Syllabus

Surgery 110
UCSF Department of Surgery
Surgery 110 Syllabus Page 2

1. PREOPERATIVE CARE

ASSUMPTIONS
The student can perform a complete history and physical examination. The student
will review pharmacology of common anesthetic medications, antibiotics, and pain
control agents. The student can integrate the physiology of cardiovascular,
pulmonary, gastrointestinal, renal, hepatic, endocrine and nervous system function.
The student is familiar with carbohydrate, protein and fat metabolism and the role
of vitamins/minerals in health and disease.

OBJECTIVES
PREOPERATIVE ASSESSMENT

1. Describe features of a patients clinical history that influence surgical decision

making. Consider: known diseases, risk factors, urgency of operation,
medications etc.
2. Discuss tools that may assist in preoperative risk assessment. Consider
laboratory studies, imaging studies etc. Include the following:
Pulmonary (example: exercise tolerance, pulmonary function testing)
Cardiovascular (ASA classification, Goldman criteria, echocardiography,
thallium studies, Doppler)
Renal (Bun/Cr, dialysis history)
Metabolic (nutritional assessment, thyroid function)
4. Discuss history, physical and laboratory findings utilized in nutritional
assessment. Be familiar with the most common forms of nutritional & deficiency
disorders. Consider: protein-calorie malnutrition and requirements of the
morbidly obese.
Discuss disease states and surgical interventions at high risk for nutritional
impairment.
Discuss the advantages and disadvantages of nutritional support.
compare and contrast enteral vs. parenteral administration complications
methods of determining requirements and assessing response
Surgery 110 Syllabus Page 3

2. POSTOPERATIVE COMPLICATION

ASSUMPTIONS
The student understands that prevention is the best form of management for
postoperative complications; is knowledgeable about the normal physiology of the
cardio-respiratory, gastrointestinal, renal, immunological, neurological, and
circulatory systems; and understands the alterations in physiology which are
produced by surgical stress.

OBJECTIVES
1. Describe the differential diagnosis of a patient having postoperative fever. For
each entity, discuss the clinical manifestations, appropriate diagnostic work-up,
and management:
Within 24 hours response to surgical trauma; atelectasis, necrotizing
wound infections.
Between 24 and 72 hours:
pulmonary disorders (atelectasis, pneumonia)
catheter related complications (IV-phlebitis, Foley-UTI)
Intraoperative malignant hyperthermia
2. Discuss the following wound complications in terms of predisposing risk factors
(patient condition, type of operation, technique), as well as their recognition,
treatment, and prevention:
hematoma and seroma
wound infection
dehiscence
incisional hernia
3. Discuss the various causes of respiratory distress and respiratory insufficiency
that may occur in the postoperative patient. For each complication, describe the
etiology, clinical presentation, management, and methods of prevention:
atelectasis
pneumonia
aspiration
pulmonary edema
ARDS
pulmonary embolism (including deep venous thrombosis)
fat embolism
4. Discuss the diagnostic work-up and treatment of oliguria in the postoperative
period. Include pre-renal, renal, and post-renal causes (including urinary
retention).
5. Discuss the possible causes of hypotension, which may occur in the
postoperative period. For each etiology describe its pathophysiology and
treatment:
hypovolemia
sepsis
Surgery 110 Syllabus Page 4

cardiogenic shock including postoperative myocardial infarction, fluid

overload, arrhythmias, pericardial tamponade
medication effects
6. Describe factors which can lead to abnormal bleeding postoperatively, and
discuss its prevention and management:
Surgical site inherited and acquired factor deficiencies, DIC, transfusion
reactions, operative technique
Gastroduodenal (i.e. stress ulcerations)
7. Discuss precipitating factors and treatment of the following postoperative
metabolic disorders:
thyroid storm
8. Discuss external gastrointestinal fistulas:
contributing factors
management
9. Describe the factors which can give rise to alterations in cognitive function
postoperatively, as well as their evaluation and treatment:
hypoxia
preoperative stroke
medication effects
metabolic and electrolyte abnormalities
functional delirium
convulsions
Surgery 110 Syllabus Page 5

3. NON-HEALING WOUNDS/PLASTIC SURGERY

ASSUMPTIONS
Student will review and understand the fundamental principles of wound healing
and the physiologic sequela of diabetes and malnutrition.

OBJECTIVES
1. Define non-healing
2. Discuss a differential diagnosis, evaluation, and treatment of a patient with:
non-healing lower extremity wound
non-healing wound of the torso, or body area other man the lower
extremity
3. Describe the pathophysiology involved for each of the diagnostic possibilities.
Consider: pressure, ischemia, infection, malignancy, and foreign body
Surgery 110 Syllabus Page 6

4. FLUID, ELECTROLYTE & ACID BASE

DISORDERS

ASSUMPTIONS
The student understands: the distribution of fluids and electrolytes in the body
compartments; the role of the kidneys in regulating fluid and electrolyte balance;
the basic physiology and biochemistry of the process of respiration.

OBJECTIVES
1. List the normal range of Na+, K+, HCO3-, Cl- in serum and indicate how these
ranges change in perspiration, gastric juice, bile and ileostomy contents
2. List at least four endogenous factors that affect renal control of sodium and
water excretion.
3. List least six symptoms or physical findings of dehydration.
4. List and describe the objective ways of measuring fluid balance.
5. List the electrolyte composition of the following solutions:
normal (0.9%) saline
1/2 normal saline
1/3 normal saline
5% dextrose in water
Ringers lactate
6. In the following situations, indicate whether serum Na, K, HCO3, Cl and blood pH
will remain stable (O), rise considerably (++), rise moderately (+), fall
moderately (-), or fall considerably (--):
excessive gastric losses
high volume pancreatic fistula
small intestine fistula
biliary fistula
diarrhea
7. In the following situations, indicate whether serum and urine Na, K, HCO3, Cl
and osmolarity will remain stable (O), rise considerably (++), rise moderately
(+), fall moderately (-), or fall considerably (--):
acute tubular necrosis
dehydration
inappropriate ADH secretion (SIADH)
diabetes insipidus
congestive heart failure
8. Describe the possible causes, appropriate laboratory studies needed, and
treatment of the following conditions:
hypernatremia
hyponatremia
hyperkalemia
hypokalemia
hypercholremia
hypochloremia
Surgery 110 Syllabus Page 7
9. Describe the concept of a third space and list those conditions that can
cause fluid sequestration of this type.

ACID BASE BALANCE

OBJECTIVES
1. List the physiological limits of normal blood gases.
2. List the factors that effect oxygen delivery and consumption.
3. Indicate the mechanisms, methods of compensation, differential diagnosis,
and treatment of the following acid base disorders:
acute metabolic acidosis
acute respiratory acidosis
acute metabolic alkalosis
acute respiratory alkalosis
Surgery 110 Syllabus Page 8

5. SHOCK

ASSUMPTIONS
Student understands the physiologic principles that govern normal blood pressure
and hemodynamic homeostasis.

OBJECTIVES
1. Define shock
2. Differentiate the signs, symptoms, and hemodynamic features of shock:
hemorrhagic
cardiogenic
septic
neurogenic
anaphylactic
3. Discuss priorities and specific goals of resuscitation for each form of shocks:
Define goals of resuscitation
Defend choice of fluids
Discuss indications for transfusion
Discuss management of acute coagulopathy
Discuss indications for invasive monitoring
Discuss use of inotropes, afterload reduction in management
4. Discuss priorities in resuscitation (ABCs)
Surgery 110 Syllabus Page 9

6. NECK MASSES

ASSUMPTIONS

The student has an understanding of head & neck anatomy, embryology, and
thyroid/ parathyroid physiology and can perform a competent head and neck
physical exam.

OBJECTIVES

1. Describe the neck masses commonly presenting in childhood.

Discuss the embryologic origin of these lesions and the anatomic
implications to consider when resecting them.
2. Describe the signs, symptoms & etiologies of inflammatory neck masses.
Discuss Ludwigs angina and why it may be life-threatening.
What is appropriate treatment for cervical adenitis?
Discuss the evaluation of suspected tuberculous adenitis.
3. Describe the most common neoplastic neck masses and their origin.
Discuss the role of fine-needle cytology, open biopsy, CT scan, MRI,
thyroscan, and nasopharyngeal endoscopy in the diagnostic work up of a
neck mass.
Discuss the relationship of smoking and alcohol abuse to squamous cell
cancers.
Discuss the evaluation and differential diagnosis of a patient with a thyroid
nodule.
Discuss the common thyroid malignancies, their cell of origin and their
management.
Which has the best prognosis? The worst? Which is associated with MEN
syndrome?
Discuss the relationship of radiation exposure to thyroid malignancy. Which
malignancies frequently metastasize to the neck? How is the metastatic
nodal disease managed and how does this differ based on the origin of the
primary?
4. Discuss the common non-neoplastic thyroid diseases that could present as a
mass.
Discuss the symptoms associated with hyperthyroidism and discuss
treatment options.
Discuss diagnosis and management of thyroiditis.

HYPERCALCEMIA
OBJECTIVES

1. Discuss and understand calcium homeostasis

2. Understand the symptoms and signs of acute and chronic hypercalcemia
3. Discuss the differential diagnosis of hypercalcemia
4. Discuss the evaluation and management of hypercalcemia
Surgery 110 Syllabus Page 10

7. LUNG NODULE

ASSUMPTIONS
Student has reviewed lung anatomy and normal physiology. Student is familiar with
TNM classification of lung neoplasm.

OBJECTIVES
1. Create an algorithm for the evaluation of a patient with a lung nodule on
chest x-ray.
2. Discuss the common risk factors and clinical symptoms of lung cancer.
3. Describe the role of surgery in lung cancer
a) Describe pulmonary function tests and values that are predictive of
severe risk of pulmonary complications following thoracic surgery.
b) Identify conditions that preclude curative surgical resection for lung
cancer.
4. List the most common sources of malignant metastases to the lungs.
5. Compare and contrast the management and prognosis of metastatic vs. primary
lung malignancies
6. Describe the most common diagnostic procedures used to evaluate pulmonary
and mediastinal lesions.
7. List the common tumors of the anterior, posterior and superior mediastinum.
8. List the common chest wall tumors.
Surgery 110 Syllabus Page 11

8. BREAST PROBLEMS

ASSUMPTIONS
Student understands benign changes within the breast and their relevance to breast
cancer surveillance. Student understands the topographic and structural anatomy of
the breast. Student understands the hormonal changes that affect the breast.

OBJECTIVES
1. Develop a differential diagnosis for a 20-year-old patient with breast mass
and a 4-year-old patient with breast mass. Consider benign vs. malignant,
abscess.
2. Describe the diagnostic work-up and sequence:
Discuss importance of the patients history: estimated duration of
illness, nipple discharge, breast cancer risk factor assessment.
Discuss physical findings to look for.
Discuss in-office procedures for evaluation and treatment (FNAC,
needle aspiration, incision & drainage, core needle biopsy) and their
diagnostic/therapeutic implications.
Discuss the importance of such breast imaging studies as ultrasound
and mammography.
3. Discuss the diagnosis and management of the patient with an abnormal
mammogram (consider microcalcifications)
4. Discuss the rationale for management with specific emphasis on:
Clinical staging of breast CA
The various possible malignant, pre-malignant, and benign pathology results
(including hormonal receptor analysis, tumor DNA analysis)
The follow-up for a patient with a benign lesion (alterations in lifestyle,
imaging studies, cancer risk)
The role of incision and drainage and antibiotics in breast abscess treatment.
Current recommendations for screening mammography
Therapeutic options for the patient with breast CA
role of surgery/when to consult a surgeon for further diagnosis & treatment
role of radiotherapy
role of chemotherapy (adjuvant or neoadjuvant)
role of hormonal therapy
surgical options including reconstruction
Surgery 110 Syllabus Page 12

9. SWALLOWING DIFFICULTY & PAIN

ASSUMPTIONS
Student will review anatomy, physiology, and pathophysiology of the swallowing
mechanism. It is assumed that the students will have this knowledge and apply it to
the clinical situation.

OBJECTIVES
1. Define dysphagia and odynophagia
2. Describe the differential diagnosis for a patient with dysphagia/odynophagia.
Motility Disorder
neurologic disorders
motor disorders
Extrinsic obstruction/compression
Intrinsic obstruction
neoplasm
inflammation
foreign body
Inflammation/Infections
3. Compare and contrast the history, presentation, physical findings, and laboratory
findings for these different conditions.
4. Discuss the diagnostic modalities available, how they are used, and how they
relate to the normal swallowing mechanism.
5. Describe the options for management of these conditions.
6. Discuss indications for operative vs. non-operative management when
appropriate.
7. For those problems where operative intervention is appropriate, discuss the
procedures available and discuss their pros and cons.
Surgery 110 Syllabus Page 13

10. VOMITING, DIARRHEA, CONSTIPATION

ASSUMPTIONS

Student understands the anatomy, embryology and physiology of the

gastrointestinal tract.

VOMITING

OBJECTIVES

1. Discuss in general, the differential diagnosis for a patient with emesis.

Consider timing and character of the emesis and associated abdominal pain.
Contrast etiologies in infants, children and adults.
Contrast dysmotility vs. ileus vs. mechanical obstruction.
2. Describe the clinical presentation and etiologies of gastric outlet obstruction.
3. Describe the types of neoplasm that occur in the stomach and discuss diagnosis
and prognosis for each.
4. Discuss the principles of curative and palliative surgery for patients with gastric
neoplasm.
5. Describe the signs and symptoms of small bowel obstruction.
6. Describe the common etiologies of mechanical small bowel obstruction.
7. Describe the pathology and relative frequency of malignant and benign small
bowel neoplasm.
8. Discuss the potential complications and management of small bowel obstruction.
9. Outline the initial management of a patient with mechanical small bowel
obstruction, including laboratory tests and x-rays.
10.Contrast the presentation and management of partial vs. complete small bowel
obstruction.

DIARRHEA

OBJECTIVES

1. Discuss the differential diagnosis of diarrhea in adults.

Consider chronicity, absence or presence of blood and associated pain.
2. Describe the presentation and potential complications of ulcerative colitis and
Crohns disease.
3. Contrast the pathology, anatomic location and pattern, cancer risk and
diagnostic evaluation of ulcerative colitis and Crohns disease.
4. Discuss the role of surgery in the treatment of patients with ulcerative colitis and
Crohns disease.
5. Discuss the clinical manifestations, risk factors, diagnosis and management,
pseudo membranous colitis.
6. Outline the risk factors, presentation diagnosis and management of ischemic
colitis.
Surgery 110 Syllabus Page 14

CONSTIPATION

OBJECTIVES

1. Discuss the potential etiologies of constipation in adults and children.

Consider chronic vs. acute
2. Describe the clinical presentation and etiologies of large bowel obstruction.
3. List the diagnostic methods utilized in the evaluation of potential large bowel
obstruction, including contraindications and cost effectiveness.
4. Outline the diagnosis and management of colonic volvulus, diverticulas
stricture, fecal impaction and obstructing colon cancer.
5. Outline the treatment of carcinoma located at different levels of the colon,
rectum and anus. Include a discussion of the use of radiotherapy and
chemotherapy for each.
6. Describe the postoperative follow-up of patients with colorectal carcinoma.
7. Discuss the staging and survival of patients with colorectal carcinoma.
8. Describe the presentation and treatment of acute and chronic colonic pseudo
obstruction.
Surgery 110 Syllabus Page 15

11. ABDOMINAL MASSES

ASSUMPTIONS

Student is familiar with the normal location, size and consistency of the abdominal
viscera.

OBJECTIVES

1. Describe the causes of hepatomegaly.

Discuss the role of liver function testing, radionucleotide imaging, ultrasound
and CT scanning in the evaluation.
Discuss the most frequently encountered benign hepatic tumors and their
management.
Discuss the most frequently encountered malignant hepatic tumors and their
management.
Discuss the role of liver biopsy in the diagnosis and the available techniques.
2. Describe the causes of splenomegaly.
Discuss the most common signs and symptoms associated with
hypersplenism.
Compare and contrast hypersplenism with an enlarged and normal sized
spleen.
Discuss the role of splenectomy in the treatment of hypersplenism.
Discuss the consequences of hyposplenism. How can these be diminished?
Discuss the short and long term complications associated with surgical
removal of the spleen.
3. Describe the differential diagnosis of a pancreatic mass
Discuss the most useful diagnostic studies.
Discuss the relationship of the pancreatic duct to the common bile duct and
how this may impact diagnosis and treatment of pancreatic lesions.
Discuss the indications and techniques of biopsy the pancreas.
Discuss the management of cystic lesions of the pancreas.
How do you differentiate a pseudocyst from a cystadenoma or true cyst?
Which patients need surgery and when?
What are the major complications of pancreatic necrosis and pseudocyst
formation?
4. Describe the most frequently encountered retroperitoneal masses.
Discuss the appropriate imaging studies and work up for these tumors.
Discuss the most frequently encountered Lymphomas and their treatment.
Discuss the most common retroperitoneal sarcomas and their management.
5. Describe the tumors most frequently associated with abdominal carcinomatosis
and omental metastasis.
Surgery 110 Syllabus Page 16
Surgery 110 Syllabus Page 17

12. ABDOMINAL PAIN

ASSUMPTIONS
Student understands: the anatomy and relationships of various abdominal viscera;
the normal structure and function of various abdominal viscera and their associated
organ systems; the physiology of pain perception and how to apply this to
differentiating visceral, somatic and referred pain patterns involved in abdominal
pathology. Students have a basic understanding of the pathophysiology of
inflammation, neoplasia, ischemia and obstruction.

OBJECTIVES

1. Gather a complete or problem focused history for various patients presenting

with abdominal pain. Emphasis will be placed on:
characterization of pain (location, severity, character, pattern)
temporal sequence (onset, frequency, duration, progression)
alleviating/exacerbating factors (position, food, activity, medications)
associated signs/symptoms (nausea vomiting, fever, chills, anorexia, wt. loss,
cough, dysphagia, dysuria/frequency altered bowel function (diarrhea,
constipation, obstipation, hematochezia, melena, etc.)
pertinent medical history: prior surgery or illness, associated conditions
(pregnancy, menstrual cycle, diabetes, atrial fibrillation or cardiovascular
disease, immunosuppression). Medications: anticoagulation, steroids etc.
2. Demonstrate the components of a complete abdominal examination including
rectal, genital & pelvic examinations.
Relate the significance of the various component examinations: observation,
auscultation, percussion, palpation as they apply to common abdominal
pathologic processes. Examples: distention, visible peristalsis, high pitched or
absent bowel sounds, tympany, mass localked vs. generalked guarding
and/or rebound tenderness.
3. Demonstrate and relate the significance of various maneuvers utilized in
evaluating acute abdominal pain. Examples: iliopsoas sign, Rovsings sign,
obturator sign, Murphys sign, cough tenderness, heel tap, cervical motion
tenderness.
4. Describe the keys to successful examination of infants and children with
abdominal pain. Characterize examination skills that may be utilized in
pregnancy, or patients with altered neurologic status.
5. Develop a differential diagnosis for various patients presenting with acute
abdominal pain. Differentiate based on:
location: RUQ, epigastric, LUQ, RLQ, LLQ
symptom complex: examples: periumbilical pain localizing to RLQ, acute
onset left flank pain with radiation to the testicle etc.
age: pediatric adult geriatric
associated conditions: pregnancy, immunosuppression (AIDS, transplant,
chemotherapy/radiation therapy)
Surgery 110 Syllabus Page 18
6. Explain the rationale for utilizing various diagnostic modalities in the evaluation
of abdominal pain.
Laboratory: CBC, amylase, electrolytes, BUN, creatinine, glucose, urinalysis,
beta-HCG, liver profile.
Diagnostic imaging: flat and upright abdominal radiographs, upright chest x-
ray, abdominal ultrasonography, CT scan of abdomen and pelvis, GI contrast
radiography, angiography, IVP.
Special diagnostic/interventional techniques: upper endoscopy,
proctosigmoidoscopy, colonoscopy, laparoscopy.
7. Discuss the presentation, diagnostic strategy, and initial treatment of patients
presenting with common or catastrophic abdominal conditions.
acute appendicitis
cholecystitis/biliary colic/choledocholithiasis/cholangitis
pancreatitis
peptic ulcer disease with & without perforation
gastroesophageal reflux
gastritis/duodenitis
diverticulitis
inflammatory bowel disease
enterocolitis
small bowel obstruction: incarcerated hernia, adhesions tumor
colon obstruction: volvulus, tumor, stricture
splenomegaly/splenic rupture
mesenteric ischemia
leaking abdominal aortic aneurysm
gynecologic etiologies: ectopic pregnancy, ovarian cysts (torsion,
hemorrhage, rupture) tubo-ovarian abscess, salpingitis, endometriosis
genitourinary etiologies: UTI, pyelonephritis, ureterolitiasis, testicular torsion
8. Discuss the common non-surgical conditions that can present with abdominal
pain. Examples: Ml, pneumonia, pleuritis, hepatitis, gastroenteritis, mesenteric
adenitis, sickle cell crisis, diabetes ketoacidosis, herpes zoster, nerve root
compression
9. Compare and contrast acute appendicitis in young adults, the very young, very
old, and pregnant women. Discuss issues relevant to presentation, diagnosis,
treatment, complications etc. Example: perforation risk
10.Discuss the diagnosis and treatment of abdominal problems with particular
relevance to the pediatric population. Include: neonates, infants, children,
adolescents. Be able to list the abdominal problems, characteristic of each
group, and outline diagnostic and intervention strategies for:
congenital: hernias, malrotation, midgut volvulus
Hirschsprungs disease
Pyloric Stenosis
Intussusception
Meckels diverticulitis
Child abuse
11.Discuss unique causes of abdominal pain in patients who are immune-
suppressed and the implication on treatment and outcomes. Examples:
neutropenic enterocolitis, CMV enterocolitis, bowel perforation, acalculous
cholecystitis, acute graft rejection.
12.Discuss the approach to patients with common abdominal problems with
emphasis on indications for surgical consultation, indications/contraindications to
Surgery 110 Syllabus Page 19
surgery, complications of disease and intervention, and expected outcomes.
Examples: laparoscopy vs. Iaparotomy; complication rates of emergent vs.
elective surgery, perforated vs. non-perforated colon cancer; complications:
intra-abdominal abscesses, fistulae, bleeding anastomotic disruption.
13.Describe the normal bacterial flora of the GI, GU and GYN systems and compare
to pathologic infections.
Discuss appropriate antibiotic therapy where indicated in various conditions
manifesting with abdominal pain.
14.Discuss the approach to patients with postoperative abdominal pain. Contrast
findings in non-operated patients with regards to:
presentation
examination
differential diagnosis
intervention strategies
15.Discuss the unique considerations and constraints in the evaluation of patients
with abdominal pain in various environments:
emergency room
outpatient clinic or office
government facility
managed care organization
16.Describe the resources available for readily accessing information to evaluate
patients with abdominal pain. Examples: Internet access sites, textbooks, pocket
handbooks, journal articles.
Compare and contrast based on information quality, timeliness, accessibility.
Surgery 110 Syllabus Page 20

13. GASTROINTESTINAL HEMORRHAGE

ASSUMPTIONS
Student understands the anatomy (including blood supply) and physiology of the
gastrointestinal tract, to include the esophagus, stomach, small bowel, colon, and
anorectum.

OBJECTIVES
1. Outline the initial management of a patient with an acute GI hemorrhage.
Discuss indications for transfusion, fluid replacement, and choice of fluids.
2. Differentiate upper vs. lower GI hemorrhage
Discuss history an physical exam abnormalities
Discuss diagnostic studies.
3. Discuss the differences in evaluation and management of the patient presenting
with:
hematemesis
melena
hematochezia
guaiac positive stool
4. Discuss medical vs. surgical management for:
peptic ulcer
variceal hemorrhage
Mallory-Weiss tear
gastric ulcer (benign vs. malignant)
Meckels diverticulum
intussusception
diverticulosis
ulcerative colitis
colon cancer
rectal cancer
hemorrhoids
AV malformation
Surgery 110 Syllabus Page 21

14. BILARY AND JAUNDICE

ASSUMPTIONS

Student understands the mechanisms for production, excretion, and metabolism of

bile and can recall the anatomy of the hepatobiliary system.

OBJECTIVES

1. Describe the differential diagnosis of a patient with jaundice.

Discuss, prehepatic, intrahepatic (both non-obstructive) and posthepatic
(obstructive) etiologies.
Discuss painful vs. non-painful
Discuss benign vs. malignant
Discuss inflammatory vs. non-inflammatory
2. List & explain justification for the diagnostic modalities used in the evaluation of
a patient with jaundice, to include limitations, relative costs and potential risks.
Discuss importance of the patients history: estimated duration of illness,
associated symptoms (pain and its characteristics), and risk factors.
Discuss important physical exam findings:
hepatomegaly
palpable mass
Courvoisiers sign
Murphys sign
scleral icterus
abdominal tenderness
Lymphadenopathy
Charcots triad
Reynolds pentad
3. Explain the rationale for using these diagnostic tests in the evaluation of a
patient with jaundice. What is the significance of abnormalities?
Liver function tests
Other laboratory tests and their indications (including hepatitis profile,
peripheral blood smear, Coombs tests, etc.)
Hepatobiliary imaging procedures (ultrasound, CT scan, ERCP, PTHC, HIDA
scan).
4. Discuss the management principles (to include initial treatment; role and timing
of surgery; and, if necessary, timing of appropriate consultation) of:
cholecystitis
choledocholithiasis
cholangitis
cholangiocarcinoma
hepatic abscess
pancreatic CA
periampullary CA
hepatic CA
Surgery 110 Syllabus Page 22

autoimmune hemolysis
hepatitis
hematobilia
periampullary duodenal diverticulum

GALLSTONES

OBJECTIVES

1. Understand the natural history of symptomatic and asymptomatic gallstone

disease.
2. Define symptomatic in the context of gallstone disease
3. Discuss the available literature on the natural history of asymptomatic
gallstones.
4. Discuss the indications for cholecystectomy.
5. Discuss the options, pros and cons, for treatment of gallstones:
cholecystectomy
dissolution therapy
watchful waiting
6. Discuss impact of associated medical conditions on the decision to treat
gallstones.
7. Discuss the association of cancer of the gallbladder and gallstones.
Surgery 110 Syllabus Page 23

15. ABDOMINAL WALL & GROIN MASSES

ASSUMPTIONS

The student understands the anatomic relationships of the abdominal wall

musculature and fascia.

OBJECTIVES

1. Discuss the differential diagnosis of inguinal pain, mass or bulge.

consider hernia, adenopathy, muscular strain
2. Describe the anatomic differences between indirect and direct hernias
3. Discuss the relative frequency of indirect, direct and femoral hernias by age and
gender.
4. Discuss the clinical conditions that may predispose to development of inguinal
hernia.
5. Discuss the indications, surgical options, and normal post-operative course for:
inguinal hernia repair
femoral hernia repair
Surgery 110 Syllabus Page 24

16. ANORECTAL PROBLEMS

ASSUMPTIONS

The student knows the basic anatomy of the anal canal and rectum and is familiar
with the basis of the mechanism of defecation.

OBJECTIVES

1. Develop a differential diagnosis for a patient with perianal pain. (Be sure to
include benign, malignant and inflammatory causes.)
2. Discuss the characteristic history findings for each of the above including:
character and duration of complaint
presence or absence of associated bleeding
relationship of complaint to defecation
3. Describe physical exam findings for each diagnosis. Indicate in which part of
exam (external, digital, anoscopic or proctoscopic) these findings are identified.
4. Discuss treatment plan for each diagnosis listed in objective one, including non-
operative interventions and role and timing of surgical interventions.
Surgery 110 Syllabus Page 25

17. VASCULAR PROBLEMS

ASSUMPTIONS

Student understands the anatomy of the lower extremities and the physiology of
the clotting cascade.

OBJECTIVES

1. Describe atherosclerosis, its etiology, prevention and sites of predilection.

Discuss the intimal injury that characterizes the process and how that injury
impacts therapy and prevention.
2. Describe the differential diagnosis of hip, thigh, buttock, and leg pain associated
with exercise.
Discuss neurological vs. vascular etiologies of walking induced leg pain.
Discuss musculoskeletal etiologies
Discuss the relationship of impotence to the diagnosis
3. Describe the pathophysiology of intermittent claudication
Discuss the diagnostic work-up of chronic arterial occlusive disease.
Discuss the role of segmental Doppler studies and arteriography.
Discuss the medical management of arterial occlusive disease.
Discuss risk factors associated with arterial occlusive disease.
Discuss operative and nonoperative interventions for aortoiliac,
femoropopliteal and distal vascular occlusion.
4. Describe the pathophysiology of ischemic rest pain.
Discuss evaluation and management of rest pain.
Discuss the role of anti coagulation in peripheral vascular disease.
Discuss the indications for amputation of acute arterial occlusion.
5. Describe the etiologies and presentation of acute arterial occlusion.
Discuss embolic vs. thrombotic occlusion.
Discuss the signs and symptoms of acute arterial occlusion (the Ps)
Discuss the medical and surgical management.
Discuss the complications associated with prolonged ischemia and
revascularization.
Discuss the diagnosis and treatment of compartment syndrome.
6. Describe the evaluation and management of abdominal aortic aneurysms.
Discuss appropriate imaging studies for aneurysms.
Discuss which patients need angiograms.
Discuss the relationship of aortic aneurysms to other vascular aneurysms.
Discuss how to determine which patients need surgical repair of the
aneurysm.
Discuss the risks of surgical treatment and the risks of the aneurysm left
untreated.
7. Describe the differential diagnosis, location, appearance and symptoms of leg
ulcers due to:
arterial disease and venous stasis disease
Surgery 110 Syllabus Page 26

neuropathy
infection and malignancy
8. Describe the differentiate diagnosis of the swollen leg.
Discuss how to differentiate lymphedema from venous stasis
Discuss painful vs. non-painful swelling.
9. Discuss the presentation of and risk groups for bony tumors.
10.Describe the factors that lead to venous thrombosis and embolism.
Discuss the usual locations for thrombosis
Discuss differing implications of deep and superficial venous
thrombophlebitis.
Discuss the common invasive and non-invasive diagnostic tests for DVT.
Discuss methods for DVT prophylaxis and identify high-risk patients.
Discuss the risks, benefits and available options for anticoagulation and
thrombolysis.
Discuss the signs, symptoms, diagnostic evaluation and treatment of
pulmonary embolism.
11.Describe the diagnosis, work-up and management options for symptomatic
varicose veins and venous ulcers.
Discuss the physical exam and tests for venous valvular competence.
Discuss the role of venography, ultrasound and plethysmography.
Discuss medical vs. surgical management.
Discuss the role of stripping, sclerosis, and laser ablation.

CAROTID BRUIT

OBJECTIVES

1. Understand the significance of a carotid bruit found in an asymptomatic person

and how and when to further evaluate it.
2. What is the significance of a bruit?
3. What are the symptoms of carotid disease?
4. How should a patient with a carotid bruit be evaluated?
5. What are the available treatments for carotid disease and what are their
indications?
Surgery 110 Syllabus Page 27

18. SKIN & SOFT TISSUE LESIONS

ASSUMPTIONS

The student understands gross anatomy and histology of the soft tissue structures.

OBJECTIVES

1. Describe the commonly used local anesthetics

Discuss the advantages and disadvantages of epinephrine in the local
anesthetic.
Discuss special precautions needed on the digits.
Discuss safe dosage ranges of the common anesthetics and the potential
toxicities of these drugs.
2. Describe the common benign skin lesions and their treatment (papillomas, skin
tags, subcutaneous cysts, lipomas).
3. Describe the characteristics, typical location, etiology and incidence of basal cell
and squamous skin cancers.
Discuss the relationship to solar irradiation, ethnicity, previous tissue injury, &
immunosuppression.
Discuss the characteristics of malignant skin lesions which distinguish them
from benign lesions.
Discuss the appropriate treatment of small and large basal cell and squamous
cell cancers and their prognosis.
4. Describe the characteristics, typical locations, etiology and incidence of
malignant melanoma.
Discuss the relationship of melanoma to benign nevi and characteristics
which help differentiate them.
Discuss risk factors for melanoma. What are the lesions which have high
potential for malignant transformation?
Discuss the various types of melanoma and prognosis for each type.
Discuss the relationship of size and thickness to prognosis.
Discuss the usual treatment for cutaneous melanoma including margins,
depth and lymph node management including sentinel node mapping.
Surgery 110 Syllabus Page 28

19. TRANSPLANTATION

ASSUMPTIONS

The student has a basic understanding of the immune system and its role in the
response to foreign antigens. The student should also have an understanding of the
anatomy and physiology of the renal, pancreatic, hepatic, pulmonary and cardiac
organ systems.

OBJECTIVES

1. Describe the common organs and tissues currently being transplanted:

Discuss issues of living related and unrelated vs. cadaveric donation
Discuss acceptable and exclusionary criteria for donation by organ system.
Discuss the criteria for establishing brain death for the purposes of organ
donation.
Discuss potential ethical issues as they relate to organ donation.
Define autograft, allograft, xexnograft, orthotopic and heterotopic as they
relate transplantation.
2. Describe the common immunosuppressive agents used for transplantation.
Discuss the mechanism of action and major side effects of steroids
cyclosporine, mycophenylate, azathioprine, FK-506, antithymocyte globulin
an OKT-3 (monoclonal antibodies).
Discuss the relation of ABO compatibility to organ transplantation.
Discuss the signs, symptoms, and pathophysiology of rejection and define:
hyperacute rejection
accelerated acute rejection
acute rejection
chronic rejection
Discuss common infectious complications of immunosuppression and their
prevention and management.
Discuss the relationship of immunosuppression to risk of malignancy and
identify the common malignancies associated with immunosuppression.
3. Describe common organ preservation techniques and their limitations for
currently transplanted organs and tissues.
Discuss the optimal and maximum preservation time for renal, pancreas, liver
and cardiac transplants.
4. Describe the most common conditions leading to transplantation, eligibility, the
results (patient and graft survival), major complications of and long term
outcome for:
renal transplantation
pancreas transplantation
liver transplantation
cardiac transplantation
lung transplantation
Surgery 110 Syllabus Page 29

20. TRAUMA

ASSUMPTIONS

The student understands the basic physiology of the circulatory system and
changes that occur due to shock. The student will review the pertinent anatomy of
the organ systems discussed in the trauma chapter.

OBJECTIVES

1. Describe the priorities and sequence of a trauma patient evaluation (ABCs).

2. Describe the four classes of hemorrhagic shock and how to recognize them.
3. Describe the appropriate fluid resuscitation of a trauma victim.
Discuss choice of IV access.
Discuss the choice of fluid and use of blood components.
Discuss the differences between adult and pediatric resuscitation.
4. Discuss the types, etiology and prevention of coagulopathies typically found in
patients with massive hemorrhage.
5. Describe the appropriate triage of a patient in a trauma system.
Discuss how the trauma system is organized in your state.
Discuss the importance of mechanism of injury on management and triage
decision making.
6. Describe the diagnostic evaluation, differences between blunt and penetrating
mechanisms of injury and the initial management of:
Closed head injury (consider Glasgow Coma Scale, ICP, subdural hematoma,
epidural hematoma, diffuse axonal injury, basilar skull fractures & CSF leaks).
Spine injury (consider mechanism of injury, level of injury, use of steroids,
immobilization, neuro exam, management of shock).
Thoracic injury (consider hemo/pneumothorax, tension pneumothorax,
tamponade, pulmonary contusion, massive air leak, widened mediastinum,
flail chest).
Abdominal injury (consider role of physical exam, ultrasound, CT, peritoneal
ravage, operative vs. non-operative management of liver and spleen injury,
which patients need urgent laparotomy, management of hematomas)
Urinary injury (consider operative vs. non-operative renal injury, ureteral
injury, intraperitoneal and extraperitoneal bladder injury, urethral trauma,
when not to place a Foley, candidates for cystogram, relationship to pelvic
fracture)
Orthopedic injury (consider open vs. closed fractures, compartment
syndromes, concepts of immobilization (splinting, internal fixation), treatment
of patients with pelvic fractures, hemorrhage control, commonly associated
vascular injuries)
7. Describe the early management of a major burn.
Discuss estimation of total body surface burn and burn depth.
Discuss fluid resuscitation, choice of fluid and monitoring for adequacy of
resuscitation (rule of 9s, differences in pediatric and adult management).
Discuss options for topical antimicrobial therapy.
Surgery 110 Syllabus Page 30

Discuss inhalation injury, CO poisoning and triage of patients to burn centers.

Discuss the basic principles of wound coverage, skin grafting, and timing.
Discuss the assessment and need for escharotomy.
8. Describe the effects of trauma on the individuals ability to return to full health
and employment.
9. Discuss the role of physical therapy, occupational therapy, speech therapy and
other rehabilitation services in the patients recovery.
10.Discuss the economic impact of traumatic injury and disability.
11.Describe the recognition of suspected child abuse and domestic violence
presenting as trauma and the physicians role in reporting.
12.Describe the importance of careful documentation in the medical record for
traumatic injury and the basic concepts of a trail of evidence in victims of
assault.