Sclerotherapy is the first-line treatment for problematic macrocystic hygroma (lymphangioma). Surgical removal of macrocystic LM is indicated if the lesion is symptomatic and sclerotherapy is no longer possible, or resection is possibly curative because the lesion is small and well localized.

Hypo-ca approach. (Tetanus including paresthesia and muscle spasms). Total < 2.12 mmol/l

Hyper-ca approach. (stones bones throans groans and psychiatric tones) total > 2.62 mmol/l

Approach to GERD symptoms and management.

Surgical therapy Indications (Equally effective alternative to medical therapy in certain patients with chronic GERD):
• Complications (e.g., Barrett esophagus, strictures, recurrent aspiration).


If s&s of GERD and Hx of vomiting blood. Endoscopy (BI) show multiple ulcers then fasting gastrin serum level (CT) . Treat with PPI and surgical resection but if mets do chemo. = zollinger

PE

Primary Amenorrhea diagnosis. (Outflow obstruction like transverse vaginal septum happens when girl 👧 with normal or low FSH/LH and no period and with secondary sexual characteristics tuner stage more or eq 2= do US for anatomic abnormality)

Delayed puberty in girls occurs when breasts don't develop by age 13 or menstrual periods do not begin by age 16.
With delayed puberty, these changes either don't occur, or if they do, they don't progress normally. Delayed puberty is more common in boys than in girls. If constitutional usually there is FHx

Cervical pap interpretation. If in exam say low grade or high grade dysplasia = high or low SIL.

Secondary amenorrhea

Hemorrhoids approach and management=
Below the dentate line there is pudental nerve so painful. in internal hemorrhoids usually inferior hypogastric artery is affected.

Complications? Did hemorrhoidectomy and came back in few months with severe pain? MC cause= anal stenosis

Tx: NGT decompression IV fluids IV antibiotics Keep viscera moist and protected until surgical reduction with primary abdominal closure