PART
TWO: BASIC SCIENCES
UNIT 2.1/2.1G
ANATOMY
UNIT OBJECTIVES:
Demonstrate knowledge of anatomy that is
pertinent to the practice of surgery.
Apply knowledge of anatomy
to the diagnosis and treatment of patients, both in and out of the operating
room.
COMPETENCY-BASED KNOWLEDGE
OBJECTIVES:
Junior Level:
1. Outline the general concepts of anatomy and its subdivisions, including:
a. Gross anatomy
b. Cellular and
subcellular anatomy
c. Molecular biology
2. Compare the organization, characteristics, and functions of the tissues and their components within each organ system, including:
a. Skin f. Digestive system
b. Circulatory system g. Urinary system
c. Nervous system h. Reproductive system
d. Musculoskeletal
system i. Organs of special sense
e. Respiratory system
3. Review, identify, and delineate the vulnerable anatomical structures encountered in common general surgical operations such as:
a. Venous and arterial access
in infants
b. Catheterization
c. Colonoscopy
d. Cricothyrotomy
e. Mastectomy
f. Inguinal hernia repair
g. Cholecystectomy
h. Cardiac procedures
i. Aortic aneurysm
repair
j. Insertion of
Swan-Ganz catheter
k. Insertion of chest
tubes
l. Application of leg
cast
m. Appendectomy
n. Burr holes
o. Vagotomy and
pyloroplasty
p. Colectomy
q. Renal transplant
r. Thyroidectomy
s. Resection of the liver
t. Urinary procedures
4. Recognize those anatomic structures commonly encountered in other surgical subspecialties, such as:
a. Orthopedics d. Gynecology
b. Otolaryngology e. Urology
c. Neurosurgery
5. Discuss the differences in visualization of organ structures by various technologies, such as:
a. Routine radiograms
b. Contrast studies
c. Computed axial
tomography (CAT) scans
d. Ultrasound
e. Magnetic resonance
imaging (MRI) scans
f. Angiograms
g. Positron emission tomography
(PET) scans
6. List and access the source materials for anatomic references, guides for exposure, and the anatomic aspects of common general surgical procedures.
7. Describe the anatomic aspects of conception, human development, normal embryology, and common developmental anomalies encountered in general surgery, such as:
a. Pelvic inflammatory
disease
b. Appendicitis in
pregnancy
c. Omphalomesenteric
remnants
d. Diaphragmatic hernia
e. VATER syndrome
f. Tracheoesophageal fistula
g. Biliary atresia
h. Malrotation
i. Gastroschisis
j. Urachal cyst
k. Imperforate anus
l. Trisomy 18
m. Tetralogy of Fallot
n. Atrioseptal defect
8. Differentiate between the following anatomic terms:
a. Topographic anatomy f. Ventral
b. Radiographic anatomy g. Median
plane
c. Supination h. Midsagittal plane
d. Pronation i. Coronal plane
e. Dorsal
9. Describe the anatomic changes due to aging on a gross, cellular, and molecular level with special emphasis on the following organs: eyes, bone, brain, GI tract, lungs, kidneys, reproductive system, and vascular system.
Senior Level:
1. Summarize the embryologic explanations for the common major birth anomalies.
2. Define and describe the anatomic aspects of even the most complex general surgical operations such as:
a. Repair of an
abdominoperineal aneurysm
b. Whipple procedure
c. Pneumonectomy
d. Abdominoperineal resection
e. Liver resection
f. Liver transplantation
g. Bilateral radical neck
dissection
h. Gastric bypass
3. Interpret various imaging technologies to derive anatomic information.
COMPETENCY-BASED PERFORMANCE
OBJECTIVES:
Integrate knowledge of
anatomy into the following:
a. The diagnosis of
general surgical disease
b. Explanations to
patients and families regarding:
(1) Embryologic
causes of disease
(2) Planning of
surgical procedures
(3) Progress of
disease
(4) Explanation of
complications
c. The performance of surgical procedures appropriate for the level of training
d. Postoperative management of the patient, including long-term follow-up
e.
The planning of procedures for different age
groups, such as split thickness skin grafts (depending upon the thickness of
the skin), and care for fracture of the wrist
The Anatomy unit was revised by Walter J. Pories, MD, from his Curriculum unit in the third edition.
SELECTED BIBLIOGRAPHY:
Adkins RB, Jr.,
Jahnigen DW, Schrier RW. Geriatric Medicine (2nd ed).
Netter
FH, Jr. Atlas of Human Anatomy (2nd
ed).
Pemberton
LB, Colborn GL, Skandalakis JE. Workbook
of Surgical Anatomy,
Pokorny WJ, Rothenberg SS, Brandt ML. Growth
and development. In: O’Leary JP (ed), The Physiologic Basis of Surgery (2nd ed).
Scott-Conner C, Dawson DL. Operative Anatomy.
Skandalakis LJ, Rowe JS, Jr., Gray SW, et al.
Surgical embryology and anatomy of the pancreas. Surg Cl of
Skandalakis JE, Skandalakis PN, Skandalakis LJ.
Surgical Anatomy and Technique: A Pocket
Manual.
Web reference
http://www.vesalius.com
Wood WC, Skandalakis JE (eds). Anatomic Basis of Tumor Surgery.
UNIT 2.2/2.2G
PHYSIOLOGY
UNIT
OBJECTIVES:
Demonstrate
knowledge of normal and disturbed human physiology causing surgical diseases.
Demonstrate knowledge of the effects of age,
as reflected in the newborn, infants, children, and the older patients
on the physiologic functions of the major
organ systems.
Apply physiological knowledge to the clinical
and operative management of surgical diseases.
COMPETENCY-BASED KNOWLEDGE
OBJECTIVES:
1. Describe concepts of normal physiology, including:
a. Fundamental processes
of cell differentiation and growth
b. Endocrine and
autocrine control of genetics and development
c. Normal pregnancy,
embryology, and parturition
d. Concept of
homeostasis and cellular mediators
e. Biochemistry of
normal nutrition and metabolism
f. Fluid mechanics and
dynamics
g. Hemostasis,
coagulation, thrombogenesis, fibrinosis
h. Excretory and
regulatory renal function
i. Biomechanics of
normal respiration and gaseous exchange
j. Wound healing and
inflammatory response
k. Oncogenesis
l. Neuroendocrine control of development of secondary sexual characteristics, breasts
m. Neurophysiology of
pain
n. Response to sepsis
o. The immune response
p. Cellular division,
telomeres, apoptosis
2. In each of the above systems, identify physiologic variations in geriatric, pediatric, immunosuppressed, and pregnant patients.
3. Indicate the normal values of commonly applied clinical tests.
4. Describe the applications of physiologic principles to surgical monitoring and therapy, including the following approaches:
a. Application of
Swan-Ganz catheters
b. Ventilator management
c. Renal function
studies
d. Noninvasive vascular
testing
e. Interpretation of results of the common metabolic panel blood tests
f. Interpretation of electrocardiogram (EKG), cardiac echograms and other cardiac function studies
g. Interpretation of a
nutritional profile
h. Endocrine function
studies
5. Describe
how aging affects the tests listed in the section immediately above.
6. Describe
the abnormal physiology of complex diseases or entities such as:
a. Cardiac failure f. Intestinal obstruction
b. Renal failure g. Malnutrition
c. Pulmonary failure h. Cardiopulmonary bypass
d. Immunosuppression i. Advanced
age
e. Malignancy
7. Analyze the aspects of aging within each organ system that can
alter the surgeon’s approach to care of the elderly patient, to include consideration of:
a. Genetic factors (e.g., alterations in DNA synthesis and chromosomal functioning)
b. Cumulative cellular damage (e.g., changes from free radicals and radiation)
c. Errors in protein synthesis
d. Alterations in the immune system
e. Effects of endogenous steroid hormones
f. The cross-linkage theory (resulting in loss of elasticity, increased tissue brittleness)
g. Apoptosis
h. Telomere function
COMPETENCY-BASED PERFORMANCE
OBJECTIVES:
1. Interpret laboratory tests and clinical findings based upon physiologic concepts.
2. Manage patients with surgical illnesses and/or major physiologic disruptions such as:
a. Liver failure
b. Malnutrition
c. Renal failure/bowel
obstruction
d. Hemorrhage
e. Cardiopulmonary
failure
f. Electrolyte
imbalance
g. Endocrine disorders such as multiple endocrine neoplasia (MEN)
h. Sepsis
i. Shock
j. Immunosuppression
k. Diabetes
l. Advanced age
3. Adapt treatment plans to reflect physiologic variations in pediatric, geriatric, and pregnant patients.
4. Utilize clinical
findings, laboratory tests, and hemodynamic measurements to alter patient
physiology.
5. Adjust treatment plans in response to abnormal physiologic values.
6. Identify and formulate treatment plans for improved nutrition.
7. Interpret hemodynamic monitoring and adjust treatment to restore homeostasis:
a. Insert and maintain arterial venous and central lines.
b. Monitor catheters.
8. Solve problems interfering with normal hemostasis.
9. Analyze pulmonary function tests, solve problems causing abnormal respiration, and delineate weaning parameters.
The Physiology unit was revised by Walter J. Pories, MD, from the
Curriculum, third edition, by Robert E. Berry, MD, and Walter J. Pories, MD.
SELECTED BIBLIOGRAPHY:
Adkins
RB, Jr.,
Cobbs EL, Duthie EH, Jr,
Murphy JB (eds). Biology of aging/age-related physiologic changes. Geriatrics Review Syllabus: A Core
Curriculum in Geriatric Medicine (4th ed).
Evers BM, Townsend CM Jr,
Thompson JC. Organ physiology of aging.
In: Zenilman ME, Roslyn JJ (eds),
Surgery in the elderly patient, Surg Cl
of N Amer 1994;74(1):23-39.
Guyton AC, Hall JE, Human Physiology and Mechanisms of Disease (6th ed).
Jahnigen DW, Schrier RW. Geriatric Medicine (2nd ed).
McLeskey CH (ed).
Physiologic changes of aging. Geriatric
Anesthesiology.
Rosenthal RA, Andersen DK. Physiologic
considerations in the elderly surgical patient.
In: Miller TA (ed), Modern
Surgical Care: Physiologic Foundations and Clinical Applications (2nd
ed).
Sanders AB. Physiology of aging. In: Sanders AB (ed), Emergency Care of the Elder Person.
Schiller HJ, Kort KC, Sillin LF. Physiologic
principles in preparing patients for surgery. In: Miller TA (ed), Modern Surgical Care: Physiologic Foundations
and Clinical Applications (2nd ed).
Schwesinger WH, Moyer MP.
Cell biology. In: O’Leary JP (ed), The Physiologic Basis of Surgery (2nd
ed).
Zenilman ME. Preoperative assessment of the
elderly. In: Cameron JL (ed), Current Surgical Therapy (6th
ed).
UNIT 2.3/2.3G
FLUID AND ELECTROLYTE HOMEOSTASIS
UNIT OBJECTIVES:
Demonstrate an understanding
of normal fluid and electrolyte homeostasis.
Demonstrate the ability to maintain homeostasis by
recognizing and correcting fluid and electrolyte derangements.
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
1. Describe body water volumes and distribution.
2. Indicate the normal electrolyte distribution of cell water and extracellular fluid to include the following:
a. Sodium e. Calcium
b. Potassium f. Magnesium
c. Chloride g. Phosphate
d. Bicarbonate
3. Outline the normal electrolyte content of body fluids such as blood, extracellular fluid (ECF), urine, saliva, gastric juice, bile, and pancreatic fluid.
4. Identify water and electrolyte changes in response to various stress situations such as:
a. Diseases, including trauma and burns
b. Operative therapy
c. Non-operative therapy
5. Analyze water and electrolyte disorders affecting the hospitalized elderly by discussing the etiology and treatment of such conditions as:
a. Water overload
b. Plasma volume depletion
c. Changes in serum sodium levels
d. Changes in serum potassium levels
6. Describe the role of the following hormones in fluid and electrolyte homeostasis:
a. Vasopressin (ADH) e. Steroids
b. Renin f. Adrenocorticotrophic hormone
c. Angiotensin (ACTH)
d. Aldosterone
7. Apply the physiology of water and sodium imbalance to the following:
a. Salt and water depletion (depletion of extracellular fluid volume [ECFV])
b. Salt and water excess (expansion of ECFV)
c. Hyponatremia (hypo-osmolarity)
d. Hypernatremia (hyperosmolarity)
8. Explain the treatment for water and sodium imbalance, including the use of and complications from diuretics and fluid restrictions.
9. Summarize normal potassium physiology, the causes and consequences of depletion and excess, and the treatment for potassium imbalance.
10. Discuss the complexities of calcium, phosphorus, and magnesium excesses and deficiencies in such situations as:
a. Metastatic breast cancer
b. Hepatic failure
c. Hyperparathyroidism
d. Milk-alkali syndrome
e. Eclampsia
11. Illustrate treatments for high or low calcium, phosphorus, and magnesium in the instances listed directly above.
12. Discuss the changes that affect water and sodium regulation, related to patient age and renal maturity, to include:
a. Concentrating ability
b. ADH secretion
c. Ability to conserve sodium
d. Secretion of atrial natriuretic peptide
13. Outline the pathophysiology of fluid and electrolyte problems in cardiac, aortic, and peripheral revascularization, including reperfusion injury.
COMPETENCY-BASED PERFORMANCE OBJECTIVES:
1. Use patient fluid balance data as general measures of fluid homeostasis.
2. Estimate the patient's state of sodium and water balance by history and physical examination in the following locations/situations:
a. Emergency department
b. Pre- and post- operative patients
c. In conjunction with nutritional considerations in patients on long-term total parenteral nutrition (TPN).
3. Provide fluid and electrolyte orders to nursing staff for such situations as:
a. Sepsis
b. Burns
c. Major surgery
requiring transfusion
d. Ascites
e. Cardiac failure
f. Malnutrition
g. Fistulas (high output
intestinal)
h. Hypertrophic pyloric
stenosis
4. Coordinate orders involving nutrition, acid-base, and electrolyte problems.
5. Apply fluid and electrolyte principles to the following special applications:
a. Neonates c. Geriatric patients
b. Infants d. Cardiac bypass patients
6. Manage outpatients and inpatients with hypo- and hyper- kalemia.
7. Manage patients with hypo- and hyper- calcemia.
The Fluid/Electrolyte unit was written by John C. Fitzpatrick, MD, and Jeffrey C. Pence, MD.
SELECTED BIBLIOGRAPHY:
Abrams WB, Beers MH, Berkow R (eds). Water and
electrolyte disorders. The Merck Manual
of Geriatrics (2nd ed).
Brandt MM, Bessey PQ. Electrolyte disorders. In: Cameron JL (ed), Current Surgical Therapy (6th ed).
Cobbs EL, Duthie EH, Jr,
Murphy JB (eds), Homeostasis. Geriatrics
Review Syllabus: A Core Curriculum in Geriatric Medicine (4th ed).
Fabri PJ. Fluid and electrolyte physiology
and pathophysiology. In: Miller TA (ed),
Modern Surgical Care: Physiologic
Foundations and Clinical Applications (2nd ed).
Glynn L, Meyer A. Fluid and electrolyte
therapy. In: Cameron JL (ed), Current Surg Therap (6th ed).
Wait R, Kahng KU, Dresner LS. Fluids and
electrolytes and acid-base balance. In:
UNIT 2.4/2.4G
ACID-BASE HOMEOSTASIS
UNIT OBJECTIVES:
Demonstrate an understanding
of the biochemistry and physiology of acid-base homeostasis.
Demonstrate the ability to
diagnose and effectively treat complex disorders of acid-base balance.
COMPETENCY-BASED KNOWLEDGE OBJECTIVES:
1. Explain hydrogen ion biochemistry and physiology to include:
a. The
Henderson-Hasselbalch equation
(1) Ventilatory
component (pCO2)
(2) Renal component (HCO3-)
b. Hydrogen ion
production and disposal
c. Buffering systems
(1) Acute
(bicarbonate)
(2) Chronic (bone,
renal, and pulmonary)
2. Relate the biochemistry of membrane gas exchange using the example of gases exchanging over the alveolar/capillary interface.
3. Explain the physiology of hydrogen ion production and renal excretion of hydrogen ions.
4. Describe renal bicarbonate reabsorption and regeneration.
5. Summarize the contributions of the skeleton, kidneys, and lungs in maintaining a normal pH.
6. Classify metabolic acidosis, including "anion gap" and hyperchloremic acidosis.
7. Identify specific causes of metabolic acidosis.
8. Given values for pH, pCO2, and HCO3-, distinguish between compensated and uncompensated metabolic acidosis, respiratory acidosis, metabolic alkalosis, respiratory alkalosis, and mixed abnormalities; derive a differential diagnosis for each.
9. Explain age-associated changes that may occur in certain respiratory and renal regulatory processes that are known to maintain normal pH. How does aging affect:
a. Ability to hyperventilate in response to acute metabolic acidosis
b. The kidney’s response to an acid load (Describe recovery of the blood pH.)
10. List disorders, common in elderly patients, that contribute to acid-base disturbances. Explain the mechanisms that can lead to acid-base disturbances associated with:
a. Heart failure d. Renal disease
b. Anemia e. Pulmonary disease
c. Sepsis f. Diabetes mellitus
11. Identify specific acid-base disturbances in elderly patients caused by such frequently used drugs as:
a. Salicylates c. Laxatives
b. Diuretics
12. Relate metabolic alkalosis to the following:
a. Chloride-responsive
alkalosis
b. Chloride-resistant
alkalosis
c. Paradoxic aciduria
13. Predict the importance of primary diseases and their complications to the evaluation of patient risk for:
a. Shock
b. Bowel obstruction
c. Sepsis
14. Analyze the acid-base problem and its cause in specific clinical situations, and determine an appropriate course of therapy for the following conditions:
a. "Medical"
problems such as:
(1) Diabetic
ketoacidosis (4) Renal insufficiency
(2) Lactic acidosis (5) Respiratory failure
(3) Renal tubular
acidosis
b. "Surgical"
problems such as:
(1) Pyloric
stenosis
(2) Gastric outlet
obstruction
(3) Fistulas
(4) Ureteroileal
conduit
(5) Shock
15. Why are disturbances of acid-base balance common in elderly patients? Explain by discussing the implications of:
a. Impaired homeostatic
mechanisms
b. High prevalence of drug use
and disease
16. Summarize the adverse effects of acid-base disturbances on the following body systems:
a. Central nervous
system / intracranial pressure
b. Renal physiology
c. Pulmonary physiology
COMPETENCY-BASED PERFORMANCE OBJECTIVES:
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