Surgery

-based on serum PSA, DRE findings & Gleason score

• 1) Serum PSA
• - <10 ng/ml - low risk
• - 10-20 ng/ml - moderate risk
• - >20 ng/ml - high risk

• 2) DRE findings
• - non-palpable - low risk
• - palpable - moderate risk
• - lesion both side of prostate (hard, irregular, solotary nodule) - high risk

• 3) Gleason score
• - lowest score 6 (3+3) - low risk
• - score 7 (3+4) - moderate risk
• - score 7-10 - high risk

Located at saphenousbopening within groin

Formed by meeting of GSV, common femoral v & superficial inguinal v

Landmark is the pubic tubercle

4cm/2 finger breadth to the side of pubic tubercle & up to 3cm below pubic tubercle

When ptient elevate their hand over the head touching the ears and maintain for 2-3mins, a facial plethora can be identified

This is d/t obstruction in thoracic inlet such as brachiocephalic causing distension of axillary, subclavian and jugular v. When elevate hand, more blood will flow to those vein causing more congestion

This can be caused by either lung carcinoma kr large goiter

• Hep B, C
• Alcoholic liver dz
• Non-alcoholic fatty liver dz
• Autoimmune hepatitis

• In Intestinal Obstruction
• Normal x-ray
• - small bowel - < 3cm
• - large bowel - < 6cm
• - cecum - < 9cm

If > than normal range, consider dilated in IO

• Haustra
• - spaced irregularly
• - do not cross whole diameter

• Valvulae conniventes
• - spaces regularly
• - cross whole diameter

• Painless palpable gallbladder + jaundice
• - periampullary tumor (pancreatic head ca)

Skull is a rigid compartment that contain 3 components (brain, blood, csf)

If there's an increase in volume of 1 component, the volume of 1 or more of other components must decrease or ICP will be elevated

Both located at left side of brain/hemisphere

Wernicke's - temporal lobe, sensory, receptive, comprehend speech, receptive/fluent aphasia (speech normal, but tak make sense)

Broca's - frontal lobe, motor, expressive, produce & articulate speech, expressive/non-fluent aphasia (speech is slurred & slow, difficult in writing)

- Left middle cerebral artery injury in stroke (supply left temporal lobe)

- sound receive by primary auditory area > wernicke area > broca area > motor area

Mid inguinal point - midpoint b/w pubic SYMPHYSIS & ASIS (femoral artery)

• Midpoint of inguinal ligament
• - midpoint b/w pubic TUBERCLE & ASIS

• Formed by folds of external oblique m/s aponeurosis forming superficial & deep inguinal rings
• - superficial
• - deep

Fibrous band extend from pubic tubercle to ASIS

Medial - (CVA)N - Lateral

• In femoral sheath
• C - femoral canal
• V - femoral vein
• A - femoral artery

N - femoral nerve

• Vein that connect superficial veins to deep veins
• They perforate deep fascia of m/s

Longitudinal split at anoderm of distal anal canal (below dentate line)

Blind end tract

Abnormal communication between 2 epithelial lining

• Communication between portal and systemic venous system
• Portal venous system transmit deoxygenated blood from most GIT and GIT organs to the liver
• If there's blockage in portal system, portosystemic anastomosis enable blood to still reach systemic venous circulation, bypass the liver
• This is dangerous because liver in charge for detoxification and break down substance in GIT such as meds or poison

Oesophageal ca

• Achalasia - relentless LES contraction
• - solid has higher pull of gravity so lg senang nk pass thru narrowing
• - bird beak appearance

• 1. Nailbed fluctuation
• 2. Loss of angle b/w nailbed and fold
• 3. Increase curvature of the nail
• 4. Expansion of distal phalanx; clubbed/drumstick appearance
• 5. Hypertrophic oateoarthropathy

Loss of schamroth's window

• Acute cholangitis
• 1- Fever
• 2- Jaundice
• 3- RUQ pain

• Severe (suppurative) cholangitis
• 1- Charcot's triad
• 2- Hypotension
• 3- Altered mental status

Obstruction/stricture of common hepatic duct d/t extrinsic compression of gallstone in hartmann's pouch ke cystic duct

To assess prognosis/severity of chronic liver dz mainly cirrhosis

• Components:
• A - albumin
• B - billirubin
• C - coag (prothrombin time)
• D - distension (ascites)
• E - encrphalopathy

• 5-6 : less severe
• 7-9 : mid severe
• 10-14 : most severe

• Hand
• - clubbing
• - leuconychia
• - palmar erythema
• - duputyren contracture
• - asterixis

• Face
• - scleral jaundice, pallor
• - xanthelasma

• Chest
• - spider naevi
• - loss of axillary, pubic hair

• Abdomen
• - caput medusae
• - ascites
• - hepatosplenomegaly
• - bruises

If gallbladder is palpable in painless obstructive jaundice, the cause is unlikely to be a stone

• Aka cystohepatic duct
• - located at porta hepatis

• Borders
• - Medial: common hepatic duct
• - Inferior: cystic duct
• - Superior: inferior surface of liver

• Contents
• 1. Right hepatic artery
• 2. Cystic artery
• 3. Lymph node of Lund (1st LN of gallbladder)
• 4. Lymphatics

• Importance
• - important during lap. chole
• - permit safe ligation

Volvulus

Colorectal cancer

• 1. Skin
• 2. Superficial fascia (fatty layer) - Camper's fascia
• 3. " (membranous layer) - Scarpa's fascia
• 4. Deep investing fascia b/w m/s
• 5. External oblique m/s
• 6. Internal oblique m/s
• 7. Transversus abdominis m/s
• 8. Transversalis fascia
• 9. Extraperitoneal fat
• 10. Parietal peritoneum

• 1. Skin
• 2. Dartos m/s & its fascia
• 3. External spermatic fascia
• 4. Cremasteric fascia & its m/s
• 6. Internal spermatic fascia
• 7. Tunica vaginalis
• 8. Tunica albuginea

Weakest point of abdominal wall where direct hernia protruding out

• Borders:
• 1. Medial: rectus abdominis m/s
• 2. Lateral: inferior epigastric artery
• 3. Inferior: inguinal ligament