(
- H9E7(?(>+> (@)% 3738917)$:(1% -@> 3(53891:(1% >9E79EB/@8)(%@ 3(07-(2+>
7/8+> QE%7%S9898*(@+:N jI* 3E*%T 2+*+-E+:N o/(@(>(@+N F2%@ 6/*B-)+N z(>%?/>(@N $6;FHE
3(((:
Y->(-)(%@ QE%7- ;*1(8-@EN R6M
! D?N *-1;2619 – ]/@.-* 38-@>(>-N
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
49/285
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
50/285
VO
?#N%H$?)($?"#H
7;-:6,91;.
!&
K+E%7/%>+@%E8%79 3KXH:
- ;>?-@)-.+ (E 4;+2.1 B;90-=;9-1;,6 %B ) 1/2+-*201;. 3E)%77(@. 1*++>(@. B2%0 - )/0%/2N E)+@)(@. )?-@)-.+ %B 1-2(/0 ET-**%T (E )+72(?-)(%@
#&
IfY
- I%@E%*(>-)(%@ 3-E7(2-)(%@ 7@+/0%@(-:
- ;@9 )2-8+?(-)(%@ ^ 0-EE+E 8%072+EE(@. %@ %+E%7E 38%22+8) B*/(> >+B(8()E -@> -*E% -@9 +*+8)2%*9)+ >+2-@.+0+@)E:
- I%@E(>+2 B++>(@. T()< B*/(>E (B 7-)(+@) 8-@ )%*+2-)+ () 3%@*9
B%%>: %)+2 )/1+ B++>(@. %2 ',$ need to correct patient’s nutritionally
>+1(*()-)+> E)-)+
- j++7 $D4 (B 7-)(+@) 8-@@%) )%*+2-)+ +?+@ B*/(>E
- '2+-) -@9 -E7(2-)(%@ 7@+/0%@(-– $D4N FM -@)(1(%)(8E
#&
?6B291;:-12 V,+ 0642+=8;6: .-092 -64 1+2-1 ;1
qK+E%7
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
51/285
V!
(!D(@(H?(
%'?7%I?"@")L
- Y-2+ 3! (@ !OONOOO: 1/) 0%E) 8%00%@ 72(0-29 %+E%79E0%)(*()9
- '97(8-**9 72+E+@)E (@ ) T()< )(EE+8)(%@ 8-22(+> >%T@ )% )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
52/285
V#
)(H$G"%H"'D()%(@ G%O@>T 7?H%(H% J)%G7M
%'?7%I?"@")Ldb
- !O5=Od %B ) 19 T++J*9 E907)%0E
- ,2+?-*+@8+ %B XQYH -@> ()E 2+*-)+> 8%07*(8-)(%@E (@ ;E(- (E 2+7%2)+> )% 1+ (@82+-E(@. ) T()<
+@>%E8%7(8 +E%7 )% I^%2 (@82+-E+> -1>%0(@-* 72+EE/2+ *+->E )% 2+B*/S %B -8(>(8 .-E)2(8 8%@)+@)E (@)%
)/8+> 0/8%E-* >-0-.+
- K) .-E)2(8 %/)*+) %1E)2/8)(%@ ̂ ]/@8)(%@-* >+*-9+> .-E)2(8 +07)9(@.
F@82+-E+> .-E)2(8 -8(> E+82+)(%@
F@-772%72(-)+ 2+*-S-)(%@ %B AQ6
F@82+-E+> (@)2-5-1>%0(@-* 72+EE/2+ – %1+E()9N )(. (@8()+E (@B*-00-)(%@ (@ )
- I%0(@-* 72+EE/2+ – 72+.@-@89N 8+2 %B %+E%7+20- 3E9E)+0(8 E8*+2%E(E:
-
H2/.E ) /77+2 *(0() %B )+)+20(@+> Ec/-0%8%*/0@-2 G/@8)(%@ 3B%2 ) B%**%T5)(-.@%E(@. 2+B*/S 3*%T E+@E()(?()9 -@> E7+8(B(8()9:
- I-@ >%8/0+@) ) >(BB/E+ %+E%7 3=: -@
-1>%0(@-* *+@.)< %B r !80 7-)(+@)E T()< %@+ %2 0%2+ %B )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
53/285
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
54/285
VU
6/2.(8-*
- F@>(8-)(%@E
]-(*/2+ %B 2+*(+B T()< 0-S(0-* 0+>(8-* )+@8+ %B - >+B+8)(?+ AQ6
I%07*(-@8+ 72%1*+0E – 7-)(+@) >%+E @%) T-@) )% 1+ %@ 0+>(8-)(%@ B%2 *(B+
6+?+2+ E907)%0E %2 72%.2+EE(?+ >(E+-E+ 3(&+& %+E%7%@+: – - =[O >+.2++ 3)%)-*: T2-7 %B )/E
-2%/@> ) 8%07*(8-)(%@N 0-9 2+E/*) (@ 0+>(-E)(@()(E (B @%)
72%07)*9 >+)+8)+> -@> 2+7-(2+> (@)2-5%7+2-)(?+*9
“SlippedKNissen” %88/2E T%T@N )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
55/285
VV
(@ !O5!Vd %B 7-)(+@)E T()< +E%7(E+-E+
- R(.>*+5-.+> TH%H E G?H^ O(!$"GH
- ;EE%8(-)+> T()< *%@.5)+20 -8(> 2+B*/S ->-7)-)(%@ 0+8+2*9(@. 2+B*/S
- A(B+E)9*+ 8 E/772+EE(%@ 3R# 2+8+7)%2 -@)-.%@(E) %2 ,,F:N E/2.+29 3E(0(*-2 72(@8(7*+
)% )2+-)0+@) %B XQYH:
- Q*(0(@-)(%@ %B 2+B*/S 0-9 (E+-E+N 72+?+@) E)2(8)/2+
B%20-)(%@N %E8%7(8
E/2?+(**-@8+
#&
Q@>%E8%7(8 E/2?+(**-@8+#_
- ,-)(+@)E T()< 8(@. XQYH E82++@(@. +@>%E8%79 2+8%00+@>+>
- ,-)(+@)E T()< established Barrett’s Oesophagus with no dysplasia # E8%7+E (@ - 9+-2 -@>
(B @+.-)(?+ 2+7+-)N %@8+ +?+29 = 9+-2E
- ,-)(+@)E T()< *%T .2->+ >9E7*-E(- B%**%T /7 KXH -) [ 0%@) (B @+.-)(?+ 2+7+-)
9+-2*9
- ,-)(+@)E T()< + >9E7*-E(-N E 1+ )2+-)+> %)+?+*%70+@)
- ,-)(+@) T()< (@>+)+20(@-)+ >9E7*-E(- T()< +?(>+@8+ %B -8/)+ (@B*-00-)(%@ >/+ )% XQYH
2+7+-) KXH -@> 1(%7E9 -B)+2 \ T++JE %B +BB+8)(?+ -8(> E/772+EE(%@ )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
56/285
V[
!(#!%G "O $D% "%H"'D()>H
%'?7%I?"@")LUQ
- 4-*+ 72+>%0(@-@8+ -.+ E)-@>-2>(e+> (@8(>+@8+ 2-)+E B%2 6II` =&\V 7+2 !OONOOO (@ 0-*+E -@>
O&\! 7+2 !OONOOO (@ B+0-*+E
- F@8(>+@8+ %B 6II (E .2+-)+2 )+@%8-28(@%0- 3(@8(>+@8+ %B ->+@%8-28(@%0- O&V 7+2
!OONOOO (@ 0-*+E:
- ]2+c/+@89 %B %+E%7+@%8-28(@%0- (E (@82+-E(@. %T(@. )% (@82+-E+> 72+?-*+@8+ %B XQYH
-@> %1+E()9 3+E7+8(-**9 (@ T+E)+2@ 8%/@)2(+E:
- F@ 8%@)2-E)N )+@8+ %B Ec/-0%/E 8+** 8-28(@%0- 36II: %B ) )2%7 (@ )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
57/285
VW
'G%H%#$($?"#
4%E) 7-)(+@)E T()< +-2*95E)-.+ >(E+-E+ -2+ -E907)%0-)(8 %2 0-9 (E)-@) 0+)-E)-E(E %@ 72+E+@)-)(%@&
!&
,2%.2+EE(?+ >9E7 0%E) 8%00%@ 72+E+@)-)(%@:
- ]*/(> -@> E%B) B%%> 1+))+2 )%*+2-)+> )
#& K>9@%7+?+*%7E *-)+N /E/-**9 >/+ )% +S)2-5%+E%7/8+> -77+)()+N 0-*@/)2()(%@ -@> -8)(?+ 8-@8+2
U&
Y+./2.()-)(%@ E+8%@>-29 )% )/0%/2 >(E2/7)(@. @%20-* 7+2(E)-*E(E -@> 8-/E(@. %+E%7
]+-)/2+E E/..+E)(?+ %B 8%07*(8-)+> %+E%7?-@8+>! D*++>(@. 3+B(8(+@89 -@+0(-:
! K1E)2/8)(?+ 30-*@/)2()(%@N -E7(2-)(%@ 7@+/0%@(-:
! R%-2E+@+EE ?%8-* 8%2> 7-2-*9E(E 3YA$` *+B) i 2(.+)+20(@+ >+7)< %B T-** (@?-E(%@:N -@> $ E)-.(@. 3(>+@)(B9
0-*(.@-@) 3 I' -E
)(-* +BB/E(%@
- '2-8+?(-)(%@ %2 +S)2(@E(8 8%072+EE(%@ %B )2-8 E/7+2(%2 0+>(-E)(@/0 (@ -@ /77+2 %+E%7 (-7 4 E)-.(@.
!
$%>+E i !O00 -2+ 8%@E(>+2+> )% 1+ 0+)-E)-)(8
U& ,%E()2%@ Q0(EE(%@ '%0%.2-7 I' 68-@ 3,Q'^I':
!
]HX5,Q' (E )(E)-@) 0+)-E)-)(8 >(E+-E+
=#
3(>+@)(B(+> (@ y#Od (B7-)(+@)E T-)+` 4-@-.+0+@) %B *%8-**9 ->?-@8+> /@2+E+8)-1*+ +E%7
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
58/285
V\
!,5*=;.-1;,69
!& ]/** 1*%%> 8%/@) A%T R1 3-@+0(- B2%0 8 *%EE:
R(.< 'P 3-E7(2-)(%@ 7@+/0%@(-:
#&
Z2+-N +*+8)2%*9)+EN 82+-)(@(@+ +*+8)2%*9)+ >(E)/21-@8+E B2%0 ?%0()(@.N 7%%2 (@)-J+ 3/2+-`
82+-)(@(@+ 2-)(% %B i !OO`! T%/*> E/..+E) 72+52+@-* 8-/E+ %B >+2-)(%@:
=&
A(?+2 B/@8)(%@ )+E)E *%T -*1/0(@ T()< @/)2()(%@-* >+72(?-)(%@
U&
A-29@.%E8%79 -EE+EE ?%8-* 8%2> 7-2-*9E(E
'+2K,*2+-1;B2 ?6B291;:-1;,69
!&
Xf4
#& ,'^,'' 5 (@ ?(+T %B 7-)(+@) .%(@. B%2 (@?-E(?+ 72%8+>/2+E 3(&+& KXH:
=& IfY ^ QIX ^ A/@. ]/@8)(%@ '+E) ̂ #H Q8 !!
A+EE (@?-E(?+N E-B+ -@>
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
59/285
V_
H0+:;.-= G292.1;,6 _ "*26 E I;6;5-==8 ?6B-9;B2 %9,*/-:2.1,58
J;M $+-691/,+-.;. %9,*/-:2.1,58 J$$%M ?B,+ @2A;9 $$% ,+ I.^2,A6 %9,*/-:2.1,58
!
F?%2 A+T(E 'T%5E)-.+ 72%8+>/2+ (@?%*?(@. .-E)2(8 0%1(*(E-)(%@ 3B(2E) E)-.+N >%@+
)*(@+ -1>%0(@-* (@8(E(%@:N %+E%7+>
*907+@+8)%09 -@> (@)2-5) %@+ (@ )E ) (@?%*?+E - 8+2?(8-* +E%7(%?-E8/*-2 I%07*(8-)(%@E
!
,%E)5+E%7
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
60/285
[O
'-==;-1;B2 1+2-15261 J-;5P +2=;2V ,391+0.1;,6 -64 489*/-:;-M – 0+>(-@ E/2?(?-* %B U 0 %@)(%) B%2 -))+07)+> 8/2+ -@> 7-**(-)(%@ %B 7-)(+@)E T()< 6II 32->(%5E+@E()(?+: >++0+>
/@E/()-1*+ B%2 2+E+8)(%@
!
ZE/-**9 .(?+@ (@ 8%01(@-)(%@ T()< 8(-)(%@ %2 12-8 ?(- $X 31/) -*E% 8%@E(>+2 8%07*(8-)(%@E T()<
*%@.5)+20 $X 7*-8+0+@) +&.& +2%E(%@E -2%/@> @-E-* -2+-N E(@/E()(E:m 8%@E(>+2 '%) *=-.25261Y B%2
*%@.5)+20 B++>(@. (B -1*+ )% .+) E8%7+ -2%/@> )/0%/2
- FB /@-1*+ )% 7-EE )/1+ %2 E8%7+ -2%/@> )/0%/2N 8%@E(>+2 ,*26 :-91+,91,58
- '%)-* 7-2+@)+2-* @/)2()(%@ (E -@%)
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
61/285
[!
>''%G H%H
(''G"(!D $" ''%G )?$
!(>H%H
M-2(8+-* D*++>
!&
X-E)2%5%+E%7
#& ,+7)(8 /*8+2 >(E+-E+ 31*++>(@. 7+7)(8 /*8+2: 3VOd:
=&
X-E)2()(EN .-E)2(8 +2%E(%@EN >/%>+@()(E
U&
4-**%295P+(EE )+-2 3!Od:
V& X-E)2(8 0-*(.@-@89 3!Od:
[& H(+/*-B%9 *+E(%@ – *-2.+ )%2)/%/E -2)+2(%*+ 3-@+/29E0: (@ )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
62/285
[#
UR
(21;,=,:;.-= .=029 J4;VV2+261;-1;6: .-0929 ,V 6,6KB-+;.2-= 3=224M
,+7)(8 Z*8+2 H(E+-E+ 30%E) 8%00%@ 8-/E+:
- R(E)%29 %B >9E7+7E(-N 72+?(%/E R& 79*%2( (@B+8)(%@EN 72+?(%/E KXH >%@+
- H2/. R(E)%29 – $6;FHEN -@)(7*-)+*+)EN E)+2%(>EN -@)(8%-./*-@)EN 'I4
- 6+8%@>-29 )% 8(22/8+> +82+-E+> /8+> 19 +*+?-)+> FI,
4-**%295P+(EE )+-2
- F) (E - >(-.@%E(E %B +S8*/E(%@
- 6+8%@>-29 )% ?(%*+@) 2+)8(@-* )+-2 1+*%T
)(@. )% (@. 8%0(@. B2%0 -@ -2+- %B -77-2+@)*9 @%20-*
.-E)2(8 0/8%E- 8 19 - *-2.+ )%2)/%/E -2)+2(%*+ (@ )E 3(&+& R'$N FRHN IY]N H4:
- 6/E7+8) (@ 1*++>(@. T()< @% (-)+ -@+0(-N 0+*+@-N 9E7@+EE
- A-)+ *%EE %B -77+)()+N *%EE %B T+(.(8+ 30+)E )% *(?+2:
gR
(5,061 ,V 3=,,4
- FB 7-)(+@) (E (@. 0%2+ )(ee(@+EEN E9@8%7+N 8 ,/*E+ ,2+EE/2+N Y+E)(@. '-8(-N ,%E)/2-* R97%)+@E(%@
=O5UOd 8*-EE = – 6/7(@+ R97%)+@E(%@N 0-2J+> )-8N -@S(%/E
i UOd 8*-EE U – 4(@(0-* /2(@+ %/)7/)N 0-2J+>*9 >+72+EE+> %2 *+) %?+2*%-> >/2(@. 2+E/E8()-)(%@ FRH^II]N IY]
'DLH?!(@ %T(I?#($?"#
!& M()-* 6(.@E 30%E) (07%2)-@):- ;EE+EE 9@-0(8 E)-1(*()9 -@> 7%E)/2-* D,- ;@9 2+E)(@. )-8(-
#& I%@B(20 ZDXF'5
HYQ B%2 0+*+@(8 E)%%* 3>(BB+2+@)(-)+ B2%0 ]+5*->+@ E)%%*E:
=&
H+)+20(@+ Q)(%*%.95
M-2(8+-* D*++> E)(.0-)- %B 8(E+-E+N G-/@>(8+5 $%@5?-2(8+-* 1*++>
!
RL$` D*++>(@. E%/28+ (@ @%E+ %2 0%/)+EN!
;1>` '+@>+2@+EEN ./-2>(@.N 2+1%/@>N +7(.-E)2(8 0-EEN -2)+2(-* 12/() %B ;;;!
Y+8)-*` ,Y 1*++>N -@-*N 7+2(-@-* %2 2+8)-* 7-)(-8 ;/E8/*)-)(%@ – E(@. 3(((: 8%**-7E(@. 7/*E+
R-@>E – 7-**%2 %B 7-*0-2 82+-E+E- A/@.E +S-0(@+ B%2 -E7(2-)(%@ 7@+/0%@(-- QS8*/>+ ,+2()%@(E0
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
63/285
[=
?II%7?($% I(#()%I%#$
P+)+20(@+ )(@. inform GS registrar on call of the patient’s admission
QR
G2909.;1-1;,6
- ;DI
;EE+EE (B 7-)(+@) 8-@ 2+E7%@> *%.(8-**9 .%%> 8+2+12-* 7+2B/E(%@N %) +)(%*%.9 -@> %/)8%0+: – >% (@ -*8%(-8 +@e90+E )% >+)+8) -@9 ;4F 36'Q4F:
\&
IfY` 2^% 7+2B%2-)(%@N -E7(2-)(%@
qP()< ?%0()(@. j kN I*5N $-k -@> R#K (E *%EE B2%0 )9 F@)2-?-E8/*-2 19 bX; -@>
*+->E )% ) R#K ?(- J(>@+9 3$-k ^jk ;',-E+: -@> +S82+)+ jk
D/) E(@8+ jk
(E 82()(8-* (@ 0-(@)-(@(@. 8-2>(-8 0+012-@+ E)-1(*(e-)(%@ 1%>9 -))+07)E )% 8%@E+2?+ jk
197-2->%S(8-**9 (@82+-E(@. +S82+)(%@ %B Rk 3-*J-*%E(E -*E% *+->E )% - *%T+2(@. %B ) 8-*8(/0N -@>
)+)-@9 8-@ %88/2:
- FB 7-)(+@) (E (@ I*-EE FF E% 0%@()%2(@.
F^K 8+2
!
3=: $%@52+E7%@>+2
'2-@E(+@) Y+E7%@>+2 jFM 8%**%(>E 3.+*%B/E(@+ ^ +2 4-@-.+0+@) jFM 8%**%(>EN Q51*%%>E -@> ->G/@8) 0%@()%2(@. 3IM, *(@+:
-(0 )% E)-1(*(E+ 7-)(+@) B%2 )2-@EB+2 )% E8%7+ 2%%0 B%2 +0+2.+@89 E8%7+ (@ )
! Y+E)2(8)(?+ )2-@EB/E(%@ E)2-)+.9 )% J++7 R1 i W.^>A 3E (072%?+> %/)8%0+E -E
8%07-2+> )% *(1+2-* )2-@EB/E(%@ E)2-)+.9 g)2-@EB/E(%@ T 3 k ?()-0(@ j:
dR
(4[06.19
- $X )/1+ (B 7-)(+@) (E %E+ UO0. 1>:
- FB E/E7+8)(@. ?-2(8+E – FM E%0-)%E)-)(@̂ %8)2+%)(>+N FM -@)(1(%)(8E
- P()
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
64/285
[U
fR
%52+:26.8 ,29,*/-:,:-91+,40,426,9.,*8J")7M ;*)+2@-)(?+*9N E8%7+ )-9:
- = F@>(8-)(%@E`!& 6-)(%@:#&
;8)(?+ DXF' 3+E7& ?-2(8+-* 1*++>
- $%) G/E) *%T R1 -E +0+2.+@89 E8%7+ 8-/E+E 0%2+ E)2+EE- Xf4 1*%%>E -@> )2-@EB/E+> -E 8*(@(8-**9 (@>(8-)+>
- Y%*+ %B +@>%E8%79 3(: >(-.@%E)(8-)+N 3((: )%E8%7(8 2+)2+-)0+@) -@> 1*%%> )2-@EB/E(%@=W
- I%@)2-(@>(8-)(%@E` ,+2B%2-)(%@ – -(2 (@E/BB*-)(%@ >/2(@. KXH T(** 8-/E+ -1>%0(@-* 8%07-2)0+@) E9@>2%0+ >+82+-E+ ?+@%/E 2+)/2@ 7-)(+@) 0-9 HFQ
E7*(@)(@. %B )(-7+72+EE(%@ E+8%@>-29 )% -(2T-9 8%072%0(E+#&
IM6 2(EJ – ;4FN IM;
,2%8+>/2-*5Y+*-)+> Y(EJ
!&
D*++>(@. -@> ,+2B%2-)(%@ 3! (@ !ONOOO:#& ]-(*/2+ %B +@>%E8%7(8 -2> KXH E8%7+ )% H# 3*(.-0+@) %B '2+()e:
=W $ Q@.* b 4+> #OOOm =U=`=!O5=![
7?()#"H$?! H$>7?%HUj
=\ ,%8J+) 4+>(8(@+ U)()(%@` X-E)2%(@)+E)(@-* D*++>(@. – 6+8)(%@ =5=
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
65/285
[V
H>#$ I(#()%I%#$
QR
G;9W H1+-1;V;.-1;,6 G,.W-== H.,+2 J922 32=,AM ,+ FRHN II]N Y+@-* ^ A(?+2 ]-(*/2+
,
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
66/285
[[
'"G$(@ DL'%G$%#H?"#
Hepatic venous pressure gradient (HVPG) ≥ [00R. 3@%20-* p !5V00R.:
Portal HTN ≥ 10mmHg – >+?+*%70+@) %B -E8()+E
$%20-* 7%2)-* B*%T 2-)+ (E -1%/) !5!&VA^0(@
(#($"IL
- ,%2)-* ?+(@E >2-(@ 1*%%> B%2 )>+2&
- ' )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
67/285
[W
!(>H%H "O '"G$(@ DL'%G$%#H?"#
,2+5 3A(?+2 L 67*++@: – 2->(%*%.(8-* B(@>(@.E`
Dilated splenic and superior mesenteric veins ≥ 11mm
67*+@%0+.-*9 i !#80
Y+>/8)(%@ (@ 7%2)-* B*%T 0+-@ ?+*%8()9 r!# 80^E+8%@> H(*-)+> 7%2)-* ?+(@ ≥ 13m0
,%2)%5E9E)+0(8 8%**-)+2-*E – 2+8-@-*(e-)(%@ %B )/*-2 *(?+2N 7%2)-*^E7*+@(8^64M )
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
68/285
[\
(H!?$%H
'($D")%#%H?H J?# !?GGD"$?! '($?%#$HM
,2%.2+EE(?+ *(?+2 8(22(-.@%E(E
!
;1>%0(@-* >(E)+@E(%@
! ]*-@J >/**@+EE E/**@+EE 37-) ) *(J+ )% 8%E+` !OO0. E7(2%@%*-8)%@+ -@> UO0. B/2%E+0(>+ K4 32-)(% !O`U: – 0-S UOO0.`![O0.
6%*+*9 -E8()+E /E+ E7(2%@%*-8)%@+N (B 8%@8%0()-@) 7+>-* +>+0- ->> B/2%E+0(>+
t ;0(*%2(>+ 3(B 7-(@B/* .9@+8%0-E)(- >/+ )% E7(2%@%*-8)%@+:
! ;@)(1(%)(8E – (B E/E7+8) E7%@)-@+%/E 1-8)+2(-* 7+2()%@()(E 36D,:
k?+ -E8()(8 B*/(> 1-8)+2(-* 8^E
↑ ascitic fluid PMN ≥ 250cells/mm= 3%2 -E8()(8 B*/(> PDI i VOO8+**E^00=:
FM 8+B)2(-S%@+ %2 %2-* c/(@%*%@+E 3(&+& 8(72%B*%S-8(@:
! ;?%(> %2 /E+ T()< 8-/)(%@ (@ 7-)(+@)E T()< 8(22+2*9(@. 8-/E+ (B 7%EE(1*+!
A(?+2 )2-@E7*-@) B%2 8(22
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
69/285
[_
N(G?!%(@ -EJ 7-)(+@) T
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
70/285
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
71/285
W!
??R 'G"'DL@(T?H "O N(G?!%(@ (E82+)+ E7%)E – resemble “blood blisters”)
- H(BB/E+ +29)
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
72/285
W#
'%'$?! >@!%G 7?H%(H%
%'?7%I?"@")Lgf J>^ (>7?$M
- Y+0())(@. -@> 2+*-7E(@. *+E(%@E 0%E) %B)+@ >(-.@%E+> (@ 0(>>*+5-.+> )% %*>+2 ->/*)E
- F@8(>+@8+ p !OO 7+2 !OONOOO 7+2 9+-2
- 4`] 2-)(% B%2 >/%>+@-* /*8+2E p =`!
- A(B+)(0+ 2(EJ B%2 >+?+*%7(@. ,ZH p !Od
- K?+2-** 0%2)-*()9 p W5!OdN /@8 B%2 *-E) # >+8->+E – 0%E)*9 >/+ )% /*8+2 1*++>(@. +E7+8(-**9
(@ +*>+2*9 T()< E(.@(B(8-@) 8%0%21(>()(+E
I(?# (%$?"@")?!(@ O(!$"GH
R+*(8%1-8)+2 ,9*%2(
F@B+8)(%@
- [Od %B 7%7/*-)(%@ -2+ 7%E()(?+ B%2 R& 79*%2( 19 -.+ #!
- ;1%/) !O5#Od %B (@B+8)+> 7-)(+@)E >+?+*%7 -@ /*8+2
- X-E)2(8 /*8+2 #O )% R& 79*%2( (@B+8)(%@ )+@> )% %88/2 %@ *+EE+2 8/2?-)/2+U[
- -^T \Vd %B >/%>+@-* /*8+2E L [\d %B .-E)2(8 /*8+2EUW
$6;FH
- \5B%*> (@82+-E+ (@ 2(EJ %B >/%>+@-* /* 8+2E
- UO5B%*> (@82+-E+ (@ 2(EJ %B .-E)2(8 /*8+2 30%2+ %B)+@ %@ .2+-)+2 8/2?-)/2+:
- Z*8+2E (@ $6;FH /E+2 T+2+ 0%2+ *(J+*9 )% 1+ -^T ZDXF'
- H%E+5>+7+@>+@) 2+*-)(%@E% @%) 2+8/2 T(E8%@)(@/+>
60%J(@.- # )(0+E (@82+-E+> 2(EJ 8%07-2+> )% @%@5E0%J+2E 3(07-(2E 0/8%E-* 1*%%> B*%T -@>
+ B-?%/2-1*+ 0(*(+/ B%2 R& 79*%2(:
K)+?+*%70+@) >+7+@>E %@ (01-*-@8+ 1)T -8(> E+82+)(%@ -@> ) -8)(?()9N 7+7E(@ -8)(?()9N R& ,9*%2( L $6;FHE
- RI* E+82+)+> 19 7-2(+)-* 8+**E 3E++ 1+*%T:
- ,+7E(@%.+@ E+82+)+> 19 8 )% 7+7E(@ 19 RI*
- 4-G%2 72%>/8)(%@ E()+ p .-E)2(8 B/@>/E -@> 1%>9
'+,12.1;B2 52./-6;959`
- 4/8/E E+82+)(%@
- D(8-21%@-)+ E+82+)(%@ (@)% 0/8/E
- Y%1/E) 0/8%E-* 1*%%> B*%T )% 2+0%?+ 72%)%@E
- Q7()(@ E+82+)(%@ 19 0/8%E- )% 0-(@)-(@ 1*%%> B*%T
- H/%>+@-* /*8+2E >/+ )% 2F.299;B2 -.;4 m *2*9;6 92.+21;,6 )+B+@8+E 3 T(@ E9@) 3U: (@ E+82+)(%@
- X-E)2(8 -8(> E+82+)(%@ 19 ) 19 /;91-5;62 3QIA 8+**E:N :-91+;6 3X 8+**E: %2
(!D 3?-.-* @+2?+ E)(0/*-)(%@: T
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
73/285
W=
'G%H%#$($?"#
QR ?6.;4261-==8 4212.124 ,6 ")7
dR
H85*1,59 ,V 489*2*9;-
3-:
Z*8+25*(J+ >9E7+7E(-` 1/2@(@.N .@-T(@.N (@)+20())+@) +7(.-E)2(8 7-(@
H/%>+@-* /*8+2 2+*(+?+> 19 B%%> -@> (@.+E)(%@ %B -@)-8(>E
X-E)2(8 /*8+2 7-(@ +S-8+21-)+> T()< B%%> (@)-J+ 7-)(+@) -?%(> B%%> -@>
72+E+@)E T()< T+(./%>+@-* /*8+2E:
31: H9E0%)(*()95*(J+ >9E7+7E(-` @%@57-(@B/* >(E8%0B%2) 3/77+2 -1>%0+@:N -^T /77+2
-1>%0(@-* B/**@+EEN @-/E+-N ?%0()(@. +-2*9 E-)(+)9N 1*%-)(@.N 1+*8 >9E7+7E(-
UR -@> 8+B(8(+@89 -@+0(-
- 6+?+2+ -@> -8/)+` E ?%0()/E: %2 0+*+@-
gR
'2+V,+-1;,6
-
P()< 8%@E+c/+@) -8/)+ 7+2()%@()(E- 6/>>+@ %@E+) %B +7(.-E)2(8 7-(@ – 7-)(+@) -1*+ )% 2+8-** +S-8) )(0(@.
- $% 2+*(+?(@. B-8)%2E
- K^Q`
'%S(8 3B+?+2:
6%0+@ T()< 8%@)2-E)
Z2.+@) D-2(/0 8%@)2-E) 0+-* T()< B%**%T )"7%#"H!"'Lt J")7M – U ?#7?!($?"#H
J-M
7;-:6,9;9
I%@B(20-)(%@ %B ,+7)(8 Z*8+2 H(E+-E+ 3,ZH: – @%)+ *%8-)(%@ %B /*8+2
D(%7E9 )% 2/*+ %/) 0-*(.@-@89 3/E/-**9 [ 1()+E: – +E7+8(-**9 (B E^E 3T+(. 0-EEN B%*>E -2%/@> /*8+2: -2+ 72+E+@)
D(%7E9 2-7(> /2+-E+ )+E)(@. 3IAK)+E): – -@)2-* 1(%7E9 B%2 R& 79*%2( 1(%7E9 )(EE/+ 7*-8+>
(@)% - 0+>(/0 8%@)-(@(@. /2+- -@> -@ (@>(8-)%2 E/8< -E 7& '/8+> 19 R& 79*%2( 2%*9E+E /2+- )% -00%@(-N T
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
74/285
WU
"$D%G ?#N%H$?)($?"#H
- D-2(/0 4+-* L ]%**%T5'(E)(@./(E(E+-E+& 3E++ 1+*%T:
- ]-E)(@. 6+2/0 X-E)2(@P E82++@ B%2 .-E)2(@%0- 3z%**(@.+25Q**(E%@ 69@>2%0+:
- 6+2/0 I-*8(/0` E82++@ B%2 0/*)(7*+ +@>%82(@+ @+%7*-E(- 34Q$:
- Z2+- D2+-)< '+E)` E82++@ B%2 R& ,9*%2( F@B+8)(%@ 3E++ 1+*%T:
- 6)%%* ;@)(.+@ '+E)` E82++@ B%2 R& ,9*%2( F@B+8)(%@
- 6+2%*%.(8 '+E)(@. 3F.X -@> F.; QAF6; )+E)E:` E82++@ B%2 R& ,9*%2( F@B+8)(%@ 3@%) 2+8%00+@>+>:
O,++291 !=-99;V;.-1;,6
]%22+E) .2->+ 3+@>%E8%7(8 E)(.0-)-: ,2+?-*+@8+ D*++>(@. 2(EJ
!; 67/2)(@. 3-2)+2(-*:!\d
!OOd!D $%@5E7/2)(@.N %%e+ 3?+@%/E: VVd 3!W5!OOd:
#; $%@51*++>(@. /*8+2 T()< ?(E(1*+ ?+EE+* !Wd U=d 3\5\!d:#D $%@51*++>(@. /*8+2 T()< ->
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
75/285
WV
$G%($I%#$ J'>7M
QR
I24;.-= $/2+-*8 m @;V2918=2 I,4;V;.-1;,69
-& 60%J(@. L ;*8% (E-..2+.-)(%@ pWWdN 7R p W&= >(E-..2+.-)(%@ p Od
,,F -2+ +BB+8)(?+ B%2 B-8(*()-)(@. /*8+2 %/1*+ >%E+ B-0%)(>(@+ 3UO0. DH: – -8E (EE)%77+>
6Q` >(-22(BB 3+E7& (@ +*>+2*9:N >+82+-E+> +BB(8-89 %B 8*%7(>%.2+*8& $6;FH5-EE%8(-)+> ,ZH
H(E8%@)(@/+ %BB+@>(@. 0+>(8-)(%@ -@> (@()(-)+ -@)(5E+82+)%29 )&
R& ,9*%2( Q2->(8-)(%@
](2E) *(@+ )2(7*+ )%E8%79
Y+5E8%7+ (@ [ T++JE )% >%8/0+@) .-E)2(8 /*8+2 + 0-*(.@-@89 B%2 XZ: -@> -*E% >% -@)2-* 1(%7E9 B%2 2-7(> /2+-E+)+E) – IAK)+E) 3)% 8%@B(20 +2->(8-)(%@ %B R& 79*%2(:
$%@5 E/2.(8-**9
UR $+-69.-1/212+ (+12+;-= %53,=;e-1;,6 J922 32=,AM
gR
H0+:;.-= $/2+-*8
- $++> B%2 E/2.(8-* (@)+2?+@)(%@ (E >+8*(@(@. T()< T(>+E72+-> /E+ %B R# 2+8+7)%2 -@)-.%@(E)
3B-0%)(>(@+: -@> *+,1,6 *05* ;6/;3;1,+9 J,52*+-e,=2M
- I%07*(8-)(%@E E/8< -E 2+B2-8)%29 (8-)(%@ B%2 E/2.(8-* 0-@-.+0+@) 3E++ 1+*%T:
H/%>+@-* 6/2.+29 X-E)2(8 6/2.+29
!& ,+2E(E)+@) D*++>(@. 3+2%E(%@ %B 7%E)+2(%2
>/%>+@-* /*8+2 (@)% .-E)2%>/%>+@-* -2)+29:
#& ,+2%2-)(%@ 3-@)+2(%2 >/%>+@-* /*8+2 )+@> )%
7+2B%2-)+:
=& X-E)2(8 K/)*+) K1E)2/8)(%@
U& ]-(*/2+ %B 4+>(8-* 4-@-.+0+@) %2 $%@5
8%07*(-@8+
!& ]-(*/2+ )% (@.
H/%>+@-* Z*8+2E
- ZE/-**9 1+@(.@ /*8+2E monitor patient’s response to medical intervention
,2%8+>/2+ Y+0-2JE
'2/@8-* ?-.%)%09 T()<79*%2%7*-E)9
$+06.-= B-:,1,58Y +*(0(@-)+ >(2+8) 8 ?-.-*
E)(0/*-)(%@ B%2 .-E)2(@ 2+*+-E+ (E -1%*(E
Y$+06.-= B-:,1,58 2+E/*)E (@ 2+>/8+> -8(> E+82+)(%@ -@> - E)%0-8< T+c/-)+*9 3)2-@E+8)+> @+2?+ %B A-)-2G+): )(@-**9 )52+>/8(@. %7+2-)(%@ (E 2+E+2?+> B%2 -8(> Q>()(%@: 7!!\
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
76/285
W[
$G%($I%#$ J!"I'@?!($%7 '>7M
I%07*(8-)(%@E H/%>+@-* Z*8+2E X-E)2(8 Z*8+2E
R-+0%22(@. 8-/E+ %B >+-)< >/+ )% ,ZH -^T V5!Vd 0%2)-*()9
- %64,9.,*;. 1+2-15261 72+B+22+> )(@. /*8+2
Q@>%E8%7(8 F@G+8)(%@ %B +7(@+7+ L ? -E%8%@E)2(8)(?+ +BB+8)
'%E8%7(8 -9E:
;) W# /8)(%@ %B U=d
H(BB+2+@8+ (@ 2+51*++>(@. 2+8/22+@8+ 2+0-(@+> E(.@(B(8-@) -) W -@> =O >-9E
Y+>/8+ @++> B%2 +@>%E8%7(8 2+5)2+-)0+@) -@> E/2.(8-* (@)+2?+@)(%@
- FB ,,F (@B/E(%@ @%) -?-(*-1*+ 2+8%00+@> E+8%@> +@>%E8%79
- $+-69.-1/212+ (+12+;-= %53,=;e-1;,6 3';Q: – -*)+2@-)(?+ )% E-*?-.+ E/2.+29
I+*(-8 -@> E/7+2(%2 0+E+@)+2(8 -@.(%.2-0 7+2B%20+> – (@ 8-E+ %B 8%@)2-E)+S)2-?-E-)(%@ E/7+2 E+*+8)(?+ 8-@@/*-)(%@ %B )(@. ?+EE+* B%**%T+> 19
-@.(%.2-7(E)-* )% 72%S(0-* 0-@@+2 T%/*> 1+ >%@+ )(**
+S)2-?-E-)(%@ 8+-E+>
';Q ?E& 6-*?-.+ 6/2.+29V= – F@ 7-)(+@)E T()< /*8+2 1* ++>(@. -B)+2 B-(*+> +@>%E8%7(8
>+@ -8/)+ %@E+) %B E+?+2+ -1>%0(@-* 7-(@ .+@+2-*(e+> 7+2()%@()(E 38%@)+@)E E7(**
(@)% -1>%0(@-* 8-?()9: %2 *%8-*(e+> 37+2B%2-)(%@ T-**+> %BB 19 %0+@)/0 %2 ->G-8+@)
E)2/8)/2+E 72+?+@)(@. 7+2()%@+-* 8%@)-0(@-)(%@:
- 4%2+ 8%00%@ (@ +*>+2*9 7-)(+@)E %@ 8+2 )(-7^%2 (B (@ >%/1)
@-* ,5261-= J)+-/-5M *-1./ +2*-;+
'2+;1,62-= 423+;425261 E A-9/,01
DR '8=,+; 2+-4;.-1;,6
q 7+2B HZ /E/-**9 *%8-)+> -) -@)+2(%2 T-** %B H!
H;5*=2 A24:2 +292.1;,6 J0=.2+2.1,58M
2=;5;6-12 *2+V,+-1;,6 -@> 2F.=042
5-=;:6-6.8 3)2-8+ 0-*(.@-@89
)-91+2.1,58 J ;8/)+ A/@. F@G/29 3'Y;AF:
;8/)+ ]+12(*+ R-+0%*9)(8 Y+-8)(%@
$%@5
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
77/285
WW
(#($"IL "O $D% H$"I(!D J''@L (#7 @LI'D($?! 7G(?#()%M
I+*(-8 )2/@J 3'!#:H*=26;. (+12+8
@2V1 )-91+;.(+12+8
Y(./%>+@-*3-@)& L 7%E)&:
6/E:
QE%7
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
78/285
W\
)(H$G?! !(#!%G
%'?7%I?"@")LVU
- W) \) 0%2)-*()9 (@ 0-*+E -@> V) W&O^ !OONOOO (@ ]+0-*+E
- A(B+)(0+ 2(EJ B%2 E)%0-8< 8-@8+2 (@ I+82+-E(@. 1/) E )% (@82+-E+> (@8(>+@8+ %B XQYH:
(@. (@ -@)2/0 -@> %88*/>(@. ()
- 3(: ,2+E+@8+ %B B%%> >+12(E -@> 3((: -1E+@8+ %B >/%>+@-* ?(E/-*(e-)(%@ (07*(8-)+E (@-1(*()9 )%
(@)/1-)+ 7-E) )-29 )% >(E)-* .-E)2(8 8-28(@%0- 3*(J+*9 D%220-@@ )97+ f:
- ,2%8++> T()< - 1S B%2 72%.@%E)(8-)(%@ 19 A-/2+n’s Classification
$8*2 g – @;6;1;9 '=-91;.-- ,%%2*9 >(BB+2+@)(-)+>
- H(BB/E+ (@?%*?+0+@) t E(.@+) 2(@. 8+**E
- ZE/-**9 (@ 9%/@.+2N B+0-*+ 7-)(+@)EN *-)+ 72+E+@)-)(%@ 30-*(.@-@) -E8()+E: T()< 7%%2 72%.@%E(E
VU '2+@>E (@ I-@8+2 F@8(>+@8+ (@ 6(@.-7%2+ #OO\5#O!# 3>-)- 2+7%2) -2+ -E %B W)< b/@+ #O!=:
G?H^ O(!$"GH – I>@$?O(!$"G?(@ J?#O%!$?"#\ %#N?G"#I%#$\ )%#%$?!HM
3H(?(>+ Y] (@)% 4-G%2 -@> 4(@%2 Y(EJ ]-8)%2E – 0-G%2 (@8*/>+E` R& 79*%2( -@> H(+):
QR
?6V2.1;,6 – D2=;.,3-.12+ '8=,+;
- ;EJ 7-)(+@) -1%/) 7-E) (@B+8)(%@N T+?+*%7(@. .-E)2(8 8-@8+2
dR
%6B;+,65261-=
- 7;21P 72+E+2?+> B%%>E 3@()2%E-0(@+E – 8-@@+> B%%>:N E0%J+> B%%>E 3 2(EJ %B .-E)2(8 8-@8+2 3(@)+E)(@-* 8-@8+2 %B >(E)-* E)%0-8 -@> >(+) -^T (@82+-E+> 2(EJ
- (9*;+;6\ O+29/ O+0;19 m N2:21-3=29\ H2=26;05 m N;1-5;6 ! *+,12.1;B2 V-.1,+9
UR
)2621;.- O-5;=8 D;91,+8` !&VS (@82+-E+> 2(EJ (@ E(1*(@.E ̂ %BBE72(@. %B 7-)(+@)E T()< .-E)2(8 I;
- )% .+20*(@+ 0/)-)(%@ %B +58->
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
79/285
W_
D?H$"@")?!(@ $L'%H
(426,.-+.;6,5-9 J]fkM
- ]2%0 0/8%/E 72%>/8(@. 8+**E (@ )(@.: )97+ – 7-7(**-29N )/1/*-2N 0/8(@%/E
K88/2 (@ +*>+2*9 0-*+E -@> (@ )(E)-* E)%0-8< 30%2+ *(J+*9 )% 8-/E+ XKK:
,2+8/2E%2 *+E(%@ %B (@)+E)(@-* 0+)-7*-E(- -@> >9E7*-E(- 3-E (@ 8 )% >(E)-* %2.-@E
31:
H(BB/E+ 3(@B(*)2-)(?+: )97+ – E(.@+) 2(@. 8+**N /@>(BB+2+@)(-)+>
-^T (@?-E(?+ .2%T)< 7-))+2@ -@> 2-7(> E/10/8%E-* E72+-> *(@()(E 7*-E)(8-
K88/2 (@ 9%/@.+2 7-)(+@)EN B+0-*+E -@> (@ ) )3!!m!\: )2-@E*%8-)(%@
85jF' 3.-(@ %B B/@8)(%@
0/)-)(%@:N ,HX]Y; 37*-)+*+)
>+2(?+> .2%T)< B-8)%2
receptor α gene mutation)
Y+0-2JEI-28(@%(> 69@>2%0+ –
-^T 0+)-E)-)(8 >(E+-E+q
4;A' p 0/8%E-* -EE%8(-)+> *907
)(EE/+
85jF' 7%E()(?+ )/0%/2E )2+-)
T()< (0-)(@(1 3'jF:
*”Carcinoid syndrome: due to release of vasoactive substances into systemic circulation; characterized by cutaneous flushing,
ET+-)(@.N 12%@8%0(@-* 7-(@N >(-22 8-2>(-8 ?-*?/*-2 B(12%E(E 3@%)+` 8-28(@%(>E 8%@B(@+> )% )(@. JQM 9;e2 c QX.5\ JdM 5;1,1;. ;642F cfEQX/*V m JUM 9;12 J2F1+-K:-91+;. *,9;1;,6M – 0-@9 -2+ B%/@> (@8(>+@)-**9 1/)
0-9 72+E+@) -E ?-./+ -1>%0(@-* 7-(@ 30-EE +BB+8):N XF 1*++> 3@+82%E(E %B %?+2*9(@. 0/8%E-:N +-2*9 E-)(+)9N AKP 3%1E)2/8)(?+
E907)%0E:
'G%H%#$($?"#
Q-2*9 )% F@)+20+>(-)+ F@)+20+>(-)+ )% A-)+ A-)+
R(E)%29
- (985*1,5-1;.- #,6K9*2.;V;. %*;:-91+;. '-;6
E 789*2*9;-32+c/(2+ +S %BE/E7(8(%/EN +-2*9 72+E+@)-)(%@-@> (@)+2?+@)(%@ p 1+))+272%.@%E(E:
;@9 72+?(%/E KXHl 3(@ b-7-@ – KXH (E - E82++@(@. )%%*:
X-E)2(8 -@)(5E+82+)%29 -.+@)ET(** (072%?+ E907)%0E -@>0-9 0-EJ X-E)2(8 I;– >(E+-E+E B(2E) 1+ +S8*/>+> 3@+T%@E+) >9E7+7E(- -) -.+ i =VE 8-/E+ 8%@8+2@:
- (625;-u\ I2=26-\D25-12529;9
- %-+=8 H-1;218 -64 489*/-:;-38-2>(- )/0%/2:
- #-092-\ N,5;1;6:3%1E)2/8)(%@ >9E7@+EE:
FB 72+E+@) T()< 79*%2(8 )/0%/2N72+E+@)-)(%@ (E *(J+ )""
u]+ H+B(8(+@89 ;@+0(- #% )%)/0%/2 1*++> – *%T B+22()(@N*%T E+2/0 ]+N 2%0+:-@> 3#: HM' -2+ >/+ )% +BB+8)E%B )+@/0
- A907
3-:
A%8-* *907 )% 7+2(5.-E)2(8 *907< @%>+E B/2) B%**%T )+E -*%@. ) G-/@>(8+ 3*(?+2:
31:
Y-2+*9` D%@9 '+@>+2@+EE 31%@+:N $+/2%*%.(8-* H+B(8()E 312-(@:N A/@.E 3/E/-**9 ) /7 B%2 0+)-E)-E(E:
- '2-@E58%+*%0(8 672+-> 3,+2()%@+-* 6++>(@.:
3-:
6++>(@. )% ) )%
E0-** 1%T+* %1E)2/8)(%@ T: ]/**@+EE (@ 7+*?(8 8/*5>+5sac (Blumer’s shelf = shelf5*(J+ )/0%/2 %B -@) 2+8)-* T-**N 2+8)-*
0-EE >>S )/1+28/*%/E 7+2()%@()(E
!"I'@?!($?"#H
- +B(8(+@89 -@+0(-N 0+*+@-N +2-)(%@N 1(%8
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
80/285
8/16/2019 Andre Tan UPDATED M3 Surgical Notes
81/285
\!
$G%($I%#$
!>G($?N% ?#$%#$?"#
- Patient’s case would be discussed at 0/*)(>(E8(7*(@-29 )/0%/2 1%-2>
%64,9.,*;. $/2+-*8
- '%E8%79 0-9 1+ 8/2-)(?+ B%2 +-2*9 .-E)2(8 8-@8+2 3.-E)2(8 8-@8+2 E/7+2B(8(-* )%
0/E8/*-2(E 72%72(- 2+.-2>*+EE %B A$ E)-)/E:
- Q@>%E8%7(8 0/8%E-* 2+E+8)(%@ 3Q4Y: %2 Q@>%E8%7(8 E/10/8%E-* >(EE+8)(%@ 3Q6H:
- QS8+**+@) ,2%.@%E(E
'+2K,*2+-1;B2
- $/)2()(%@-* 6/77%2)
;EE+EE – -9
- $+%->G/?-@) I(@. $D4 )(** ,KH =5V B%**%T+> 19 +E8-*-)(%@ %B B++>E )% >(+) %B 8?(E+ E0-**N B2+c/+@) 0+-*E T()< @/)2()(%@-* E/77*+0+@)-)(%@ 3 72%)+(@:
M()-0(@ D!# (@G+8)(%@ )% 8(28/0?+@) *%EE %B F] -@> ]+5)-1*+)E B%2 ]+ >+B(8(+@89 -@+0(-
- F>+@)(B9 I%07*(8-)(%@E 3E++ 1+*%T:
- ;>G/?-@) I%E8%7(8 E/2?+(**-@8+
V[ $ Q@.* b 4+>& #OO[m=V[V`!! 34;XFI '2(-*:
6/1)%)-* .-E)2+8)%09 T()< D(**2%)< FF -@-E)%0%E(E '%)-* .-E)2+8)%09 T()< Y%/S5+@5v
8/16/2019 Andre Tan UPDATED M3 Surgical Notes