Welcome to the University of Colorado School of Medicine on the Anschutz Medical Campus. A Top Ten Medical School, our departments, centers and institutes work with the University of Colorado Hospital, The Children's Hospital and Barbara Davis Center.

Critical Learning Objectives

1. Define "hernia" and differentiate direct inguinal hernia, indirect inguinal hernia, femoral hernia, lumbar hernia, obturator hernia, incisional hernia, and spigelian hernia.
2. Describe the anatomy of the inguinal region including the layers within the spermatic cord.

Important Learning Objectives

1. Identify and state the incidence, identification of, operative risks and complications of abdominal wall hernias, to include femoral, inguinal, and ventral hernias.

"Nice to Know" Learning Objectives

1. Outline the fundamentals of surgical repair of various groin, umbilical, and ventral hernias.

Critical Learning Objectives

1. Define and explain the significance of the term "acute abdomen".
2. Describe how to obtain a history of abdominal pain, including the importance of the location of pain and the distinctions between visceral pain, parietal pain, and referred pain.
3. Perform a detailed physical examination of the acute abdomen and be able to describe bowel sounds, the use of percussion, techniques of palpating the abdomen, techniques to identify diffuse and localized tenderness, and explain the importance of including the inguinal region, rectum, and pelvis in the exam.
4. Explain the uses of the CBC, serum electrolytes, blood urea nitrogen, creatinine, arterial blood gas, amylase, and liver function tests.
5. Explain the importance of urinalysis and stool for occult blood.

Critical Learning Objectives

1. Explain the clinical finding of the most common presentations of appendicitis including symptoms and signs, laboratory findings, and x-ray findings.

Important Learning Objectives

1. Describe how pregnancy alters the presentation of appendicitis.
2. List the differential diagnosis for acute appendicitis.
3. Describe the complications of acute appendicitis.
4. Explain the management of acute appendicitis, including the management of an appendiceal abscess.

"Nice to Know" Learning Objectives

1. State the incidence of primary malignant tumors of the appendix and for carcinoid tumors.

Critical Learning Objectives

1. Outline the signs and symptoms of acute and chronic gallbladder disease including common duct stones as well as the diagnostic tests used in detection of biliary stone disease and rationale for treatment.

Important Learning Objectives

1. Describe the usual gross anatomy of the biliary system and the physiologic function of each of its parts.
2. Describe the pathophysiology of gallstone formation.
3. Describe the complications of untreated gallstones.
4. Outline the diagnostic procedures necessary to differentiate obstructive from non-obstructive jaundice and the proper treatment for common duct obstruction.

Presenting Complaints or Disease Entities

• Breast mass
• Mammographic abnormality
• Breast pain
• Nipple discharge

Critical Learning Objectives

1. Describe the differential diagnosis for a breast mass and the distinguishing feature of each lesion.
2. List the major risk factors for breast cancer.
3. List the three components recommended to women for breast cancer screening and efficacy of each.
4. Describe the history, physical exam, and diagnostic modalities for:
   • A patient with a breast mass
   • A patient with a nipple discharge
   • A patient with a mammographic abnormality
5. Describe the treatment options for breast cancer by stage of disease.

Important Learning Objectives

1. Describe the staging of breast cancer and understand the critical features which place the patient's disease into local, local-regional-or systemic category.
2. Describe the rationale for adjuvant chemotherapy and hormonal therapy in the treatment of localized breast cancer.
3. Describe the common surgical procedures used for the local treatment of breast cancer, including indications, contraindications, and pertinent anatomical boundaries.

"Nice to Know" Learning Objectives

1. Describe the survival rate for breast cancer, the length of necessary follow-up, and the prognostic factors which most influence survival.
2. Describe the common presentations and treatment for locally recurrent and metastatic breast cancer.
3. Describe the BRCA 1 gene.

Presenting Complaints or Disease Entities

• Melena
• Bowel Obstruction
• Inflammatory bowel diseases
• Rectal abscess

Critical Learning Objectives

1. Discuss neoplasms of the colon, rectum, and anus. This should include risk factors, etiology, signs, symptoms, and treatment.
2. Describe signs and symptoms of diverticular disease.
3. How can colon obstruction be differentiated from small bowel obstruction?
   Know the signs of obstruction due to volvulus and its treatment.
4. Outline the differences between ulcerative colitis and Crohn's disease of the colon. Include the indications for surgical treatment for each.
5. Differentiate between perirectal abscess, hemorrhoidal disease, anal fissures, and fistulas.

Critical Learning Objectives

1. Complete the following table of normal values:

   	Na	K	HC03	CI
   Serum
   Gastric Aspirate
   Bile
   Ileostomy Aspirate

   
   
2. Describe the extracellular, intracellular, and intravascular volumes in a 70-kg man.
3. List at least six physical findings or symptoms of dehydration.
4. List and describe the objective way of measuring fluid balance.
5. Describe the 24-hr sensible and insensible fluid and electrolyte losses in the routine postoperative patient.
6. Describe the possible causes (differential diagnosis), appropriate laboratory studies needed, and treatment of the following conditions:
   1. Hypernatremia
   2. Hyponatremia
   3. Hyperkalemia
   4. Hypokalemia
   5. Hypercalcemia
   6. Hypocalcemia
   7. Hypomagnesemia
7. List the physiological limits of normal blood gases

Important Learning Objectives

1. List at least four endogenous factors that affect renal control of sodium and water excretion.
2. List the composition of electrolytes in the following solutions:

   	Glucose	Na	K	CI	HCO3	Ca
   0.9% NaCl
   Ringer's Lactate
   D5W
   D5 Ringers

   
   
3. Given a patient with the condition in the left columns, list representative values and pH for the serum electrolytes observed:

   	Na	K	HC03	CI	pH
   Excessive gastric losses
   High volume Pancreatic fistula
   Small intestinal fistula
   Biliary fistula
   Diarrhea
   Closed head injury

   
   
4. List representative values that might be obtained in patients with the conditions listed in the left column:

   	Serum
   	Na	K	HCO3	CI	Osmolality
   ATN
   Dehydration
   Inappropriate ADH Secretion
   Diabetes Insipidus
   CHF

   
   

   	Urine
   	Na	K	HCO3	CI	Osmolality
   ATN
   Dehydration
   Inappropriate ADH Secretion
   Diabetes Insipidus
   CHF

   
   
5. List representative values that might be obtained in patients with the conditions listed in the left column:

   	Arterial Blood
   	pH	PO2	PCO2	HCO3	Base Excess
   Acute Metabolic Acidosis
   Acute Respiratory Acidosis
   Chronic Respiratory Acidosis
   Acute Respiratory Alkalosis
   Compensated Metabolic Acidosis

Critical Learning Objectives

1. Outline the diagnostic and therapeutic approach used in the patient presenting with upper gastrointestinal bleeding.

Important Learning Objectives

1. Outline the anatomy of the stomach and the physiology of gastric secretion.
2. Discuss the significance of the anatomic location of ulcers in the stomach and duodenum (e.g., anterior duodenal – risk for perforation; posterior duodenum – risk for bleeding and penetration; pyloric channel – risk for obstruction; gastric – risk for malignancy).
3. Describe the methods and relative importance of the following procedures used in diagnosing gastric ulceration: gastric analysis, diagnostic x-ray, gastrocopy, and biopsy.
4. Describe the types of gastric tumors and essential diagnostic maneuvers.
5. Describe the medical management of peptic ulcer disease.
6. Define the significance of free intraperitoneal air.

"Nice to Know" Learning Objectives

1. List the causes for surgical failure and recurrent ulcer following surgery for peptic ulcer.
2. Differentiate antrectomy and vagotomy, pyloroplasty and vagotomy, and parietal cell vagotomy currently performed for peptic ulcer disease and the physiologic rationale, risks, and effectiveness of each.
3. Discuss the potential complications of the commonly used surgical procedures for duodenal and gastric ulcers.
4. Describe the basal acid output (BAO) and maximal acid output (MAO) that would characterize duodenal ulcer, gastric ulcer, and Zollinger-Ellison syndrome.

Presenting Complaints or Disease Entities

1. Painless jaundice
2. Splenic rupture
3. Hermatemesis from esophageal varices
4. Pancreatitis
5. Pancreatic cancer

Critical Learning Objectives

1. Describe the work-up of a patient with jaundice and recognize the common surgical lesions in the differential.
2. Recognize the significance of "Charcot's Triad" and Reynolds' Pentad".
3. Describe Child's criteria and the management algorithm for a patient with hermatemesis and a history of esophageal varices.
4. Describe the role of Ranson's criteria in the management of a patient with acute pancreatitis.
5. Outline the treatment options for ruptured spleen.
6. Describe the staging and treatment options for pancreatic cancer.

Important Learning Objectives

1. Discuss the pathophysiology and management of liver cysts, hemangioma, adenoma, and hepatoma.
2. Describe the indications for splenectomy and the outcome for hematological indications.
3. Discuss the pathophysiology of pancreatitis including the complication and management options.

"Nice to Know" Learning Objectives

1. Understand the critical biology of pancreatic cancer and its patterns of spread.

Critical Learning Objectives

1. Determine maintenance fluid requirements and normal urinary output for infants and children.
2. Determine the blood volume and describe methods of replacement of blood loss in infants and children.

Important Learning Objectives

1. Describe the typical presentation and findings on physical examination of hypertrophic pyloric stenosis.
2. Define gastroesophogeal reflux disease and describe its typical presentation and methods of evaluation.
3. Describe the typical presentation of neonatal bowel obstruction and methods of evaluation. Be able to describe the differential diagnosis of neonatal bowel obstruction.
4. Explain the typical clinical presentation of intussusception, including the principles of resuscitation, use of barium enema, and indications for and principles of operative treatment.
5. Explain the anatomical defect in Hirschprung's disease, and relate this to the functional bowel obstruction.
6. Describe the differential diagnosis for constipation and methods of treatment.
7. Describe the medical management of vomiting in infants and children.
8. Describe the differential diagnosis of vomiting and the importance of bilious vomiting in children.

"Nice to Know" Learning Objectives

1. Describe congenital diaphragmatic hernia and eventration of the diaphragm including diagnosis and treatment.
2. Define the most common types of esophageal atresia and describe the typical clinical presentation of an infant with esophageal atresia, the radiologic method of determining presence or absence of a distal tracheoesophageal fistula.
3. Describe the embryologic problem resulting in malrotation, the mechanism of duodenal obstruction, and small bowel volvulus.
4. State the principle of medical management of necrotizing enterocolitis and explain the indications for surgical intervention.
5. Describe a Meckel's diverticulum and list the four most common complications.
6. Define and distinguish gastroschisis and omphalocele and how the appearance of the herniated bowel differs from that of the omphalocele.

Presenting Complaints or Disease Entities

• Cold and/or painful extremity
• Pain with walking
• Extremity swelling
• Foot and leg ulcers and gangrene
• Pulsatile abdominal mass
• Unilateral defects in vision or speech
• Sudden shortness of breath

Critical Learning Objectives

1. Describe the signs and symptoms of peripheral arterial insufficiency: differentiate between claudication and rest pain; understand the role of non-invasive vascular testing; and understand the fundamentals of medical and surgical therapy.
2. Describe the signs and symptoms of acute major arterial occlusion.
3. Describe the signs and symptoms of abdominal aortic aneurysm; understand its diagnosis, treatment, and prognosis.
4. Describe the signs and symptoms of pulmonary embolism, essentials of diagnosis, and treatment options.
5. Define the symptoms of cerebrovascular disease (TIA, RIND, Stroke, amarosis fugax); understand the mechanisms of symptoms; describe the prognosis and risks of extracranial cerebrovascular disease. Outline test for making the diagnosis; describe the various options for treatment.

Important Learning Objectives

1. Define superficial, deep, and communicating veins of the lower extremity and have a general knowledge of venous pathophysiology.
2. Discuss the etiology of deep (DVT) and superficial (SVT) venous thrombosis, the risk factors for this disease, clinical signs and symptoms, the utility of Duplex ultrasound. Outline the differential diagnosis for DVT, the complications of DVT, and its treatment and prevention.
3. Describe the signs and symptoms of chronic venous insufficiency, be able to differentiate between arterial and venous ulcers, and have a general knowledge of treatment.
4. Describe the visceral ischemic syndromes and their etiology.
5. Differentiate between manifestations of peripheral arterial disease in diabetic and non-diabetic patients.

Presenting Complaints or Disease Entities

• Intestinal obstruction
• Diseases of the small bowel

Critical Learning Objectives

1. Describe the signs and symptoms of a patient presenting with intestinal obstruction.
2. List signs and symptoms suggesting strangulating obstruction.
3. Describe the signs, symptoms, and indications for surgical therapy in Crohn's disease.

Important Learning Objectives

1. List six causes of small bowel obstruction and relative frequency of each of these.
2. Differentiate mechanical small bowel obstruction and paralytic ileus by history, examination, and x-ray studies.
3. Compare large bowel obstruction and small bowel obstruction by etiology, symptomatology, x-ray, and other diagnostic procedures.
4. Prepare a management plan for a patient with small bowel obstruction, utilizing appropriate diagnostic methods (both laboratory and x-ray), fluid and electrolyte therapy, antibiotic therapy, intestinal intubation, and operative treatment.

Critical Learning Objectives

1. Describe the important pathogenic factors of surgical infections and their mechanisms of spread.
2. Discuss the signs, symptoms, and management of patients with peritonitis.

Important Learning Objectives

1. Outline the general principles of diagnosis and management of surgical infections, including necrotizing fasciitis, and clostridial gangrene.
2. Know locations of intra-abdominal abscesses and their relative frequency of occurrence.
3. List the clinical signs of tetanus and the current recommendation for prophylaxis.

"Nice to Know" Learning Objectives

1. Outline the general principles of diagnosis and management of intra-abdominal abscesses.
2. List the common etiologies of acute and chronic peritonitis.
3. Define furuncle, carbuncle, hidradenitis, and cellulites.
4. Outline the fundamentals of the anatomy of the peritoneal cavity.
5. Describe the circulation of the intraperitoneal fluid including lymphatic drainage.

Critical Learning Objectives

1. Outline an organized approach to assessing critically ill surgical patients, incorporating both the physical examination and data from appropriate monitoring equipment.

"Nice to Know" Learning Objectives

1. Demonstrate the ability to maintain an accurate intake and output record and hourly flow sheets on an acutely ill patient.

Critical Learning Objectives

1. Discuss the evaluation, treatment, and differential diagnosis of a patient with a thyroid nodule.
2. Discuss the evaluation and treatment of a patient with a persistently elevated serum calcium level.
3. Describe the biology and treatment of papillary, follicular, medullary, and anaplastic thyroid cancer.
4. Explain how multiple endocrine neoplasia (MEN) syndromes relate to the thyroid and parathyroid glands.

Important Learning Objectives

1. Describe and discuss the inflammatory processes of the thyroid gland.
2. Discuss the etiology, signs, symptoms, medical treatment, and the selective use of surgery in the treatment of hyperthyroid state.
3. Describe the symptoms of hypothyroidism.
4. Describe the differential diagnosis of hypercalcemia.
5. Differentiate primary and secondary hyperparathyroidism and discuss the surgical principles in the treatment of both diseases.

"Nice to Know" Learning Objectives

1. Outline the clinical features and treatment of parathyroid crisis.
2. Differentiate the treatment and associated conditions between parathyroid adenoma and hyperplasia.
3. Describe tertiary hyperparathyroidism.
4. Discuss the recognition and treatment of hypocalcemia.

Presenting Complaints or Disease Entities

1. Shock
2. Blunt and penetrating abdominal trauma
3. Pneumothorax and tension pneumothorax
4. Spine injury

Critical Learning Objectives

1. Understand the basic approach to a trauma patient and rationale for the sequence of evaluation and care.
2. Outline the diagnosis and treatment of upper airway obstruction.
3. Diagnose and treat shock.
4. Diagnose and treat hemoperitoneum and its treatment priorities.
5. Understand the pathophysiology of tension pneumothorax and its treatment.
6. Plan for fluid resuscitation on a burned patient.
7. Outline a plan for fluid resuscitation for a patient in shock.

Important Learning Objectives

1. Closure of lacerations.