Revision - of - Surgery - by - Medad - Team سؤال و اجابه و حالات محلوله

RevisionofSurgery
Index
Section 1: Cases
Section 2: Written Questions
1
12
Vascular surgery
Thyroid
Breast
Hernia, Skin and Subcutaneous Tissues, Head and neck
Jaundice, Liver, Gall Bladder
Gastrointestinal Emergencies
Gastrointestinal Miscellaneouses
Urology
Testis
Orthopedics
Chest surgery
Neurosurgery
Section 3: Explain
13
15
18
21
24
28
29
32
33
34
36
37
39
Special Thanks to Prof Amr El-Shayeb
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RevisionofSurgery
Section 1: Cases
Case
number Diagnosis
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10
Case 11
Case 12
Case 13
Case 14
Case 15
Case 16
Case 17
Case 18
Case 19
Case 20
Open arterial injury of incomplete type

Open arterial injury of complete type
Arterial embolism
Leaking aortic aneurism
Diabetic foot infection with superimposed septicemia
Iliofemoral deep venous thrombosis
Thyrotoxicosis (mostly primary)
Cancer thyroid
Breast lump
Malignant obstructive jaundice
Hematemesis
Rupture spleen
Bleeding peptic ulcer
Acute appendicitis complicated with appendicular mass
Perforated peptic ulcer
Pyloric stenosis
Acute osteomyelitis
Chest injury
Tension pneumothorax
Head trauma
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SummaryofSpecialSurgery
Case 1
2.For arterial injury: INcomplete
72 years old male come to ER 24hours after

transfemoral coronary angioplasty with a
progressive pulsatile swelling in right femoral
triangle, pulse 120/min, blood pressure 70/60
Analysis of the case:
3.Postoperative:
- After 24 hours: indicate hypovolemia especially with

tachycardia and hypovolemia
- Transfemoral angiography: mostly the arterial injury is
incomplete
A. What is your diagnosis?

Answer: Arterial injury (incomplete (open)
B. What investigations would you order?
Answer:
Investigations for the arterial injury:
1. Angiography
2. Doppler ultrasound
3. Colored duplex
- Searching for the following findings:
Site of injury
Type of injury whether complete or incomplete
Extent of injury
Presence of false aneurysm
DISTAL RUN OFF
Investigations for cardiac condition:

ECG
Echocardiography
Investigations to assess fitness for surgery:

- Kidney function tests
Serum urea, creatinine and creatinine clearance
To exclude renal tubular necrosis
- Blood sugar: for diabetes
- Cooagulation profile: especially prothrombin time
and concentration
- Arterial blood gases and serum electrolyte
C. What is the treatment of the case?

Answer:
Correction of hypovolemia
1.For volume resuscitation:
a. IV fluids ( Ringer's lactate or saline )
b. fresh blood transfusion
c. volume expanders (dextran or gel fusion )
2.Proper oxygenation
3.General care: discuss general care of patient from
management of class III / IV hemorrhage, page 13
Absolute bed rest in trendelenburg position and warmth
Analgesia (pethidine)
IV Na bicarbonate to correct
Inotropics and vasopressors
Proper monitoring of vital signs
Treatment of arterial injury:

1.Exploration with evacuation of hematoma.
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a. if transverse tear : measure the tear

i. If < 1/2 circumferential : direct suture or patch graft
ii. If > 1/2 circumferential : turn into and treat as
complete , do end to end anastomosis or vein graft
b. If longitudinal tear: vein patch graft
You should look for pedal (peripheral) pulsations for
48 hours to ensure patency.
-you should predict acute tubular necrosis and renal
shut down.
-you should predict possibility of myocardial
infarction
Case 2
33 years old males presented to ER after he

sustained a stab wound in the region below
left inguinal ligament. The wound was oozing
red blood , pulse , 110/min , blood pressure:
80/60
Analysis:
-Stab wound: if arterial injury, it should be complete.
-Below inguinal ligament: in femoral triangle.
-Tachycardia and hypotension: indicating hypovolemia
-Bright red blood: excluding venous injury
A. What is your diagnosis and differential

diagnosis?
Answer:
- Diagnosis: open arterial injury of complete type.
- Differential diagnosis:
1. Incomplete arterial injury
2. Artero venous injury with later communication
3. Muscular injury

Answer:
Investigations for arterial injury:
1. Angiography
3. Colored duplex
Site of injury
Type of injury whether complete or incomplete
Extent of injury
Presence of false aneurysm
DISTAL RUN OFF
Investigations to assess fitness for surgery:
- CBC: for hemoglobin and hematocrite

- Kidney functions tests: serum urea, creatinine and
creatinine clearance
- Coagualtion profile
- Arterial blood gases and serum electrolytes
RevisionofSurgery
C. Discuss clinical evaluation and preparation

for treatment.
Answer:
Clinical evaluation:
Evaluation of hypovolemia:
Discuss signs of hypovolemic shock, page 17
- CNS: anxious to drowsy
- Pulse: tachycardia (rapid, weak) thready
- Blood pressure: hypotension
- Respiratory rate: tachycardia and air huger
- Temperature: hypothermia
- Skin: pale, cold, sweaty with collapsed vein
- Urine output: oliguria
Evaluation of limb condition (viable or not

viable): discuss
The 5 cardinal signs of acute ischemia, page 90 +
th
capillary circulation as 6 item.
i- Pain: discuss
ii- Pallor: discuss
iii- Pulse: if peripheral pulse is :
FELT but weak: incomplete injury
NOT felt: complete injury
iv- Parasthesia: discuss
v- Paraplegia: discuss
vi- CAPILLARY CIRCULATION : THE MOST
IMPORTANAT ITEM:
If present, so VIABLE limb
If FIXED color changes, so NON viable limb.
Preparation for treatment:

Investigations: as above
4As:
Analgesia
Antitetanic
Antibiotic
Anti shock measures: discuss correction of hypovolemia
Predict and treat possible complications:

A. Acute tubular necrosis and renal shut down:
From hypovolemia or from myoglobin from injured or
ischemic muscle
Treatment: by forced diuresis by mannitol OR By dialysis
B. DVT and pulmonary embolism:

Treatment: thrombolytic therapy.
C. Reperfusion injury: especially hyperkalemia

Treatment: IV glucose + insulin
D. Compartmental syndrome:
Treatment: fasciotomy
Case 3
A 28 years old female with a history of mitral

stenosis presented to ER with sudden severe
pain in Right lower limb, by examination, the
limb was pale and cold.
Answer: arterial embolism

Answer:
Investigations for cardiac condition:
ECG
Echocardiography
Investigations for arterial embolism:

1.angiography
2.Doppler ultrasound
3.Colored duplex
Site of impaction of embolus
Extent of secondary arterial embolism
Distal run off (collateral circulation)
Investigation to assess fitness for surgery

1.CBC: for hemoglobin & hematocrite.
2. Kidney function tests.
3. Liver function tests.

Answer:
1. Surgery: Urgent embolectomy :
Under Local Anaesthesia.

Immediate heparinization: to prevent propagation of
arterial thrombosis.
Urgent embolectomy: Discuss.
Delayed embolectomy: Discuss.
Complication of embolectomy & their treatment: Discuss
2. Fibrinolysins (Thrombolytic Therapy): Discuss.

3. Amputation: in late cases with limb gangrene.
After correction of embolism, the patient should be
transferred to cardiology department for proper cardiac
assessment & management.
Case 4
A 75 years old patient came to ER with

sudden severe epigastric pain referred to
back. On examination, there was pulsatile
epigastric swelling. Pulse: 110/min, Blood
pressure: 70/50, Respiratory Rate: 35/min.
A. What is the Diagnosis & Differential
Diagnosis?
- Diagnosis: Leaking Aortic aneurism.
- Differential Diagnosis: Pseudopancreatic cyst is the
commonest Differential diagnosis:
Disappear on sitting on knee-elbow position.
By Barium Meal: Shows forward displacement of the
stomach in lateral view.
B. What investigation would you order?

Answer:
Investigation to reach diagnosis:
1.Abdominal scan
2.CT scan with IV contrast
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Site of the aneurism: supra- or infra- renal (above or

below L2)
Size of aneurism: if > or < 5 cm
If there is a dissecting element or not.
3.Angiography: after resuscitation & stabilization of
general condition of the patient.
N.B.: Do NOT Order Doppler or Duplex; of NO
importance an a such a case
Investigation to detect possible complications:

1. CBC, Hemoglobin & Hematocrite: for hemorrhage.
2. Kidney function test:
Serum urea, creatinine, creatinine clearance.

For possibility of acute tubular necrosis & Renal Shutdown by hypovolemia or involvement of renal A.
in Dissection.
3. Investigation for lower limb ischemia: Doppler &
Duplex on lower limb vessels.
4. ECG & Electrocardiography: for Myocardial
infarction.
5. Fasting Blood Sugar.

6. Coagulation profile: esp. Prothrombin Time &
Concentration.
7. Arterial Blood Gases & Serum electrolytes.

Answer:
1. Correction of hypovolemia: Discuss

2. Repair of aneurism: open surgery by opening the
aneurism sac & implanting synthetic graft inside it.
3. Post operative ICU care: for proper maintaining &

management of possible complications mentioned
above, Renal shut down, MI.
Case 5
A 68 years old male came to ER drowsy,

flushed with swollen warm left foot. The
patient is diabetics. On examination, Pulse:
120/min, Blood Pressure: 70/50, Temperature
39, the foot was hot & tender. Analysis:
Hypotension, Drowsy & flushed indicate
septicemia.
A. What is your Diagnosis?
Answer: Diabetic foot infection with superimposed
septicemia.

Answer:
Investigation for diabetic foot:
1. Fasting blood sugar.
2.Culture & Sensitivity for pus from infected foot.
3.Plain X-ray on foot: to exclude osteomyelitis.
4.Doppler & Duplex scan on ankle vessels.
Investigation for septicemia & septic shock:

Blood Culture.
Arterial blood gases.
Serum lactate.
Kidney function tests
Liver function tests (Coagulation Profile)
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Serum electrolytes.
ECG.

Answer:
Treatment of Diabetic foot: Discuss ttt of Diabetic
foot
Treatment of Septicemia: Discuss ttt of Septic shock

p.20. Note that some items are repeated the same as in
diabetic foot, Do NOT Repeat.
-In ICU.
-Antioxidants: for oxygen free radicals.
-Indomethacin: anti-inflammatory medications.
-Circulatory support by vasopressin & inotropes.
-IV Na Bicarbonate for acidosis.
- Proper monitoring: by CVP, ECG, PAWP, Pulse, Blood Pressure, Temperature, urine output, ABG
Case 6
31 years old female after labor developed

severe pain & swelling of her right lower limb.
On examination, the peripheral pulses were
felt, vital signs are normal, No fever.
Analysis:
Felt peripheral pulses exclude ischemia.
No fever excludes cellulitis.
A. What is your diagnosis & Differential

Diagnosis?
Answer:
- Diagnosis: Iliofemoral Deep Venous Thrombosis.
- Differential Diagnosis:
Pblgmania Alba Dolens: Painful white swelling
- Pallor, coldness, diminished pulsations.
Pblgmania Cerulae Dolens: Painful Blue swelling

- Cyanosis, severe pain, marked LL edema, venous gangrene.

Answer:
1.Doppler ultrasound
2.Colored duplex
3.Venagraphy
4.Helical 3D CT scan
i.
ii.
iii.
iv.
Level of thrombosis
If there are incompetent perforations
State of superficial system
Starting recanalization or not

Answer: Discuss curative treatment of DVT,
prophylaxis treatment is NOT required.
Aims of treatment: enumerate

Lines of treatment:
1.Bed rest & bandage: discuss
2.Anticoagulants:
RevisionofSurgery
- Heparin: discuss mechanism of action, methods,
duration & control of Administration, antidote &

complications of heparin.
- Overlap: discuss
- Oral anticoagulants: discuss mechanism of action,
methods & control of Administration, antidote &
complications of oral anticoagulant.
3.Thrombolytic therapy: plasminogen activation

4.Surgery:
IVC interruption by filter insertion through jugular vein
to prevent recurrent pulmonary embolism
Case 7
34years old pregnant female (14week)

presenting with recent insomnia, loss of
weight, palpitation .on examination, she was
found to have tachycardia and big pulse
volume.
Answer: thyrotoxicosis (most probably primary toxic
goiter, Gravess disease)

Answer:
1. T3, T4: obligatory free (more accurate), not total which is
affected by proteinuria in pregnancy.
2. TSH: decreased
3. ECG, Echocardiography, very important because
hyperdynamic state of both pregnancy and
thyrotoxicosis.
4. CBC, Hemoglobin and hematocrite:

- Because of:
Physiological anemia during pregnancy
Catabolic state of thyrotoxicosis
5. Neck ultrasound & colored duplex scan on

neck: Showing diffuse swelling & hypervascularity
(Hallo sign)
6. Serum Ca and alkaline phosphatase

NB: thyroid scan must NOT be done because radioactive
iodine is teratogenic.
C. Discuss treatment of this case

Answer:
This pregnant female is at the start of second trimester
*During this period, minimal dose of B blocker
(propranolol,inderal) should be given till 3rd trimester
- Mechanism of action, dose, side effects of inderal: discuss
*Postoperative L thyroxine replacement should be

postponed till time of delivery to avoid fetal
hypothyroidism.
Case 8
A58 years old male presenting by recent hard

swelling in the lower part of the neck with
pain referred to ear, examination revealed
palpable firm neck node.
A. What is your diagnosis and differential
diagnosis?
Answer:
- Diagnosis: - cancer thyroid
- Differential diagnosis: - from other hard swelling in
thyroid
Riedles thyroiditis Calcified simple nodular goiter

Answer:
Discuss all investigations of cancer thyroid including those of
different pathologies (follicular, papillary, anaplastic,
medullary)
C. What is the ttt of that case?

Answer: discuss ttt of cancer thyroid
Operable case: discuss
Inoperable case: discuss
Histological surprise & prognosis: not required
Case 9
43 years old female presenting with a lump in

the upper quadrant of her right breast
A. Discuss differential diagnosis of this case
Answer:
Enumerate all causes of chronic breast lumps
including hard & cystic masses
Hard masses:
Cancer breast
Chronic breast abscess
Calcified hematoma
Cystic masses:
Hard fibroadenoma
Duct ectasia
Traumatic fat necrosis
Cyst of fibroadenosis
Retention cyst due to duct papilloma
Galactocele
Cold abscess
Hydatid cyst
Traumatic fat necrosis
Degenerated carcinoma
*Antithyroid drugs are TOTALLY CONTRAINDICATED,

to avoid fetal hypothyroidism.
*If developed severe manifestations of thyrotoxicosis
during 3rd trimester, go ahead for surgery; subtotal
thyroidectomy
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Table
Differential diagnosis of most important causes of chronic breast lump

History
General
examination
Local examination
Cancer breast
Accidental discovery
of painless lump.
Nipple discharge.
Skin manifestations
Metastasis
Firm to hard.
Early mobile, later fixed.
With FLAT UNDERSURFACE.
Enlarged, painless, hard,

early mobile, later
fixed.
Fibroadenoma
Free
Free
No palpable Axillary
nodes.
Fibrocystic
disease
History of
premenstrual tension
syndrome ( discuss)
Free
Duct papilloma
Free
Free
Duct ectasia
Free
Free
Extremely firm.
Freely mobile (Breast mouse).
Well defined, rounded.
Bilateral Cystic Tender
Mobile
Well defined
Felt ONLY by Tips not flat of hand
Firm Mobile Painless.
Well defined.
RETROAREOLAR
With BLEEDING PER NIPPLE.
Firm Mobile Painless.
Well defined.
RETROAREOLAR
Well defined.
TENDER.
With palpable TENDER

Axillary LNs.
Breast mass
Axillary nodes
nodes.
nodes.
nodes.
With CREAMY NIPPLE

DISCHARGE.
Chronic breast
abscess
History of lactational
mastitis
Traumatic fat
necrosis
History of trauma
Constitutional
manifestations
ROUNDES with LIMITED MOBILITY
Free
B. What investigations are required to reach

definitive diagnosis?
Answer:
Table
Investigations to reach definitive diagnosis

Breast ultrasonography
Step I
Cystic.
Cystic
Solid
Aspiration
Step II
Searching for
criteria of
malignant aspirate:
enumerate
Searching for criteria of malignancy in

mammography: enumerate (if
suspicious of being malignant, do PET
scan)
Step III
Mammography
Biopsy
1. Needle biopsy:
a. FNAC
b. True cut needle
2. Surgical biopsy
a. Incisional
b. Excisional
Tumor markers
If proved to be malignant, so do:
Step IV
Estrogen receptor status
Metastatic work up
GIT Surgery
Case 10
62 years old male patient, presented to
outpatient clinic with progressive jaundice,
dark urine. On examination, a mass was felt
in upper abdomen with pain referred to back.
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Firm to hard.
Fixed.
Painless.
nodes.

Answer: Malignant obstructive jaundice (most
probably due to cancer Head of pancreas).

Answer:
A. Laboratory investigations: Discuss laboratory
investigations of obstructive jaundice as before.
1.Urine analysis: absent urobillirogen, positive

billirubin & bile salts
2.Stool analysis: absent stercobillirogen & bile salts,

increased fat may be occult blood.
3.Liver function test:
- Increased total & direct billirubin, alkaline

phosphatase enzyme
- Normal liver enzymes except if prolonged obstruction
- Gamma glutamyl transpeptidase
- Prolonged Prothrombin time & lowered Prothrombin
concentration (Should be above 60% before
surgery, PTC, sphincterotomy)
4.Kidney function test: to exclude renal impairment
B. Radiological investigations: Discuss laboratory

investigations of malignant obstructive jaundice as
before.
1.CT scan with IV contrast, investigation of choice
showing pancreatic tumors.
2. ERCP: diagnostic & therapeutic.
Inserting stent in.
Detect level of obstruction & causes.
RevisionofSurgery
3. PTC: Especially in patients with cholongiocarcinoma:

show level & cause of obstruction.
4. Hypotonic dudenography: shows:
'Inverted 3' in periempullory carcinoma.
'C' in cancer head of pancreas.
C. Treatment of the case

Answer:
Preoperative preparation of jaundiced
patient: Discuss.
Treatment:
Operable cases:
- For cancer head of pancreas: radical resection by

Whipple's Pancreatoduodenectomy: Enumerate
- Structures to be removed in Whipple's operation, p.
105.
Structures to be removed in Whipple's operation:
i.Head & neck of pancrease.
ii.While duodenum.
iii.Gastric antrum.
iv.Gall bladder & CBD.
Inoperable cases:
- Biliary stent:
Internal by ERCP.
External by PTD.
- Surgical drainage by Cholecystojejunostomy.
Case 11
A 45 years old female presented to ER with

attack of hematemesis,
Discuss management of this case?
Answer:
Possibilities:
1. Bleeding varices.
2. Bleeding peptic ulcer.
3. Gastric erosions.
Management:
A. Clinical:
History:
i.History of Bilharziasis, Jaundice, Ascitis, Previous
Sclerotherapy in bleeding varices.
ii.History of ulcer dyspepsia & hunger pain in bleeding
peptic ulcer.
iii.History ulcerogenic during intake as Aspirin & NSAIDs in
bleeding peptic ulcer.
General Examination:
- Signs of Hypovolemia:
CNS: anxious to drowsy

Pulse: tachycardia (rapid, weak) thready
Blood pressure: hypotension
Respiratory rate: tachycardia and air huger
Temperature: hypothermia
Skin: pale, cold, sweaty with collapsed vein
Urine output: oliguria
- Jaundice, manifestations of Liver cell failure in

varices as:
Ascitis.
Bleeding Tendency.
Palmar erythema, Spider nevi, Gynecomastia.
Hepatic coma.
Local Examination:
i. Evidence of liver cell failure, Splenomegally & Ascitis in

bleeding varices.
ii. Pointing sign in bleeding peptic ulcer.
iii. Epigastric Tenderness in Gastric erosions.
B. Investigations:
1)
Laboratory: Discuss Laboratory

tests in investigations of
hematemesis p.193.
2) Radiological: Discuss abdominal scan & CT in
investigations of hematemesis p.194.
3) Endoscopy: Discuss endoscopy in investigations of
hematemesis p.193.
Investigation of choice, also therapeutic.
C. Treatment:
1. Correction of hypovolemic shock: Discuss in brief.
2. Specific management: if:
Bleeding varices:
- To prevent Encephalopathy: Discuss how to prevent

encephalopathy in active bleeding from varices, p.62.
- To stop Bleeding: Discuss how to stop bleeding in active
bleeding from varices, p.62 & 63.
Bleeding peptic ulcer:

Choice of management depends on amount of
blood loss.
- Surgical Treatment: if blood loss > 1L.
i. Gastrotomy or Duodenotomy to visualize the ulcer;

the bleeding vessels are ligated under vision.
ii. Definitive ulcer treatment if good general condition:
Truncal Vagotomy & Gastrojejonostomy. OR
Billroth I partial Gastrectomy.
- Conservative Treatment: if blood loss < 1L.
Discuss Conservative treatment of bleeding peptic

ulcer, p.33.
Gastric erosion: Discuss treatment of gastric erosion,
p.21 & 22.
Case 12
8 years old boy presented to ER with in left

upper
abdomen
following
abdominal
trauma.Pulse:120/min, BP: 90/60, with tender
left hypochondrium.
A. What is your Diagnosis?
Answer: Rupture Spleen.
Answer:
Laboratory:
i.CBC: Hemoglobin & Hematocrite.
ii.Coagulation profile.
iii.Arterial blood gases & electrolyte.
N.B.: if old patient, add investigations to assess fitness for
surgery.
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Radiological:
Abdominal Ultrasonography & CT scan with contrast:
for the following:
Type & Degree of rupture spleen.
Perisplenic hematoma.
Free fluid in peritoneal cavity.
Other associated abdominal injuries.
Others:
Abdominal paracentesis: reveals blood.
Diagnostic peritoneal Lavage (DPL) :
- Criteria of positive DPL: Enumerate.

N.B.: Selective Splenic angiography should NOT be done
because patient is in shock.

Answer:
A. Anti shock measures: Discuss in Brief.
B. Urgent Splenectomy (Open or
Laparoscopic): is the classic.
C. Splenic preservation: is considered as the patient
is CHILD:
i. Splenorrhaphy: suture of small lacerations or tears.

ii. Partial Splenectomy: if only avulsed one pole.
iii. Autosplenectomy: Discuss.
N.B.: Conservative non-operative management is totally

contraindicated because patient is in shock. Also,
Therapeutic Embolization is NOT favorable line of
treatment.
Case 13
60 years old male present with recent attack

of vomiting of fresh blood, pulse 110/min, BP
90/70. On examination there was epigastric
tenderness, the patient mentioned he was
receiving medications for dyspepsia.
A. What is your diagnosis & differential
diagnosis?
Answer:
Diagnosis: bleeding peptic ulcer.
Differential diagnosis: Cancer stomach.

Answer:
Laboratory:
CBC
ABG & electrolytes.
ECG & kidney function tests.
Coagulation profile.
Liver function tests.
Endoscopy:
Investigation of choice.
Diagnostic for bleeding peptic ulcer.
Therapeutic by injection sclerotherapy or laser
electrocautary.
Other investigations: should be done after initial
resuscitation.
Barium meal:
- Ulcer niche for peptic ulcer.
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- Irregular filling defect, ulcer niche outside ulcer

burning area, linitis plastica for cancer stomach.

Answer:
1) Anti shock measures: Discuss in brief.
2) Surgical treatment: conservative treatment is NOT
suitable in this case.
Methods:
i. Gastrotomy or Duodenotomy to visualize the ulcer;

the bleeding vessels are ligated under vision.
ii. Definitive ulcer treatment if good general condition:
Truncal Vagotomy & Gastrojejonostomy. OR
Billroth I partial Gastrectomy.
Case 14
28 years old female presented with history of

vague umbilical pain 3 days ago, now the
pain is well localized to right iliac fossa. On
examination, pulse 90/min, BP 120/80, temp
38c with a palpable tender mass in right iliac
fossa.
Answer: Acute appendicitis complicated with
appendicular mass.

Answer:
Laboratory: CBC for Leucocytosis & ESR.
Abdominal sonar: Discuss.
Laparoscope: Discuss.
C. Treatment of the case?

Answer:
Treatment of appendicular mass: Discuss.

If complicated by appendicular abscess: Discuss
treatment of appendicular abscess.
Case 15
32 year-old-male presented to ER with severe

epigastric pain with nausea & vomiting, pulse
120/min, BP 100/70. On examination, ther
was tenderness & rebound tenderness in the
epigasterium with shifting dullness. The
patient gave history of recent intake of
NSAID.
Answer: Perforated peptic ulcer.
Answer:
The most important are laboratory & plain x-ray:
1. Laboratory:
i.CBC, leucocytosin, hemoglobin & hematocrite.
ii.ABG, serum electrolytes & renal function tests.
RevisionofSurgery
2. Plain x-ray abdomen erect reveals:

- Air under right copula of diaphragm.
- Multiple air fluid level.
- CBC, hemoglobin, hematocrite.

- Serum, electrolytes, PH.
- Liver function test: most important is serum albumin.
3. Gastrografin swallow reveals:
2. Barium meal: soup dish appearance
4. Sonar reveals:
3. Endoscopy: reveals:
- Escape of dye.
- Intra-abdominal fluid.
- Excludes other causes.
5. Peritoneal tapping.
6. Endoscopy.

Answer:
Preoperative urgent resuscitation: Discuss, similar
to IO)
Operative:
1.Simplest, most popular: is omental patch: Discuss.
2.Definitive ulcer treatment:
- Provided that:
The patient is generally fit.
The surgeon is competent.
The hospital is well equiped.
- So defenitive ulcer surgery should be done:

For duodenal ulcer, do vagotomy &
gastrojejunostomy.
For gastric ulcer, do partial gastrectomy &
gastroduodenostomy.
Postoperative care:
Continue preoperative care, then:

The patient should continue on medical conservative
treatment of peptic ulcer (antacids) provided
the simplest procedure was done.
Case 16
32 years old male presented with upper

abdominal distension,vomiting after meals
wih old history of dyspepsia which was
medically treated on examination rital signs
are normal with hyper resonance,distended
upper left abdomen.
A. What are the possible causes?
Answer:
Possible diagnosis: pyloric stenosis due to
scarred(fibrosed) duodenal ulcer.
Diffrential diagnosis: from other causes of pyloric

stenosis except congenital.
- Traumatic: impact foreign body or corrosive stricture.
- Inflammatory: crohns disease.
- Neoplastic: cancer pylorus, less commonly liomyoma.
- Pressure from out side: lymph nodes, Cancer head of
pancreas, pseudo pancreatic cyst.

Answer:
1. Laboratory:
- Discuss findings.
- Stenosed pyloric ring.
- Retention gastritis.
C. Treatment of the case?

Answer:
Preoperative preparation: all initial effort is
directed at building up nutritional status of the patient
in order to decrease complications of surgery.
i.
ii.
iii.
iv.
Nasodigastric tube suction.

High protein diet.
Correction of fluid, electrolyte disturbance.
Chest physiotherapy & antibiotics.
Surgery:
1. Truncal vagotomy & posterior gastrojejonostomy
for drainage of obstructed stomach.
2. If stomach is hugely dilated, so do partial
Gastrectomy.
Case 17
7 years old boy brought to ER, complaining of

inability to walk with severe pain over his
lower right thigh. There was history of mild
trauma 1 month ago. On examination, severe
tenderness & hotness over lower right thigh
with diffuse swelling.
P 110/min.
temperature 39.
A. What is your diagnosis & differential
diagnosis?
Answer:
Diagnosis: Acute osteomyelitis.
Differential diagnosis:
- 2 Tumors:
i. Osteosarcoma.
ii. Ewings sarcoma.
- 2 Arthritis
iii. Septic arthritis.

iv. Rheumatic arthritis.
v. Cellulitis.

Answer:
Laboratory:
- Blood picture: Leucocytosis & ESR.
- Blood culture.
Radiological:
- Radio isotopic bone scanning:

Increased activity in early stages of inflammation.
- Pain X- Ray:
No bony changes before 3 weeks. Changes
indicate chronicity.
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C. Discuss clinical picture & X-ray finding

Answer:
Clinical picture: Discuss clinical picture of acute
osteomyelitis.
Plain X- ray finding:
Answer: Discuss urgent investigations in cases of chest

injuries.
Laboratory: Discuss.
Radiological: Discuss.
Instrumental:
ECG, Echocardiography.
Thoracocentesis: Discuss.
Bronchoscopy.
- No bony changes before 3 weeks.

- Changes appear in chronic condition in form of:
Involucrum: New bone formation.
Sequestrum: Separated dead pieces of bone.
Abscess.
Sinuses.
Cloaca: Openings.
D. Treatment of the case

Answer: Discuss treatment of acute osteomyelitis.
Case 18
30 years old male brought to ER after road

traffic accident, alert but Dyspnic, Pulse
140/min, Bp 90/60. Temperature 37. There
were abrasions & contusions on his left chest
wall. Abdominal examination is free.
Analysis:
Alert: No head injury.
Dyspnic: indicating chest injury.
Severe tachycardia, hypotension: shock.
Free abdominal examination with left chest injury: No
rupture spleen.
A. How to proceed to proper clinical

examination?
Answer:
Main causes of death in cases of chest
trauma:
i. Circulatory failure.
ii. Respiratory failure.
First aid measures:

1. Support circulation by anti shock measures:
Discuss in brief.
2. Support respiration:
General:
i. Maintain patient upper airway.
ii. Analgesics.
iii. Aspirate secretions.
iv. Proper oxygenation:
By:
O2 mask.
Tracheastomy.
Endotracheal tube & mechanical ventilation.
If:
RR > 40/min.
PO2 < 60 mmHg.
PCO2 > 45mmHg.
Flail chest.
N.B.: No head trauma in this case.
Specific: For flail chest:
Support of flail segment by external Strapping or

positive pressure ventilation.
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CVP.
Esophagescopy.
C. What are the possible diagnosis & its

management?
Answer:
Possible Diagnosis:
1. Fracture ribs & flail chest:
Management:
i. If small: cotton bad & adhesive plaster.

ii. If severe in old: Intermittent Positive Pressure
Ventilation.
2. Hemothorax:
Management:
3.
Intercostal tube inserted at 5th space midaxillary line,

connected to underwater seal drainage or
Thoracotomy.
Tension Pneumothorax (provided the patient has
Tracheobronchial tear).
Management:
nd
- Wide bare needle in 2 intercostals space,

th
midclavicular then intercostals tube in 5
Intercostal space midaxillary.
- Surgery if bronchopleural fistula (continuous
bubbling of air in Intercostal tube).
Case 19
25 years old male injured in a car accident. He

was alert but very Dyspnic. Examination
reveals Hyperresonsnce & diminished air
entry on right side.
Discuss management of the case
Analysis:
Alert: No head injury.
Severe Dyspnic: serious chest injury.
Answer:
Diagnosis: Pneumothorax, most probably tension
Pneumothorax.
Management:
Main causes of death in cases of chest injuries:
Circulatory failure.
Respiratory failure.
First aid measures:

1.Support circulation by anti-shock measures:
Discuss in brief.
2.Support respiration:
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General:
i. Maintain patient upper airway.
ii. Analgesics.
iii. Aspirate secretions.
iv. Proper oxygenation:
By:
O2 mask.
Tracheastomy.
If:
RR > 40/min.
PO2 < 60 mmHg.
PCO2 > 45mmHg.
Flail chest.
Specific: For tension Pneumothorax.
- Wide-bare needle (14-16) inserted in 2nd

intercostals space, Midclavicular.
Urgent investigations:
Instrumental:
Answer: From management of head injuries.

Initial care at hospital (emergency room):
Discuss from page 190.
Initial examination: Discuss from page 190,191.

Glasgow coma scale: Discuss (already discussed).
Urgent investigations: Discuss from page 191,192.

Nursing care & observation & repeated
observation: Discuss from page 192.
ECG, Echocardiography.
Thoracocentesis: Discuss.
Bronchoscopy.
Causes of deterioration of patient under observation

after head trauma: Enumerate.
Management of injuries: Discuss from page 193.
CVP.
Esophagescopy.
Specific treatment: Tension Pneumothorax

Management:
nd
- Wide bare needle in 2 intercostals space,

th
midclavicular then intercostals tube in 5
Intercostal space midaxillary.
- Surgery if bronchopleural fistula (continuous
bubbling of air in Intercostal tube).
Case 20
30 year patient admitted to ER after head

trauma. The patient was drowsy. After few
hours, the level consciousness started to
deteriorate.
A. Mention two causes for deterioration of
level of consciousness?
Answer:
i. Massive brain edema.
ii. Intracranial hematoma.
iii. Airway obstruction & hypoventilation.

Answer:
Glasgow coma scale to assess condition:
Discuss from page 191.
Laboratory investigations: very important:

ABG: PO2, PCO2.
Blood gases.
Blood picture.
Serum electrolytes.
Renal function tests.
Radiological investigations:
Plain X-ray.
CT brain with IV contrast, MRI: for intracranial
hematomas.
N.B: DO NOT mention lumbar puncture; it is
contraindicated.
C. Discuss treatment of condition
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Section 2: Written Questions
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13
Vascular Surgery
1. Enumerate causes and discuss complications
of acute ischemia.
Answer:
Causes of acute ischemia: enumerate the 5 causes of
acute ischemia
1. Embolism
3. Arterial injuries
5. Dissecting aneurysm
2. Acute thrombosis
4. Phlegmasia alba dolens
Complications of acute ischemia:

- Complications of acute ischemia:
1. Secondary distal thrombosis: discuss
2. Nerve ischemia: discuss
3. Peripheral Edema: discuss
4. Incomplete recovery: discuss
5. Moist non septic gangrene: describe
Black swollen edematous limb with skin blebs and
offensive odor.
Complete venous obstruction

Cyanosis, severe marked U edema (Compartemental
Syndrome) causing Venous gangrene
Late complications:
1. Secondary varicose veins & their complications:

Discuss skin & vein complications of varicose veins,
page 131
2. Chronic venous insufficiency (post-phlebitis

limb): discuss
5. Discuss clinical picture and investigations of

DVT.
Answer:
Risk factors: enumerate risk factors for DVT
- Post-operative: THE COMMONEST
- Females during pregnancy and perpurium
- Old age, malignancy, obesity and delivery
- Contraceptive pills
How to suspect DVT after operation: if fever,
tachycardia, increased ESR in early post operative
period, unexplained from operation
Symptoms and signs: discuss

6. Volkman ischemic contracture: define

Massive infarction of forearm flexors, followed by
fibrosis contracture and deformity, when brachial A. is
injured due to supracondylar fracture of humerus.
- Complications of treatment:
- From other causes of leg swellings: enumerate causes of

leg swellings.
- From other causes of leg pain: enumerate causes of leg
pain
Investigations:
1. Sudden death due to pulmonary embolism

2. Compartmental syndrome: discuss
3. Reperfusion injury: discuss
2. Colored duplex
3. Venagraphy
4. Helical 3D CT scan
2. Discuss management of arterial embolism

Answer: Discuss management of arterial embolism
including differential diagnosis with Acute
thrombosis Table p.95
3. Discuss predisposing factors for DVT.

Answer:
Virchow's triad: discuss
Abnormalities of thrombosis & fibrinolysis:
enumerate
4. Discuss fate & complications of DVT.

Answer:
Fate of DVT: discuss fate of venous thrombosis.
Complications of DVT:
Early complications
1. Pulmonary embolism:
Fatal type: discuss
Massive type: discuss
Moderate type: discuss
Recurrent showers: discuss
2. Venous gangrene: phlegmasia cerulae dolens:

discuss
Painful blue swelling
5. Radio-iodine labeled fibrinogen.

-Searching for the following findings:
i. Level of thrombosis
ii. If there are incompetent perforations
iii. State of superficial system
iv. Starting recanalization or not
Complications: discuss, enumerate or ignore according
to marks and time of question.
6. Give an account on capillary hemangioma

Answer:
Definition: define capillary hemangioma
Differences between hamartoma and true
benign tumors: discuss
Types:
- Strawberry angioma: discuss
- Port wine stain: discuss
- Spider naevi: discuss
- Hereditary hemorrhagic telangectasia: discuss
7. Discuss pathology of TB lymphadenitis.

Answer:
Organism: human or bovine bacilli
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Types:
1. Blood borne TB: military TB in immunocompromised
adult patient, rare condition
2. Lymph borne TB: localized to upper deep cervical

LNs in children
Fate of lymph borne TB:

Fate depends on body resistance and virulence of
organism:
Body resistance = virulence of organism: discuss
Body resistance virulence of organism: discuss
Body resistance < virulence of organism: discuss
Complications: enumerate
Gross description:
- Matted LNs due to peri-adenitis

- Rosary beads
Pathology of blood borne TB: discuss
8. Discuss pathology and complications of

Lymphedema
Answer:
Definition: define Lymphedema
Causes: Enumerate causes of Lymphedema
- Filariasis: discuss N.B. P.137
Pathology: discuss 4 stages of Lymphedema

Complications: enumerate.
9. Discuss differential diagnosis of enlarged
upper deep cervical LNs. What investigations
you need to reach diagnosis?
Answer:
Differential Diagnosis: Enumerate causes of diseases

of LNs p.140
-Among the above mentioned causes, the most

important are:
Tuberculosis: Discuss clinical picture &complications of
TB lymphadenitis
-Children with poor general condition

-LNs: matted due to periadenitis, with rosary beads
-Complications: enumerate.
Lymphomas:
*Non Hodgkins lymphoma:
Affected LNs are amalgamated with heterogenous

consistency, early mobile later on fixed
*Hodgkins lymphoma:
- LNs: firm, mobile, rosette shaped
- Systemic manifestations:
Pel Ebstein fever: 2 weeks of fever alternating with

2 Weeks of freedom
Pain at the site of disease induced by alcoholics.
Metastasis:
- Presented either:
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Evident well-defined primary malignancy of head

&neck e.g. (Cancer thyroid, cancer tongue, cancer
anal cavity)
Hidden malignancy e.g. (Cancer pharynx and larynx)
Metastasis first presentations with occult primary e.g.
(In cancer thyroid with lateral aberrant LNs)
- LNs: hard, painless, early mobile later on fixed to
surroundings.
Investigations:
Laborotomy:
1. Blood picture:
To exclude leukemia
Leucocytosis in acute inflammation
Lymphocytosis in chronic inflammation
2. ESR
3. Serum LDH: characteristically increased with lymphoma
4. Tuberculin test & PCR
5. Bone marrow aspirate: for leukemia & lymphomas
Radiological:
1. Chest x-ray: for TB

2. Abdominal Ultrasonography & CT: for assessment of:
Paraortic LNs
Liver & spleen involvement
Other visceral involvement esp. in lymphoma
3. Lymphocentography
LNs BIOPSY: THE MOST IMPORTANT INVESTIGATION
10. Discuss Differential diagnosis of leg ulcers

Answer:
1. Vascular ulcers:
Venous ulcers: describe

Ischemic ulcer: describe
Lymphedema ulcer: describe
2. Traumatic ulcers (neuropathic):
Diabetic ulcer
Spinal cord lesion (esp. syringomyelia)
3. Inflammatory:
Chronic inflammatory: TB, chronic osteomyelitis
4. Neoplastic:
Squamous cell carcinoma: describe
Ulcerating malignant melanoma: describe
5. Blood: sickle cell anemia (vaso-occlusive)

6. Others:
Autoimmune diseases (SLE, SS)
Rheumatoid diseases.
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15
2.Superior mediastinal syndrome: discuss symptoms of
Thyroid
superior mediastinal syndrome
Signs: discuss signs of superior meditational syndrome
1. Give an account on thyroglossal duct

Answer:
Anatomical consideration: discuss embryology of
thyroid gland page 148
rd
Thyroid gland appears at the 3 week IU as a median
epithelial growth at the floor of primitive pharynx
(foramen cecum) .It descends to lower part of front of
the neck connected to foramen cecum of tongue by
THYROGLOSSAL DUCT which disappears before birth.
Definition: unobliteration remnant of thyroglossal duct,

considered as tubulodermoid cyst.
Pathology: discuss including site

Complications: COMMENST is abscess and fistula
(ALWAYS ACQUIRED) then discuss thyroglossal fistula.
Clinical picture:
- Discuss clinical picture of thyroglossal cyst
- OR by fistula
Differential diagnosis: from other causes of cystic
swelling in the midline of the neck

Enumerate cystic swelling of midline of neck page 294
Cold abscess
Dermoid cyst
Sub hyoid bursitis
Laryngocele
Cystadenoma of thyroid isthmus
Treatment: discuss Sistrunk operation (this NOT
considered operative details)
2. Give an account on RETROSTERNAL goiter.

Answer
Definition: it is an anatomical entity NOT a pathological
one
Anatomical consideration: discuss attachment of

pretracheal fascia page 148
Thyroid gland moves up and down with deglutition, being
enclosed within pretracheal fascia which is attached to:
Above: to hyoid bone and oblique line of thyroid cartilage
Below: to adventitia of aortic arch
Laterally: to carotid sheath
At the isthmus: fuses to tracheal rings 2, 3, and 4
So it is retromanubrial extension
Types:
1.Retrosternal extension of large goiter: discuss: will
eventually pass into plunging goiter.
2.Plunging goiter: discuss

3.Intrathoracic goiter: discuss
Clinical picture:
Symptoms: 2 main presentations:
1.Thyroid disease: either (just enumeration)
SNG
Toxic goiter OR
Malignant goiter
Inspection, palpation, percussion: discuss
Differential diagnosis: from other causes of

superior mediastinal syndrome: enumerate.
Thymoma
Aneurysm of aortic arch
Enlarged superior mediastinal syndrome
Investigations: in order of importance
1. CT SCAN CHEST: discuss: MOST IMPORTANT

2. Tc 99 thyroid scan: thyroid traced in chest not in neck
3. Chest x ray
Treatment: only treatment is surgery

- Discuss treatment of retrosternal goiter
- Preoperative preparation of thyrotoxic retrosternal
goiter patient: discuss (NB)
3. Discuss complications and treatment of

simple nodular goiter.
Answer:
Complications:
1. Tracheal obstruction by compression: discuss
2. Secondary thyrotoxicosis: discuss pathophysiology of
secondary toxic goiter page 160
- Long standing simple nodular goiter before toxicity

due to stimulation of internodular tissues
by thyroid antibodies.
- Nodules are inactive, while the internodular thyroid
tissues are overactive.
3. Malignant transformation into follicular

carcinoma in 3%
Discuss behavior of follicular carcinoma of thyroid
page 171
- Incidence: 17%
- Females
- Little TSH dependent
- Radioactive iodine uptake
- Bad response to radiotherapy
- Mortality rate: 24%
4. Cyst formation: discuss
5. Hemorrhage into cyst

6. Calcification: discuss
7. Retrosternal goiter
- Retrosternal extension: discuss its pathology from P 176
- Plunging goiter: discuss its pathology from P 176
- Do NOT discuss intrathoracic goiter.
Treatment:
Prophylactic:
By correction and avoidance of predisposing factors for
physiological and colloidal goiter: (enumerate causes of
simple goiter page 156)
- Iodine deficiency: relative or obsolete
- Enzymatic deficiency: Pendred's syndrome by screening
- Goitrogens
Curative:
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- Indications:
Complications: (enumerate if the question is
treatment only)
Cosmetic disfigurement
Treatment:
1. If cyst, so do aspiration:
- If you find criteria of malignant aspirate which are:
Hemorrhage
Residual mass after aspiration
Rapid accumulation of fluid
+ve cytology for malignant
- Procedure:
For solitary nodule: hemithyroidectomy = one lobe + isthmus
For multinodular: subtotal thyroidectomy, discuss
- Postoperative:
L thyroxine: discuss
NB: NOT below 25 years: discuss
4. How can you solve a problem of solitary

nodule?
Answer:
Definition: either
- True solitary: define OR
, So proceed to surgery
2. If benign condition, hemithyroidectomy is enough

3. If malignant condition:
- If papillary: proceed to total thyroidectomy, being
multicentric
- If follicular:
If non invasive: hemithyroidectomy is enough

If invasive: proceed to total thyroidectomy
- Dominant nodule: define
5. Discuss postoperative complications of

thyroidectomy operation.
Answer
examination
General postoperative complications:
Differentiation between different causes of solitary thyroid nodule
Table
Causes: enumerate the 6 causes of solitary thyroid nodule

Differentiation by history, general and local
History
Carcinoma
Toxic
nodule
Simple
nodule
Adenoma
-recent swelling
rapidly
progressive
- pain referred to
ear
Metabolic , CNS,
CVS, symptoms
of thyrotoxicosis
: discuss
-ve
General
examination
+/- metastasis
Swelling:
Firm to hard
Painless
Early mobile, later fixed
+/- palpable enlarged LNs in neck 1.
Signs of hypervascularity :
- Inspection:
Visible pulsation
Dilated veins over neck
2.
- Palpation: warm
Palpable thrill
3.
Palpable expansile pulsations
- Auscultation: audible bruit
Metabolic ,
CNS, CVS,
signs of
thyrotoxicosis
: discuss
-ve
Swelling:
- firm -painless -mobile
+/- complications
As simple nodule , differentiated by biopsy
May find history

of other
autoimmune
disorders
May find
features of
autoimmune
disorders
Unilateral complete: discuss

Bilateral complete: discuss
External laryngeal N injury

Hypoparathyroidism
- Cause: discuss
- Clinical picture: discuss latent and manifest tetany
much gland
5. Progressive exophthalmos:
- In some toxic patients, not treated and before
operation (for at least 6 months)
- Treatment: discuss
6. Thyrotoxic crisis:
- Causes, clinical picture, treatment: discuss
Investigations for solitary thyroid nodule

T3, T4, thyroid scan
, hot
nodule
Toxic
nodule
Recurrent laryngeal N. injury

Unilateral partial: discuss
Bilateral partial: discuss
4. Hypothyroidism &myxedema: from removal of too
Swelling : cystic either by cross

fluctuation or Paget's test
Swelling :
- Firm - tender - mobile
+/- enlarged LNs in neck(inflamed)
Investigations:
Table
2-Hemorrahge
4-Pulmonary complications
Local manifestations:
Cyst
Localized
hashimoto
enumerate
1-Shock
3-Infection
Local examination
Normal, cold nodule
Neck ultrasound
Cyst
Solid
Thyroid antibody titer

+ve
Localized
hashimoto
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- ve
Simple nodule,
Malignant nodule or
Adenoma
Differentiated by:
- Tumor markers
- Biopsies:
FNA, True cut needle,
open biopsy
7. Injury of important structure: trachea, esophagus,

muscles, hematoma
8. Recurrence of thyrotoxic manifestations: due to

inadequate removal of thyroid tissue.
9. Keloid and adherent scar: in low manubrium area.
10. Post operative dyspnea: enumerate its causes
6. Causes and management of dyspnea in post

thyroidectomy cases.
Answer
Causes and their management:
1. Recurrent laryngeal nerve injury:
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17
- Management: tracheostomy
2. Hypoparathyroidism:
- Management: IV calcium gluconate
3. Thyrotoxic crisis:
- Management: discuss management of thyrotoxic crisis
4. Injury of important structures:

Tracheal injury:
- Management: by repair
- Discuss pathology of medullary carcinoma & lymphoma of

thyroid.
9. Discuss outline of treatment of Graves

disease
Answer:
1. Medical treatment:
Indications: For a period of 18 months Children & young pts
Pre-operative preparations
Post operative recurrence
Refusal of surgery
Hematoma compressing trachea:

- Management: by evacuation
5. Tracheomalacia:
- Discuss tracheomalacia
- Management: tracheostomy
6. Postoperative pulmonary complications

A. Atelectasis:
- Define: obstruction of tracheobronchial tree by thick mucus
Contraindications
Retro-sternal extensions Pregnancy & lactation.
NB: - dont say Toxic autonomous nodule
Lines of treatment: discuss

Drugs used:-
plug
- Management: discuss management of atelectasis "book

special surgery page 172"
Expel obstructing plug by: turning patient, percussing
Mucolytic
Expectorant
Antibiotics
Suction
B. Pulmonary embolism:
i. B- blocker: discuss (mainly mechanism & side effect)

ii. Anti thyroid drugs: discuss (mainly mechanism & side
effects)
Disadvantages: discuss
2. Radio active iodine:

Indications: Recurrence of toxicity after operation
Thyrocardiac pt or refusal of surgery
After Age above 45 years
NB: - DONT mention (toxic autonomous nodule)
- Cause: Vircow's triadDVT Pulmonary embolism

- Treatment:
Thrombolytic therapy
Heparin and oral anticoagulant
C. Adult respiratory distress syndrome:
Contraindication:-
- Definition: syndrome of acute respiratory failure with the

formation of a non cardiogenic pulmonary edema
leading to reduced lung compliance &hypoxemia
refractory to O2 therapy
Diffuse pulmonary infiltration on x ray
Pulmonary A. wedge pressure < 16 mmHg
PO2/ Fi O2 ratio: of < 200 mm Hg
- Treatment: discuss treatment OF ARDS book special

surgery, page 175
7. Discuss outlines of treatment of cancer

thyroid
Answer:
- Treatment of Operable cases: discuss
- Treatment of Inoperable cases: discuss
- Treatment of complications: discuss
- Postoperative follow up: discuss
- Histological surprise: discuss
- Prognosis: discuss
8. Compare between different types of cancer

thyroid in table form?
Answer:
- Discuss pathological differences between different types
of adenocarcinoma (follicular, papillary, and anaplastic)
in table form, including following items: Incidence, Age,
Sex, microscopic picture, multiplicity, spread &behavior.
Young age Pregnancy & lactation Iodine allergy
Mode of action, onset, dose: discuss

Complication: discuss
3. Surgery:
Indication: Severe toxicity Retrosternal goiter Failed medical ttt
Pre operative preparation: discuss

Operation: subtotal thyroidectomy
Post-operative follow up: discuss
Complication: enumerate
4. Special problems with toxicity:

A.
B.
C.
D.
Thyrotoxicosis in pregnancy: discuss

Thyrotoxicosis in children: discuss
Thyrocardiac pt: discuss
Progressive exophthalmos: discuss management
only (cause not required)
E. Recurrent thyrotoxicosis after surgery: discuss
F. Thyro-toxic crisis: discuss management only (cause
& clinical picture not requried)
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Table
Breast
How to differentiate between causes of nipple discharge

Nature of
discharge
1. Discuss management of acute breast abscess

Answer:
Clinical picture:
Signs:
- General: general constitutional symptoms & sings:
enumerate
- Local:
Breast: discuss breast signs in milk engorgement, acute

mastitis & acute abscess including the following
items: pain, fever & physical signs
Axillary nodes: enlarged, firm, tender, mobile
Differential diagnosis: from mastitis carcinomatosa
Discuss difference between lactational mastitis & mastitis
carcinomatosa in a table form, from page 197
Complications:
1.Milk fistula: pointing into skin
2.Antibioma (chronic breast abscess): if acute abscess
heavily antibiotics without drainage of acute abscess

3.Toxemia: due to spread into circulation
Investigations:
- ESR & total leucocytic count: leucocytosis
- Mammography: to exclude mastitis carcinomatosa
Treatment:
- Treatment of acute mastitis: discuss

- Treatment of acute abscess:
NEVER wait for fluctuationevacuation
Under general anesthesia
Discuss treatment of acute abscess
2. Discuss differential diagnosis & management

of a case of nipple discharge
Answer:
Possible causes:
How to differentiate:
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Single or
multiple
ducts
Yes
unilateral
Yes
Unilateral
Multiple
(usually)
Single
Creamy ,
cheesy,
brownish (if
2ry infected )
or bloody
Yes
Unilateral
Single
Fibrocystic
disease
Pills
Galactorrhea
Inflammation
Serous or
serosanginous
Yes
(masses)
Bilateral
Multiple
Serous
Milky
Purulent
Bilateral
Bilateral
Unilateral
Multiple
Multiple
Single
Severe
trauma
Bloody
No
No
(may be
abscess)
Yes
Unilateral
Single
Duct
papilloma
Duct ectasia
- In addition to the above mentioned criteria,

general examination may reveal:
i. Constitutional manifestation: for inflammation
ii. Signs of metastasis: for cancer
iii. Signs of endocrine disturbance: for galactorrhoea
In other conditions, general examination may be free
Investigations:
1. Cytological examination of discharge: looking for
RBCs. Pus cells, inflammatory cells, malignant cells
2. Ultrasound on breast:
If cyst, do aspiration: looking for criteria of malignancy

aspirate (enumerate):
Hemorrhagic
Rapid re-accumulation
Residual mass
+ve cytology
3. Mammography: if not cyst by sonar
Looking for criteria of malignancy: enumerate

Micro density
Hyper dense
Hyper vascular mass
Prophylaxis: discuss
Treatment:
1. Cancer breast
3. Duct ectasia
5. Pills
7. Inflammation
Unilateral
or bilateral
Serosangious
or bloody
Bloody
Cancer breast
Symptoms: lactating female with redness, hotness &

pain in her breast
Associat
ed mass
2. Duct papilloma
4. Fibrocystic disease
6. Galactorrhoea
8. Severe trauma
4. Biopsy: if associated with a mass
FNAC
True cut needle
Open surgical biopsy
Treatment: discuss treatment of nipple discharge
3. Discuss differential diagnosis & management

of a case of bleeding per nipple:
Answer:
Discuss the full differential diagnosis & management
of the following 5 conditions:
1. Cancer breast
2. Duct papilloma
3. Fibroadenosis
4. Inflammation severe
5. Breast trauma
4. Discuss differential diagnosis & investigations

of a case of chronic breast lump.
Answer:
- Enumerate ALL causes of chronic breast lump including
hard & cystic swellings.
- Discuss differential diagnosis of the most important 7
causes of chronic breast lump concerning history,
general examination & local Examination, from case 9
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- Discuss Scheme for investigations required to reach

definitive diagnosis of a case of chronic breast lump,
from case 9
5. Give an account on pathological

classification & staging of cancer breast
Answer:
Pathological classification of cancer breast:
1. Lobular carcinoma: from acinar epithelium
A. Non invasive:
-Multicentric
-Never turn invasive
B. Invasive:
-Bilateral mirror image in 25% of cases.
2. Duct carcinoma: from duct epithelium.

A. Non invasive (DCIS):
i. Papillary tumor: discuss
ii. Comedo tumor: discuss
B. Invasive:
i. Scirrhous carcinoma: discuss gross & microscopic
picture of schirrous carcinoma.
- Atrophic schirrous carcinoma:
Subtype from schirrous carcinoma
Discuss atrophic schirrous carcinoma
ii. Medullary carcinoma (Encephaloid Carcinoma):

Discuss gross & microscopic picture of medullary
carcinoma
- Mucinous carcinoma:
Subtype of medullary carcinoma
Discuss gross & microscopic picture of Muanous
carcinoma
Discuss its prognosis
iii. Mastitis carcinomatosa

Most malignant, resembling mastitis, occurs during
pregnancy & lactation, of poor prognosis, it simulates
acute mastitis& must be differentiated from it.
Table for differentiation between mastitis
carcinomatosa & acute lactational mastitis is NOT
REQUIRED.
3. Pagets disease of areola and nipple

Malignant eczema of nipple, caused by either duct
carcinoma in situ or invasive breast cancer
growing into ducts and onto nipple surface
Table for differentiation between Pagets eczema
and ordinary eczema is NOT required
Staging of cancer breast:

1.TNM staging: discuss
2.Manchester classification: discuss
6. Give an account on skin manifestations of

cancer breast
Answer:
1. Dimpling:
Discuss
NOT pathognomonic
2. Puckering:
Discuss
NOT pathognomonic
3. Peau dorange:
Discuss
NOT pathognomonic
4. Skin nodules:
Discuss
Pathognomonic
5. Cancer en cuirass: discuss

6. Malignant ulcer:
Discuss
Pathognomonic
7. Dilated veins over skin of the breast

8. Mastitis carcinomatosa:
- Discuss criteria of mastitis carcinomatosa from
table P 197:
Extensive lesions affecting >1/3 breast, with dusky red
color
Breast is mildly tender, with non tender axillary LNs
with no response to antiobiotics in one week course
9. Pagets disease of areola and nipple:

- Discuss criteria of Pagets eczema from table P
198:
Unilateral well defined eczema with NO itching,
vesciles or oozing
Nipple is eroded
Breast lump is left
NO response to eczema treatment
10.Retracted nipple:
Unilateral
Recent
Associated with breast mass
7. Give an account on Pagets disease of nipple

and areola
Answer:
Definition: malignant eczema of nipple and areola
Pathology: 2 theories, usually followed by or
associated with breast mass:
1. Duct epithelium turning malignant, spreading
into 2 ways:
A. Intraductal, implanted in nipple and areola causing
Pagets eczema
B. Invading basement membrane and breast stroma
causing duct carcinoma (however not accepted
nowdays)
2. 2 separate primaries; predisposed to cancer
Clinical picture:
Unilateral, Non itchy, eroding eczema of areola and nipple
Breast mass (firm to hard, mobile or fixed)

With palpable enlarged painless axillary LNs
Staging:
TNM staging: either:
Tis, N0, M0
if no breast mass
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T1, N1, M0
B. Detect local recurrence, distant metastasis or

carcinoma of the other breast (e.g. lobular
carcinoma)
if developed breast mass
Manchester: stage I
Differential diagnosis: from ordinary eczema:

Discuss table for differentiating Pagets eczema from
ordinary eczema, P 198
5. Reconstruction: discuss
NB: NO pregnancy for 3 yeasr with NON hormonal
contraceptivon
Investigations:
1. Biopsy from skin eczema: for the characteristic
Pagets cell:
Large giant cells with darkly stained nucleus and
vacuolated cytoplasm
2. Mammography or PET scan: for detection of
associated breast mass
Treatment:
Surgical options: either
1.Conservative breast surgery: for the case without
breast mass
Discuss conservative breast surgery
2.Modified radical mastectomy: for the cases with
breast mass
Discuss modified radical mastectomy
Axillary node sampling: discuss
8. Give an account on outlines of treatment of

early cancer breast
Answer:
1. Surgery:
For breast: either
A. Conservative breast surgery: discuss
B. Radical mastectomy:
- If the mass is attached to pectoral muscles which
entails removal of:
The whole breast including nipple and areola
2 pectroal muscles
Evacuation of axillary nods
C. Modified radical mastectomy: discuss
For axillary nodes:

A. Sentinel node biopsy: discuss
B. Axillary node sampling: discuss
2. Radiotherapy:
Postoperative radiotherapy to breast bed, supraclavicular,
mediastinal areas and axilla is indicated after the above
mentioned operations to prevent local recurrence, NOT
to increase survival
3. Adjuvant therapy:
- If ER positive, so hormonal treatment: discuss
- If ER negative, so chemotherapy: discuss
4. Follow up for 5 years: for

A. Complications of operation:
Postoperative arm edema: discuss
Cosmotic and psychiatric problems
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6. Prognosis: discuss prognosis of cancer breast

9. Enumerate 5 risk factors for cancer breast
Answer: enumerate 5 risk factors for cancer breast; try to be
the most important risk factors
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21
Hernia, Skin and

Subcutaneous Tissue,
Head and Neck
B. Anatomical Types :
Subcutaneous
1. Enumerate Types of Dermoid cyst

Answer
Def: cyst lined by sq. epithelium containing sebaceous
material +/- hair.
Types:
1. Sequestration Dermoid:
- Inclusion of sq. epithelium of skin in subcutaneous

tissue at the line of fusion dermoid cyst.
- Never in upper + lower limp grows by Budds.
3. Tubulo Dermoid:
intracranial
4. Discuss D.D. Of ulcer of face?

Answer
Types & Clinical Picture:
1. Traumatic:
Site anywhere.
Size variable.
Shape rounded or oval. Edges punched out.
Floor unhealthy granulation tissue.
Base painfully indurated.
No palpable L.N.s in neck.
2. Inflammatory:
a. Acute herpetic ulcer:
Small, extremely painful.

Vesicle ruptures & ulcerates.
Along trigeminal nerve distribution.
Shallow ulcers.
Floor healthy granulation tissue.
Margin hyperemic.
Palpable tender L.N.s in neck.
- Due to degeneration in remnants of tubular structure.

E.g.:
-Thyroglossal cyst discuss C/P.
-Bronchial cyst discus sC/P.
4. Teratematous Dermoid:
- Arises from totipotent cells.

- Contains elements from ectoderm, mesoderm and
endoderm.
- Contains sebaceous materials.
- Commonly arises in testis & ovaries.
5. Implantation Dermoid (Acquired)
- Due to puncture wound causing inclusion of epidermal

cells into S.C. Tissue.
b.Chronic ulcer:
TB ulcerDiscuss from table of ulcers of tongue.
Syphilitic ulcerDiscuss from table of ulcers of
tongue.
3. Neoplastic
a. Basal cell carcinoma:
- Site: commonly at outer + inner canthas and along

nosolabial fold.
2. Discuss Complications of sebaceous cyst?

Answer
- Criteria:
Rolled in edges + beaded.
Necrotic floor.
Indurated base.
1. Infection: abscess formation.

2. Sebaceous Horne: contents become inspirated in
layers over base.
3. Rupture: cock's peculiar tumor.
- Forming one ulcer with raised everted edge, (mistaken

with squamous cell carcinoma) so Biobsy is
needed.
4. Localized allopecia.
3. Enumerate Types of lipoma

Answer
A. Pathological Types:
Pure lipoma fat tissue only.

Fibro lipoma fat & fibrous tissue.
Angiolipoma fat & vascular tissue.
Mylolipoma fat & cartilaginous tissue.
Subfascial.
Intermuscular type.
Subperiosteal type.
Intra articular.
Submucosal.
Subserous.
Extraduralinside vertebral column only not
Intraglandular.
2. Inclusion Dermoid:
- Inclusion of epidermis inside a cavity during closure of

these Cavities. E.g.:
-Mediastinal Dermoid cyst.
-Sublingual Dermoid cyst.
-Supra sternal Dermoid cyst.
Diffuse type.
Localized type.
- Types:
Deep excavating.
- No palpable L.N.
Fire field.
If palpable:
Epitheliometous transformation
Secondary infection.
b.Squamous cell carcinoma: Discuss.

c. Ulcerating malignant melanoma:
4.
5.
Nodular melanoma Discuss.

Superficial spreading type Discuss.
Criteria of transformation of a benign naevus into
malignant melanoma (Discuss).
Keratoacanthoma: Discuss.
Rare conditions: brown's disease of skin, burn ulcer,
senile reratesi, infected ulcerating granuloma.
Investigations:
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Biopsy from the edge
- M/P of basal cell carcinoma Discuss.

- M/P of sq cell carcinoma Discuss.
- M/P of Malignant melanoma Discuss.
- Other ulcers Macrophage, lymphocytes & Plasma cells.
5. Discuss Pathology and management of

basal cell carcinoma?
Answer: discuss
- Incidence
- Risk factors.
- Site.
- Gross picture. - Microscopic picture.
- Spread.Types (excavating + fire field).
- Investigations.
- Treatment.
6. Give an account on management of parotid

abscess?
Answer
Clinical Picture:
1-Swelling at parotid region raising ear lobule with
general constitutional manifestations (throbbing
pain + hectic fever).
2-Local examination :
- Tender with +ve erc fluctuation and overlying skin is

hot red & edematous.
3-Enlarged tender mobile upper deep cervical

nodes.
Investigations
1.CBC Leucocytosis & ESR.
2.sonar & CT lesion with central break down.
Treatment:
1.Don't wait for fluctuation.
2.Under general anesthesia.
3.Drained by Helton method.
- A longitudinal skin incision along hair line, Abscess

will be drained after rotating the forceps 90 to
be parallel to facial nerve.
Complications:
1.Facial nerve injury.
2.Grey's syndrome (auriculotemporal) artificial
synapse between Secretory fibers & sympathetic
fibers eating Causes sympathetic overactivity.
3.Salivary fistula if not healed.
7. Discuss pathology of paleomorphic

adenoma?
Answer: discuss
- Pathology.
- DD.
- Investigations.
- Clinical Picture.
- TTT.
8. Discuss complications and management of

salivary stones
Answer
Complications:
- Chronic Submandibular sialadenitis.
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- Abscess (obstruction stasis infection).

- Salivary fistula.
Management:
- C/P: discuss
- DD from enlarged Submandibular L.N.s (multiple,
rolled on mandible, better felt from out side not from

inside the mouth).
- Investigation: discuss
- TTT: discuss
9. Discuss pathology C/P, investigations and

treatment of cancer tongue
10.DD of tongue ulcer? P271, P272
11.Enumerate different types of inguinal
hernia
Answer
Direct :
Medial type.
Lateral type.
Indirect type
- Congenital
- Infantile
- Acquired
Pubonocele
Funicular
Complete and scrotal
12.Discuss pathology and management of

strangulated hernia
13.Discuss causes, complications,
investigations, TTT of thoracic outlet
syndrome
14. DD of swellings in Neck triangle
15.Give a report on discharging openings
around umbilicus
Answer
Causes:
1. Congenital:
Patent umbilicus.
Patent vetillo- intestinal tract: (feculent discharge).
2. Inflammatory:
a. Chronic infective granuloma.

b.Chronic abscess.
c. Sinus following surgery.
3. Neoplastic:
- Ulcerating intestinal malignancy.

- Abdominal malignancy opening on skin e.g. Cancer
colon
4. Pilonidal sinus:
Clinical Picture:
- There is an opening
- Discharge nature:.
Urine patent uracus.
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FeculentVetillo- intestinal tract.

Purulent inflammatory.
Hemorrhagicneoplastic.
Purulent with hair tuft Pilonidol sinus.
Investigations:
- Cytology.
- C&S.
Treatment:
1.Treatment of underlying cause.
2.Broad spectrum antibiotics.
3.Chronic abscess should be opened ,curetted ,washed
with antiseptic solution with proper daily dressing
until healing with healthy granulation tissue.
16.Discuss differential diagnosis of irreducible

inguinoscrotal swellings
Answer:
1.Irreducible hernias: Discuss clinical picture of inguinal
& femoral hernias.
2.Enlarged inguinal nodes: Discuss clinical picture &

investigations of:
- Hodjkins lymphoma.
- Non Hodjkins lymphoma.
- Metastasis.
3.Iliopsoas abscess: Discuss clinical picture &
investigations of Potts disease.
4.Subcutaneous lipoma: Discuss clinical picture of
subcutaneous lipoma.
5.Clotted aneurysm.
6.Undescended inguinal testis:
- Empty corresponding aspect of scrotum.

- Sickening sensation on pressure.
7.Encysted hydrocele of the cord: Discuss clinical
picture of encysted hydrocele.
8.Thrombosed varicocele.
9.Chronic inflammation.
TB: beaded.
Filariasis: amalgamated.
Bilharziasis: nodular.
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Liver, Jaundice,
Gall bladder
1. Discuss pathology & types of gall stones
Answer:
Pathology:
Incidence: Fatty, fertile, female above 40 years.
Mechanism of formation :
- Metabolic: Discuss.
- Stasis: Discuss.
- Infection:
2. Discuss complication, investigation &

treatment of gall stones
Answer:
Complications:
Obstructive complications: Discuss.
Infective complications: Enumerate.
Ulcerative complications:
- Chronic peptic ulcer:
Due to reflex pylorospasm which causes gastric
stenosis stimulation of G.cells at pyloric antrum
secretion of Gastrin HCL Duodenal ulcer.
- External & internal Biliary fistula:

Due to acute cholycystitis which causes pericholycystic
abscess, which may open in:
Internal organ as stomach, duodenum or colon
causing INTERNAL Biliary fistula.
Skin causing EXTERNAL Biliary fistula.
Malignant complications (<1%): Enumerate.
Investigations: in order of importance:

1. Abdominal ultrasound: MOST ACCURATE, NON
INVASIVE, shows the stones & thickness of gall
bladder wall.
Oral cholycystography: Discuss findings.
Plain X-ray: Discuss.
2.
3.
4. Laboratory investigations:
- Liver function test: Prothrombin time &

concentration.
- For the cause:
Complete Blood Count.
- To assess fitness for surgery:
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1. Patients with silent gall stones: Discuss.

2. Patients with symptomatic gall stones:
Conventional open cholecystectomy or
laparoscopic cholecystectomy.
Advantages & contraindications of laparoscopic
cholecystectomy: Enumerate.
3. Give an account on pathology &

management of acute cholycystitis
Answer:
Pathology:
Type:
cystic duct or Hartmann's pouch.
pigment stones.
Serum cholesterol.
Electrophoresis.
Treatment:
i. Acute obstructive (95%): due to stone obstructing
Causative organism: Enumerate.

Mechanism of formation: Discuss.
Types: Discuss table of differentiation between the 3
types of gall stones; mixed, infected, cholesterol &
Blood sugar, kidney function test, ECG.
ii. Acute non obstructive (5%).
Organisms: Enumerate.
Fate: Discuss pathology including fate.
Clinical picture:
Symptoms:
- Picture of simple obstruction: Discuss.
- Picture of inflammation: Discuss.
Signs:
- General:
Fever, tachycardia, tachypnea.
Jaundice in 10% of cases: Explain.
- Local abdominal:
Inspection: loss of movement with respiration.

Palpation:
Tenderness & rigidity in right hypochondrium.
Mass: Discuss.
Auscultation: silent abdomen if ileus.
Boa sign.
Differential Diagnosis: from other causes of acute

upper abdomen: Enumerate.
Investigations:
Laboratory investigations:
- CBC: for Leucocytosis & ESR.
- Liver function tests.
Radiological:
- ULTRASONOGRAPHY: investigation of choice 90%
accuracy.
- HIDA scan: Discuss finding.
Treatment:
Early surgery: Cholecystectomy within 3 days.
- Advantages: Enumerate.
Conservative treatment: Discuss
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4. Compare between Calcular & Malignant

obstructive jaundice in a table form
Answer:
Calcular obstruction
Patient
Pain
Other symptoms
General condition
Jaundice
General
examination
Abdominal
examination
(Courvoisier's law)
Middle aged, fatty, female.

Onset of jaundice is preceded by Biliary colics
(Painful jaundice)
May be nausea, distention and fatty dyspepsia.
Good.
Moderate (orange yellow).
May show evidence of hypercholestremia or
hemolytic anemia.
Usually gall bladder is NOT felt, Murphy's sign
may be positive. (Courvoisiers law).
Malignant obstruction
Usually old male.
Onset is NOT associated with pain except in late
cases.
May be symptoms due to metastasis.
May be poor (malignant cachexia) in advanced cases.
Deep (Olive green).

Distant metastasis e.g.: Troisier's sign.
Evidence of Thrombophlebitis migrans
(Trousseau's sign)
The gall bladder may be felt distended, palpable
epigastric mass +\- ascitis.
*Both conditions are sharing the following data:

Jaundice.
Clay colored stool.
Dark colored urine.
Steatorrhea.
Bleeding tendency.
Constipation.
Headache, irritability, drowsiness.
Bradycardia, hypotension.
Dilated bile duct, Biliary mud, ascending cholangitis Hydronephrosis.
White bile
More common (requires long duration)
Less common
2ry Biliary cirrhosis
More common
Less common
Acute liver cell failure
Less common
More common
Pruritus.
Frothy urine.
Investigations:
A. Laboratory:
Both conditions share the same laboratory investigations which are:

1. Urine analysis: absent urobillirogen, positive billirubin & bile salts.
2. Stool analysis: absent stercobillirogen & bile salts, increased fat may be occult blood.
3. Liver function test:

-
Increased total & direct billirubin, alkaline phosphatase enzyme.

Normal liver enzymes except if prolonged obstruction.
Gamma glutamyl transpeptidase.
Prolonged Prothrombin time & lowered Prothrombin concentration. (Should be above 60% before surgery,
PTC, sphincterotomy)
4. Kidney function test: to exclude renal impairment.
B. Radiological: in
1. Abdominal ultrasound: investigation of
1.CT scan with IV contrast: investigation of
order of
choice showing:
choice showing pancreatic tumors.
importance:
Gall stones, CBD stones.
2.ERCP: diagnostic & therapeutic.
Site of obstruction, Dilated bile ducts.
Inserting stent.
2. ERCP: diagnostic & therapeutic.
Detect level of obstruction & causes.
Remove stone by dormia basket.
3.PTC: Especially in patients with
Detect level of obstruction & cause.
CholangioCarcinoma: show level & cause of
- PTC is NOT useful in Calcular obstructive
obstruction.
jaundice.
4. Hypotonic Duodenography: shows:
'Inverted 3' in periempullory carcinoma.
'C' in cancer head of pancreas.
Treatment:
1. ERCP + laparoscopic cholecystectomy.

2. Surgery: exploration of CBD & stone
Operable cases:
3. Choledochoduodenostomy.
Inoperable cases:
extraction.
Radical resection 'Whipple's

Pancreatoduodenectomy.
-Biliary stents: either:

Internal by ERCP.
External by PTD.
-Surgical drainage by Cholecystojejunostomy.
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5. Discuss clinical picture, investigations &

treatment of acute pancreatitis
Answer:
Clinical picture:
Symptoms:
- Type of patient: middle aged males or females bet 4060 years
- Symptoms: Discuss.
Signs:
- General :
Signs of hypovolemia
Jaundice may be present: Explain.
- Local:
Inspection:
Loss of abdominal mobility with respiration.
Discoloration of flanks (Grey-turner sign) or around
umbilicus (Cullens sign).
Palpation, percussion, auscultation, P/R: Discuss.
Complications:
- Systemic complications: enumerate systemic effects in
pathology of acute pancreatitis, P.97.
Acute lung injury & ARDS. Hypocalcaemia & Tetany.
Hypoxemia & hypoxia due to opening of
bronchopulmonary shunts.
Acute tubular necrosis & renal failure from
hypovolemia.
Paralytic ileus, fluid & electrolyte imbalance, metabolic
acidosis.
Consumption coagulopathy & DIC.
- Local complications:
Infection: causing pancreatic abscess.
Pancreatic Pseudocyst: Discuss definition, pathology,
clinical picture, complications, investigations &
treatment of pancreatic Pseudocyst, P.101.
Differential diagnosis from other causes of acute

upper abdomen: Enumerate.
Investigations:
Investigations to confirm diagnosis:
A. Laboratory: Enumerate.
B. Radiological: in order of importance:
i. CT scan with IV contrast: Discuss.
ii. Plain X-ray: Discuss.
iii. ERCP: based on fact that 50% of cases of acute

pancreatitis are caused stones obstructing at
ampulla of Vater.
Investigations to grade severity & assess

prognosis :
Discuss ONE of the 2 systems of classification; EITHER:
- Glasgow system.
- Ransons criteria.
Treatment: Discuss.
6. Mention 5 causes for pain in Right iliac fossa
- For each, mention 4 symptoms or signs.
- For each, mention 2 investigations.
Answer:
Causes of pain in right iliac fossa:
1. Acute appendicitis.
2. Intestinal obstruction.
3. Gynecological problems.
4. Perforated duodenal ulcers.
5. Ureteric colics.
6. Meckels diverticulosis.
4 symptoms or signs, 2 investigations:

1. Acute appendicitis:
4 symptoms or signs: Mention.
2 investigations:
i.Blood picture; for Leucocytosis & ESR.
ii.Laparoscopy: Diagnostic & therapeutic.
2. Intestinal obstruction:
4 symptoms or signs: Enumerate (suggestion: the 4
cardinal symptoms).
2 investigations:
i.Plain X-ray.
ii.CT scan with water soluble contrast.
3. Gynecological problems; as disturbed ectopic

pregnancy:
4 symptoms or signs:
i.History of short term amenorrhea.
ii.Vaginal bleeding.
iii.Tenderness & rigidity in tubal points.
iv.Cervical motion tenderness.
2 investigations:
i.Ultrasonography.
ii.HCG.
4. Perforated duodenal ulcers:

4 symptoms or signs: enumerate, suggestions:
i.Pain in epigastrium then shift to right side, Hunger
pain.
ii.Dyspepsia.
iii.Obliterated liver dullness.
iv. Fluid on P/R.
2 investigations:
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i.Plain X-ray abdomen erect: air right capsular of

diaphragm.
ii.Endoscopy.
5. Ureteric colics:
4 symptoms or signs:
i.Pain from loin to groin, radiating to scrotum or
labia majora.
ii.Hematuria.
iii.Dysuria.
iv. Burning Micturation.
2 investigations:
i.Urine analysis
ii. Plain X-ray
7. Discuss Differential diagnosis of mass in

Right Iliac Fossa
Answer:
Causes of a mass in right iliac fossa: Enumerate
causes of mass in right iliac fossa including appendicular
mass, P.117.
Differential diagnosis of Most important

causes:
1. Appendicular mass: Discuss clinical picture &
investigations of appendicular mass P.116, P118.
2. Cancer cecum: Discuss clinical picture &

investigations of cancer cecum P.142, P.143, P.144,
P.145.
3. Ectopic kidney: Discuss clinical picture &

investigations of ectopic kidney P.12 in Basics of
special surgery.
4. Tubal ovarian abscess:

Clinical picture:
i.
ii.
iii.
iv.
v.
General constitutional manifestations.

Pain & mass felt at tubal point.
Cervical motion tenderness.
Fullness at lateral fornix.
Purulent vaginal discharge.
Investigations of choice: Ultrasonography.
8. Discuss differential diagnosis of a mass in

left iliac fossa
Answer:
1. Bilharzial pericolic mass: Discuss clinical picture &
investigations of Bilharzial colitis, P.137.
2. Cancer sigmoid: Discuss clinical picture &

investigations of cancer sigmoid, P.143, 144, 145.
3. Diverticular disease complicated by

peridiverticular abscess: Discuss clinical picture &
investigations of Diverticular Disease, P.133.
4. Ectopic kidney: Discuss clinical picture &

investigations of ectopic kidney, P.12 in Basics of special
surgery
5. Tubo ovarian abscess.
Then enumerate other causes of a mass in left iliac

fossa which are the same as a mass in right iliac fossa
except for: appendicular mass, cancer cecum.
9. Enumerate 5 causes, 4 complications of

acute septic peritonitis
Answer:
5 Causes:
1.Inflamed internal organs.
2.Leaking organ (perforated viscus).
3.Direct entry by stab wound or operative.
4.Blood spread.
5.Primary peritonitis.
4 Complications:
1. Septicemia & septic shock. 2. Paralytic ileus.
3. Localization & abscess formation e.g. subphrenic or
pelvic abscess.
4. Dehydration & hypovolemia.
10. What are the possible injuries of a stab in

left hypochondrium? Discuss
investigations for this condition
Answer:
Possible injuries:
Supradiphragmatic:
- Base of left lung & pleura: causing
Pneumothorax, hemothorax, lung lacerations.
Diaphragmatic.
Infradiaphragmatic:
Spleen.
Splenic flexure of colon.
Tail of pancrease.
Stomach.
Left kidney.
Investigations: Discuss urgent investigations in

management of abdominal trauma & intrabdominal
bleeding, P.202.
11.What are the possible injuries of a stab in

right hypochondrium? Discuss
investigations for this condition
Answer:
Possible injuries:
Supradiphragmatic: Base of Right lung & pleura:
causing Pneumothorax, hemothorax, lung lacerations.
Diaphragmatic.
Infradiaphragmatic:
Liver.
Gall bladder.
Hepatic flexure of colon. CBD.
Right kidney.
nd
Head of pancrease.
2 part of duodenum.
Investigations: Discuss urgent investigations in

management of abdominal trauma & intrabdominal
bleeding, P.202.
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Gastrointestinal
Emergencies
1. Discuss etiology, clinical picture,
investigations, & treatment of liver injuries
Answer:
Etiology:
Incidence: commonest solid intrabdominal organ liable
for injury because of big surface area.
Types of trauma: Discuss.
Clinical picture:
Symptoms:
- History of trauma to upper abdomen or lower chest,
Right upper abdominal pain.
- Symptoms of hypovolemia: enumerate
Signs:
- General:
o Signs of hypovolemia:
- Local:
o Inspection:
Associated other abdominal injury.
Treatment:
1. Anti shock measures: Discuss in brief.
2. Urgent laparotomy & management: Discuss.
2. Discuss clinical picture & treatment of

chronic anal fissure?
Answer:
Clinical picture:
Symptoms: Discuss.
Signs: Discuss P/R examination in chronic anal fissure.
Differential diagnosis of painful anal
conditions: Enumerate.
Treatment:
1. Closed lateral sphincterotomy: Early cases without
fibrosed edge. No details are required.
2. Posterior fissurectomy: For cases with thick fibrosed

edges with sentinal pile. No details are required.
3. Give an account on clinical picture,

investigations & treatment of piles
Answer:
Clinical picture:
Symptoms: Discuss.
Signs:
- Inspection: dilated, elongated & tortuous veins at 3,7,11.
- Digital examination: for:
i. Thrombosed piles.
Differential diagnosis: from other anal causes of

fresh blood per rectum:
*Signs of external trauma: Enumerate.

* Loss of abdominal mobility with respiration.
o Palpation:
* Tenderness & rigidity of right hypochondrium which

later on becomes localized.
* Palpable tender liver.
o Percussion: shifting dullness.
o Auscultation: dead silent abdomen.
o P/R: fluid in Douglas pouch.
Complications: Enumerate.
Investigations:
Laboratory:
i.
ii.
iii.
iv.
CBC, hemoglobin & hematocrite.

Coagulation profile.
Arterial blood gases & electrolytes.
Liver function test.
Radiological:
Abdominal & ultrasound & CT scan with contrast:

for the following:
Type & degree of liver injury.
Subphrenic collection.
Free fluid in peritoneal cavity.
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ii. Rectal carcinoma.
- Proctoscopy: to detect underling colorectal carcinoma.
i. Anal fissure.
ii. Anal carcinoma.
iii. Ruptured perianal hematoma.
iv. Advanced perianal suppurations.
Treatment:
For 1st & 2nd degree:
-
Conservative treatment: Discuss.

Injection sclerotherapy: Discuss.
Rubber band ligation: Discuss.
Photocoagulation: Discuss.
For 3rd & 4th : Haemorrhidectomy
4. Give an account on treatment of prolapsed

Thrombosed (or strangulated) piles
Answer: Discuss treatment of prolapsed Thrombosed piles.
5. Enumerate causes of fresh blood pert
rectum
Answer: Enumerate causes of fresh blood pert rectum.
6. Give an account on types & treatment of
imperforate anus
Answer: Discuss types & treatment of imperforate anus.
RevisionofSurgery
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Gastrointestinal
Miscellaneouses
1. Discuss clinical picture & management of
perforated duodenal ulcer
Answer:
Clinical picture: Discuss 3 stages of clinical picture of
perforated duodenal ulcer
Differential diagnosis from other causes of

acute upper abdomen: Enumerate.
Investigations:
The most important are laboratory & plain x-ray:
1. Laboratory:
iii. CBC, leucocytosin, hemoglobin & hematocrite.

iv. ABG, serum electrolytes & renal function tests.
2. Plain x-ray abdomen erect reveals:
- Air under right copula of diaphragm.
- Multiple air fluid level.
3. Gastrografin swallow reveals:
- Escape of dye.
4. Sonar reveals:
- Intra-abdominal fluid.
5. Peritoneal tapping.
6. Endoscopy.
Type of patient: Discuss.

Symptoms: Discuss.
Signs: pointing sign, the patient localizes the point of
maximum tenderness by 1 finger.
Investigations:
Laboratory:
- Gastric function test: reveals hyperacidity.
- Gastrin hormone assay: to exclude Zollinger Elison
Syndrome.
- Liver function tests & serum Ca+2:
For cirrhotic patient with hyperacidity.
For Hyperparathyrodism.
- Investigation to detect helicobacter pylori:

Serology.
Culture of mucosal biopsy from pyloric antrum.
Radioactive carbon urea breath test.
Radiological:
- Barium meal: discuss findings.
Endoscopy: investigation of choice.
Treatment: is essentially medical.

Medical: essential line of treatment
1.Modification of life style: avoid
Stress.
Irritant food, smoking & alcohol.
2.Drugs: Enumerate & Give an example.

- Excludes other causes.
Treatment:
Preoperative urgent resuscitation: Discuss (similar
to IO).
Operative:
1.Simplest, most popular: is omental patch: Discuss.
2.Definitive ulcer treatment:
- Provided that:
The patient is generally fit.

The surgeon is competent.
The hospital is well equiped.
- So defenitive ulcer surgery should be done:

For duodenal ulcer, do vagotomy & gastrojejunostomy.
For gastric ulcer, do partial gastrectomy &
gastroduodenostomy.
Postoperative care:
- Continue preoperative care, then:

- The patient should continue on medical conservative
treatment of peptic ulcer (antacids) provided the
simplest procedure was done.
2. Give an account on clinical picture,

investigations & treatment of chronic
duodenal ulcer
Answer:
Clinical picture:
- Acid neutralizers (Antacids) e.g.:Aluminum hydroxide.

- Anticids:
i.H2 blockers e.g.:rantidine, famotidine.
ii.Proton pump inhibitors e.g.:ameprazole.
iii.Cytoprotictive drugs e.g.:sucealfate,De-Nol.
- Drugs for eradication of helicobacter prlori:

Triple therapy: amoprazol, amoxacilline,
metronidazole.
Surgry;
1.Vagotomy:
i. Truncal: Discuss.
ii. Selective: Discuss.
iii. Highly selective: Discuss.
2. Billaroth I pontial gastrotomy (antrodudenectomy):

Discuss.
3.Billaroth II subtotal gastrotomy:
Discuss.
This operation is NOT done nowadays (Too much
price to offer for peptic ulcer).
3. Enumerate causes of pyloric stenosis &

discuss the one due to fibrosed duodenal
ulcer
Answer:
1. Congenital hydrotropic pyloric stenosis.
2. Traumatic: impacted foreign body or corrosive stricture.
3. Inflammatory: FIBROSED DUODENAL ULCER or
Crohn's disease.
4. Neoplastic: cancer pylorus, less common leoimyoma of

stomach.
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5. Pressure from outside: lymph nodes, Cancer head of

pylorus, pseudopancreatic cyst.
Fibrosed duodenal ulcer: Discuss clinical picture,

investigations & treatment of pyloric stenosis
4. Discuss differential diagnosis of case of

pyloric stenosis
Answer:
Causes of pyloric obstruction (stenosis):
Enumerate.
Among the above mentioned causes, the

most important are:
1. Congenital hypertrophic pyloric stenosis:
2.
3.
Discuss clinical picture & investigations of congenital

hypertrophic pyloric stenosis, P.19.20.
Stenosed duodenal ulcer: Discuss clinical picture &
investigations of stenosed duodenal ulcer (pyloric
stenosis), P.34, 35.
Cancer pylorus: Discuss clinical picture &
investigations of cancer pylorus (from cancer stomach),
P.38, 39.

treatment of achalaria of cardia
Answer:
Clinical picture: Discuss.
Differential diagnosis from other esophageal
causes of dysphagea: Enumerate from page 15.
Causes in lumen: foreign bodies.
Causes in wall:
Congenital stenosis.
Corrosive stricture.
Inflammatory as reflux esophagitis.
Neoplastic as carcinoma.
Compression from outside by:

Malignant thyroid.
Thoracic aortic aneurysm.
Mediastinal syndrome.
LNs.
Cold abscess.
Disphagea lusoria.
Investigations:
1. Esophageal manometric studies: investigation of
choice.
- Findings: Enumerate.
2. Barium swell: Discuss findings.
3. Esophegescopy: Discuss findings.
4. Classic laboratory investigations to assess fitness

for surgery:
- CBC, hemoglobin, hematocrite.
- Serum electrolytes.
- Kidney function test.
- Fasting blood glucose.
Treatment: 3 options:
1. Surgery (Heller's cardiomyotomy): Discuss.
Most common to be used.
2. Dilatation by Plummer's hydrostatic balloon:

Discuss.
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3. Injection of botulinum toxin in wall of

esophagus guided by endoluminal sonar.
6. Give an account on reflux esophagitis;

clinical picture, investigations & treatment
Answer: it is about sliding hiatus hernia.
Clinical picture: Discuss clinical picture of sliding hiatus
hernia.
Heart burn: Most important: Discuss.

Regurgitation: especially on bending.
Dysphagea: Discuss.
The most important of which is Barrette's esophagus.
Differential Diagnosis
From other esophageal causes of dysphagia:
enumerate
Causes in lumen: foreign bodies.

Causes in wall:
Congenital stenosis.
Functional: achlasia of cardia
Neoplastic as carcinoma.
Corrosive stricture.
Malignant thyroid.
Thoracic aortic aneurysm.
Mediastinal syndrome.
LNs.
Cold abscess.
Disphagea lusoria.
Compression from outside by:
From other causes of Retrosternal pain:

Ischemic Heart Disease.
Pericarditis, Pleurisy.
Diffuse esophageal spasm.

Dissecting aortic aneurysm.
Investigations: In order of importance:

1. PH study: Most Important Investigation: Discuss
findings.
2. Manometric studies: Discuss findings.
3. Barium meal trendlenberg: Discuss findings.
4. Esophagescopy: Discuss the four stages.
Treatment: Mainly conservative:

Conservative: Main line of Treatment: Discuss.
Surgery:
- Indications: Enumerate.
- Principles: Discuss.
Floppy Nissens fundoplication: Discuss.
7. Discuss Differential Diagnosis of a case of

Dysphagia
Answer:
Causes of Dysphagia: Enumerate.
Among which the most important are:
1. Cancer Esophagus: Discuss Clinical picture &
Investigation of Cancer Esophagus from p.12 & 13.
2. Achlasia of Cardia: Discuss Clinical picture &
Investigation of Achlasia of cardia from p. 5.
8. Enumerate cause of postoperative Fever

Answer: Enumerate cause of postoperative Fever from
p.196.
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9. Enumerate cause of postoperative Paralytic

ileus
Answer: Enumerate cause of postoperative Paralytic ileus
from p.163.
10. Enumerate cause of postoperative

Distention
Answer: Enumerate cause of postoperative Distention from
p.196.
11. Enumerate cause of postoperative

abdominal pain
Answer:
i. Surgical wound infection.
ii. Abdominal distention in ileus.
iii. Intrabdominal infection, leakage causing
peritonitis or abscess e.g. Subphrenic.
iv. Gastroenteritis.
v. Urinary tract infection especially if catheterized.
vi. Basal Myocardial infarction especially if elderly.
vii. Diabetic Ketoacidosis.
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Urology
1. Discuss management of renal calculi
Answer:
Clinical picture:
- Silent: discovered accidentally during examination.
- Pain:
Caused by movement of stone, especially Ca oxalate.

Character: dull aching due to stretch of renal capsule.
Site: renal angle.
Radiation: anterior renal point.
- Complications: Enumerate complications of urinary

stones.
Investigations: Discuss.
Treatment:
Management of the patient during an attack
of pain: Discuss.
Elective treatment:
- Conservative: Discuss indications, procedure,
contraindications of conservative treatment.
- Instrumental:
ESWL: Discuss indications, contraindications, and

complications of ESWL.
PCNL: Discuss procedures, advantages, indications,
contraindications &complications of PCNL.
- Surgery: Discuss the 5 options for surgery; incision is not
required.
Metabolic work-up to prevent recurrence:

Discuss.
2. Discuss pathology & management of

hypernephroma
Answer:
Pathology:
Incidence, predisposing factors: Discuss.
Site, gross picture, and microscopic picture,
and spread, complications, staging: Discuss
(under item pathology).
Clinical picture:
Typical presentation: Discuss.
Atypical presentation: Discuss.
Differential diagnosis from other causes of

renal masses: Enumerate.
- Investigation of choice is CT scan with contrast.
Treatment:
Operable: Radical nephrectomy:
- Removal of: Enumerate structures to be removed in

radical Nephrectomy.
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- Approach is better done anterior transperitoneal:

Explain.
Inoperable:
- Palliative radiotherapy.
- Radiotherapy & chemotherapy.
3. Discuss cancer bladder

Answer: Discuss cancer bladder.
4. Discuss Bilharziasis of bladder
Answer: Discuss Bilharziasis of bladder.
5. Enumerate causes of Hematuria. Discuss
investigations to reach diagnosis
Answer:
Causes of Hematuria:
General causes: Enumerate.
Local causes:
Most of diseases of urinary tract can cause Hematuria, but

Most important are:
- Tumors: cancer bladder, cancer prostate,
Hypernephroma.
- Trauma: to bladder, urethra and kidney.
- Stones.
- Infections: particularly Bilharziasis.
Among the above mentioned causes:

They must be differentiated from causes of red
coloration of urine: Enumerate causes of red urine.
Hemoglobinuria, Myoglobinuria.
Intake of beer roots.
Jaundice.
Drugs: Rifampicin.
According to relation of Hematuria to act of

Micturation, they are classified into:
- Total Hematuria: Discuss.
- Initial Hematuria: Discuss.
- Terminal Hematuria: Discuss.
Investigations to reach diagnosis:

Laboratory:
- Urine analysis:
Bilharzial ova.
RBCs, pus cells.
Malignant cells.
Urinary casts.
- Kidney function test: urea, creatinine and creatinine
Clearance.
- Blood picture: hemoglobin, hematocrite & clotting
Abnormalities.
Radiological:
- Plain x-ray & IVU: Discuss findings in important

subjects.
- Sonar & CT scan: Discuss findings in important

subjects.
Cystoscopy.
6. Causes & management of acute retention

of urine
Answer:
Causes of acute retention of urine:
RevisionofSurgery
33
- Obstructive causes: Enumerate.

- Post-operative reflux retention causes: Enumerate.
- Neurological causes: Enumerate.
- Gynecological causes: Enumerate.
Management of acute retention of urine:

Diagnosis:
- Acute retention of urine:
The patient hasn't passed urine for some hours,

unable to do.
Median Pyriform swelling in suprapubic region,
painful.
- Exclude possibility of anuria:
Ureters & kidney: back pressure; Hydroureter &

Hydronephrosis.
Effects of straining & increase intraabdominal pressure: e.g. hernia, piles

9. Discuss investigations & treatment of
benign prostatic hyperplasia
Answer:
Treatment:
Medical treatment & watchful waiting: Discuss.
Surgical treatment:
Dull painful on percussion.

By pelvic sonar, shows full bladder.
Treatment:
- Indications: Enumerate.
- Procedures:
- Treatment of classic cases of acute retention of

urine: Discuss.
- Treatment of specific cases of acute retention of
urine:
In cancer bladder:
i. Urethrocathetrization.
ii. TUR.
iii. Urine diversion.
iv. Uretrocutaneous implantation.
In cancer prostate & senile enlargement of prostate:
i. Urethrocathetrization.
ii. TUR.
iii. Suprapubic cytocathetarization.
iv. IV hormonal therapy "estrogen (in SEP only).
7. Discuss clinical picture, complications &

indications for surgery of a case of benign
prostatic hyperplasia
Answer:
Clinical picture:
Symptoms uncomplicated cases: Discuss.
Symptoms of complications: See later.
Signs:
- General:
Evidence of uremia.
Effect of straining: e.g. piles, hernia.
- Abdomen:
Renal mass from Hydronephrosis.

Suprapubic mass from retention.
- P/R: 5 Ss:
Enumerate the 5 Ss.

Done to differentiate from cancer prostate.
Complications: Discuss secondary effect of SEP
(complications).
Indications for surgery: Enumerate.

8. Discuss complications of senile
enlargement of prostate
Answer:
Urethral complications: Discuss.
Urinary bladder complications: Discuss.
o Endoscopic surgery: Discuss.

o Open surgery: Just names.
Transvesical prostatectomy.
Retropubic prostatectomy (Millin's).
- Complications: Discuss.
Treatment of urine retention due to BPH:

Discuss.
10.Discuss pathology, investigations &

treatment of cancer prostate
Answer: Discuss pathology, investigations & treatment of
cancer prostate.
Testis
1. Enumerate classification of hydrocele

Answer: Enumerate & define each type of
hydrocele:
1. Congenital hydrocele: persistent patency of the
whole processus vaginalis with small
communication with peritoneal cavity.
2.Infantile hydrocele: Incomplete obliteration of
processus vaginalis extends up to external ring but
doesn't communicate with peritoneal cavity.
3.Encysted hydrocele: Persistent dilatation of
intermediate portion of the processus vaginalis
causing encysted cystic swelling at scrotal neck.
4.Primary vaginal hydrocele:
- Cystic scrotal swelling, translucent, no impulse in

cough, bipolar fluctuation, ill defined testis.
5.Secondary vaginal hydrocele:
- Small soft hydrocele detected by pinching test.
6.Hydrocele of hernial sac:
- Distension of empty henial sac which is shut off from

peritoneal cavity by omentum and adhesions.
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2. Discuss clinical picture & treatment of

primary vaginal hydrocele
Answer:
Clinical picture:
No exposit impulse on cough.
Purely scrotal swelling.
Ill defined testis.
Translucent or Transillumination.
Positive bipolar fluctuation test.
Treatment:
Aspiration: is TOTALLY CONTRAINDICATED as it may
cause:
- Hematocele, pyocele, recurrence, injury.
Surgery: just Enumeration.
- Eversion of tunica vaginalis.

- Excision of tunica vaginalis.
3. Discuss clinical picture, investigation &

treatment of primary varicocele
Answer:
Clinical picture:
Symptoms: Discuss.
Signs: 2 items inspection, 6 items palpation.
- Inspection:
1. Affected side of scrotum hanges lower than normal.

2. Dilated veins beneath skin of scrotum.
- Palpation:
3. Felt as a bag of worm.

4. Soft, compressible, not tender.
5. Palpable thrill & expansile impulses on cough.
6. Veins empty on elevation of scrotum.
7. Small secondary varicocele.
8. Examination of renal angle for hypernephroma.
Complications: Discuss.
Investigations:
1.Semen analysis: Discuss.

2.Doppler & duplex scan on testicular veins.
Treatment:
Conservative treatment: Discuss.
Surgical treatment:
- Indications: enumerate
- Operations: enumerate
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Orthopedics
1. Discuss Supracondylar Fracture of Humerus

Answer:
Trauma, Clinical Picture, X- Ray and
Treatment: Discuss putting in mind General Scheme.
Complications:
1.Local Complications: Discuss.
2.Complication of Treatment: Discuss.
Treatment:
1.Reduction.
2.Fixation.
2. Discuss Fracture Neck of Femur

Answer:
Complications:
Treatment:
1.Reduction.
2.Fixation.
3. Discuss Colles Fracture

Answer:
Definition: Define
Complications:
Treatment:
1.Reduction.
2.Fixation
4. Discuss Shaft of Femur Fracture

Answer:
Trauma, Clinical Picture, X- Ray: Discuss putting in
mind General Scheme.
Complications:
1.General Complications: Discuss.
Treatment:
1.First aid Treatment: Discuss.
2.Reduction: Discuss.
3.Fixation: Discuss.
5. Discuss Fracture Spine
RevisionofSurgery
35
Answer:
Trauma, Clinical Picture, X- Ray: Discuss putting in
mind General Scheme.
Complications:
1.General Complications: Discuss.
Treatment:
1.First aid Treatment: Discuss.
2.Reduction: Discuss.
3.Fixation: Discuss.
4.Care of paraplegic: Discuss.
i.Care of Skin: Bed Mattress, Frequent Positioning,

Alcohol & Powder.
ii.Care of Respiration: Suction of Secretions, O2
inhalation, Tracheastomy.
iii.Care of Nutrition: Parentral or Tube Nutrition.
iv.Care of Bowel: Daily Enemas.
v.Care of Urine: Self retaining, catheter, Antiseptics.
6. Discuss Complications of Fractures

Answer:
A. General Complications: Discuss.
B. Local Complications:
1. Skin injury: Compound fracture or Skin infection.

2. Muscles & Tendons injury:
- Tear.
- Myositis Ossificans: Discuss Cause, Site,
Predisposing factors, Clinical picture & Treatment

of Myositis Ossificans.
3. Vascular injury:
- Spasm, Contusion, Division causing Acute

Ischemia.
- Gangrene.
- Volkmanns Ischemic Contracture: Discuss
Definition, Pathology, Clinical picture &
Treatment of Volkmanns Ischemic Contracture.
4. Nerve injury.
5. Bone Complications:
- Osteomyelitis.
- Avascular necrosis of head Femur.
- Malunion, Delayed union & Non- union: Discuss
table of Union P.93. (Sound Union is NOT
included).
Joint injury: Enumerate.
6.
7. Visceral injury:
- Intra pelvic rupture bladder & urethra in fracture

pelvis: Give a Brief Note.
Sudecks Atrophy: Discuss.
C. Complications of Treatment: Discuss.

7. Discuss complications of fracture pelvis
Answer:
A. General complications: Discuss.
B. Local complications:
1. Skin injury: compound fractures or skin infections.

2. Muscles & tendons injury: Tears (Myositis
Ossificans is NOT included).
3. Vascular injury: (Volkmann's ischemic contracture

is NOT included).
4. Nerve injury.
5. Bone complications:
- Osteomyelitis.
- Malunion, delayed union & non-union: discuss
table of union p.93. (Sound union is not included)
Joint injury: Enumerate.
6.
7. Visceral injury:
Intrapelvic rupture of bladder & urethra: Discuss

clinical picture of intrapelvic rupture bladder
p.25 & intrapelvic rupture urethra p.26.
C. Complications of treatment: Discuss.

8. Enumerate 4 complications for each of the
following fractures:
A. Supracondylar fracture of humerus
Answer:
1. Volkmann's ischemic contracture:
- Infarction, contracture of forearm flexors due to
injury of Brachial A.
2. Myositis Ossificans:
- Following fracture, periosteal cells proliferate within

hematoma & ossify since new bone replaces hematoma.
3. Cubitus varus or valgus: Loss of carrying angle of

arm.
4. Delayed ulnar neuritis.

B. Fracture clavicle
Answer:
1. Malunion.
2. Injury of subclaviclar A.
3. Injury of subclavius muscle.
4. Injury of brachial plexus roots.
C. Colle's fracture
Answer:
1. Sudeck's atrophy: pain, swelling, osteoporosis &
stiffness of hand.
2. Malunion & delayed union.

3. Carpal tunnel syndrome.
4. Injury of extensor tendons of thumb.
D. Fracture pelvis
Answer:
1. Hypovolemic shock.
2. Rupture bladder & urethra.
3. Paralytic ileus.
4. Complications of prolonged recumbancy.
E. Fracture neck of femur
Answer:
1. Avascular necrosis.
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2. Thromboembolism.
3. Malunion causing Coxa Vera deformity.
4. Complications of healing (being elderly
osteoprotic: delayed union, nonunion).
F. Fracture shaft of femur

Answer:
1. Crush syndrome.
2. Hypovolemic shock.
3. Volkmann's ischemic contracture, Myositis
Ossificans: Define.
4. Fat embolism.
9. Discuss ivory Osteoma

Answer:
Definition:
- It is NOT a true benign tumor, it is a hamartoma.

- Table for Differentiation between benign tumor &
hamartoma: Discuss.
Pathology, Clinical picture & Treatment:

Discuss.
10. Discuss Osteochondroma
Answer:
Chest surgery
1. Give an account on clinical picture &
management of flail chest
Answer:
Definition: Fracture more than 4 ribs both Anteriorly &
Posteriorly, so segment of chest wall becomes flail (loose).
Clinical picture:
Clinical manifestations of respiratory distress:
- Dyspnea, cyanosis, diminished air entry.
Clinical manifestation of circulatory distress:

- Tachycardia & hypotension.
Complications of rib fractures: Discuss

Complications of rib fractures p.161.
Investigation: Discuss urgent investigations in the case

of chest surgery P.160.
Instrumental:
- ECG, Echocardiography.
- CVP.
- Thoracocentesis.
- Bronchoscopy.
- Esophagescopy.
- Discuss origin, Pathology, Clinical picture, Complications,

Plain X-ray & Treatment of Osteochondroma.
11. Discuss Osteoclastoma

Answer:
- Discuss Origin, Pathology, Clinical picture, Investigations

& Treatment of Osteoclastoma giant cell tumor.
Treatment :
First aid:
1.Support circulation by anti shock measures:

Discuss in brief
2.Support respiration :
General: discuss
12. Discuss Osteosarcoma

Answer:
- Discuss Origin, Pathology, Clinical picture, Investigations

& Treatment of Osteosarcoma.
13. Discuss bone Secondaries

Answer:
- Discuss Etiology, Pathology, Clinical picture,

Investigations & Treatment of secondaries.
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v. Maintain patient upper airway.

vi. Analgesics.
vii. Aspirate secretions.
viii.
Proper oxygenation:
By:
O2 mask.
Tracheastomy.
If:
RR > 40/min.
PO2 < 60 mmHg.
PCO2 > 45mmHg.
Flail chest.
Support of flail segment by external Strapping or
positive pressure ventilation.
Definitive treatment: Discuss P. 163.
2. Discuss Etiology & Complication of

hemothorax
Answer:
Etiology:
1. Traumatic: from injury to:
Lung.
Intercostal or internal mammary vessels.
Major intrathoracic vessels.
2. Pathological from:
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Bronchogenic carcinoma Leaking aortic aneurysm
3. Hemorrhagic blood disorders.
Complication:
General: if massive, cause hypovolemic shock.
Local:
1.
2.
3.
4.
Defibrination: Discuss.
Clotting: Discuss.
Organization: Discuss.
Infection: Discuss.
3. Discuss Post-operative lung collapse

Answer:
Pathology: Discuss.
Clinical picture:
Symptoms: Discuss.
Signs:
- Inspection: affected side of chest is flattened and

immobile.
- Palpation: Mediastinal shift toward side of collapse.
- Percussion: dullness.
- Auscultation:
Diminished breath sound.

Tubular breathing and coarse crepitations as attack
subsides.
Investigations:
Plain X-ray: Discuss.
Treatment:
Prevention: avoid predisposing factors.
- Pre-operative, operative, post-operative causes of postoperative pulmonary complications: Enumerate, P.171.

Treatment: Discuss.
4. Discuss Etiology, Clinical picture and

Management of Post-operative
pulmonary embolism
Answer:
Etiology: Discuss predisposing factors for DVT, P. Book 1.
Clinical picture: Discuss clinical subtypes of pulmonary
embolism.
Treatment: Discuss.
Neurosurgery
1. Give an account on depressed fracture of
skull; clinical picture, investigations &
treatment
Answer: Discussion of extradural hematoma is required.
Clinical picture:
Bone fracture +/- scalp wound (Simple or
compound fracture).
Clinical picture of extradural hematoma.
1.Concussion: Discuss from page 186.

2.Lucid interval: Discuss from page 168.
3.Compression: Discuss from page 168-169.
4.Sings of lateralization: Enumerate from page 169.
Investigations:
1.Plain X-ray skull.
2. CT brain with IV contrast: Discuss findings of
extradural hematoma.
- Localized biconvex hematoma.
- Compression of hemisphere with compensatory
dilatation of opposite cerebral ventricle.
3.MRI brain.
4.Carotid angiography.
Treatment: Discuss treatment of extradural hematoma

from page 188.
2. Discuss Clinical picture & investigations of

intracranial hematoma
Answer: Intracranial hematoma include extradural &
subdural (Acute &Chronic) hematomas.
Clinical picture:
Of extradural hematoma & acute subdural
hematoma:
- Concussion, lucid interval, compression & sings of

lateralization: Discuss from page 186,187.
Of chronic subdural hematoma:
- Manifestation of increase ICT: Enumerate from P189.

- Focal signs: Give examples.
- Herniation & cone formation: Discuss clinical
manifestation of cerebral herniation from page 186

(already discussed).
Investigations: discuss
3. Discuss Glasgow coma scale

Answer: Discuss Glasgow coma scale; definition, score &
interpretation.
4. Discuss principles of management of patient

with head injuries
Answer: Discuss management of patient with head injuries
page 190,191,192,193.
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treatment of carpal tunnel syndrome
Answer:
Clinical picture:
Type of patient: middle aged female.
Symptoms:
- Pain in distribution of median nerve in the hand.

Worse by elevations of arms & at night.
Relieved by hanging the hand over the edge of the bed.
- Wasting of thenar muscles & anesthesia over

lateral 3 fingers in late cases.
Signs:
- Slight tenderness over the carpal tunnel by

percussion.
- Increase pain if fingers & wrist are held fully
flexed for few minutes.
- Look for intracranial injury: most probably

extradural hematoma: Discuss treatment of
extradural hematoma from page 188.
Simple fracture: conservative treatment unless:

> I inch.
Compress motor area.
Causes cosmetic disfigurement.
Overlying air sinus.
7. Mention five signs denoting development of

intracranial hematoma
Answer:
i. Deterioration of level of consciousness.
ii. Change of vital signs in concussion (Cushing
response): Respiratory rate, bradycardia,
hypotension.
iii. Pupillary changes: Pupllioconstriction then dilatation

then dilated fixed pupils.
iv. Contralateral hemiplegia.

v. Compression of RAS.
Investigations:
Investigations for diagnosis:
- Nerve conduction study: on median nerve shows

delay at carpal tunnel.
- Electromyography: to detect disuse atrophy.
Investigations for differential diagnosis:
- To exclude: cervical rib & cervical spondyolosis
causing pain, tingling, and numbness in females.
- By: plain X-ray neck; lateral & AP view.
Treatment:
Conservative: for mild cases, by anti-inflammatory
& corticosteroids.
Surgery: for severe cases, by surgical splitting of

flexor retinaculum.
6. Discuss management of fracture vault of

skull
Answer:
2 types of fracture:
Fissure fracture:
- Conservative treatment unless CT brain revealed
intracranial damage.
Depressed fracture:
Compound fracture:
- Discuss treatment of compound fracture p 182.

- Wound: discuss treatment of scalp wounds from p 181:
Closure in 2 layers (glea to glea, skin to skin).
If scalp defect, so rotational flap.
- Hematoma: Discuss treatment of scalp hematoma

page 181:
i. Cold then hot fomentation.
ii. Antibiotic.
iii. Aspiration or surgical evacuation (If large).
- If complications develop, there are indications for

urgent Surgery: Enumerate complications of
depressed fracture.
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Summary of Special Surgery

This is a Summary of Special Surgery that
contains concise brief notes on the following
surgical specialties; Urology, Orthopedics, Chest
surgery, Neurosurgery and Anaesthesia. Using
keywords, and outstanding some titles, has been
considered in this Summary. This helps you to
memorize topics before exam. Tables in
different topics aim at making them easier to
recall.
RevisionofSurgery
39
General Surgery
1. Discuss factors affecting wound healing
Answer: Discuss factors affecting wound healing.
2. How can you detect post-operative wound
infection?
Answer:
Clinical picture:
General: fever at 6th, 7th day post-operative.
Local:
- Red, hot, tender, swollen (signs of local
inflammation) wound.
- Discharge:
Early: serosanginous.
Late: purulent.
- Wound dehiscence & gaping.

- Burst abdomen (The most serious): Discuss it from
page 236, book 1.
Definition: complete disruption of an abdominal
incision in early postoperative period.
Clinical picture:
- Warning sign: (Red sign) serosanginous
discharges soak the dressing.
- If intestine prolepses, so evisceration.
- If intestine does not prolapse, so dehiscence.
Investigations:
- CBC: Leucocytosis. - Culture & sensitivity of discharge.
3. Enumerate different types of shock. How to

differentiate between them from clinical
point of view?
Answer:
Different Types of Shock:
1.Hypovolemic shock.
2.Cardiogenic shock.
3.Vasogenic shock.
5. Discuss management of stab wound in

femoral triangle
Answer:
1. First aid treatment: 4As.
2.
Analgesics for pain.

Prophylactic antibiotics.
Antishock measures: Discuss in brief.
Antitetanic.
Primary survery (ABCDE): Discuss primary survery
in management of several trauma & multiple injured
patient, p.7, 8 Book general.
3. Secondary survey:
A. Femoral arterial injury: open with devision

(complete & incomplete):
B.
Discuss clinical picture (p.90, 91) of acute ischemia,

investigations (p.92) & treatment (p.93) of arterial
injuries (open; complete & incomplete).
Femoral vein injury causing DVT: Discuss
prevention of DVT from p. 125.
C. Femoral nerve injury: According to time of

presentations
First 6 hours: primary repair.
After the first 6 hours: delayed (secondary)
repair mark both cut edges with black silk
suture then delayed repair by:
i. Nerve graft.
ii. Nerve transposition.
iii. Cutting of unimportant branches.
1st 6 hours: primary repair: Discuss.

8-24 hours: primary suture: Discuss.
After 24 hours : delayed primary suture: Discuss
How to differentiate:
Table: How to differentiate between different types of shock:
How to differentiate between different types of shock
Vital signs
Pulse
BP
Temp
Neck veins
CVP
Periphery
Laryngeal edema & asphyxia.

Carbon monoxide & cyanide poisoning.
Septicemia & septic shock.
Adult respiratory distress syndrome.
Neurogenic shock.
D. Muscular injury.
E. Skin wound itself:
a. Septic shock.
b. Neurogenic shock.
c. Anaphylactic shock.
d. Endocrine shock.
Table
4. Enumerate causes of immediate death in

burned patient in closed room
Answer:
Hypovolumic
Cardiogenic
Vasogenic
Rapid weak
Hypotension
Subnormal
Collapsed
-ve
Cold pale
Rapid weak
Hypotension
Normal
Congested
+ve
Cold pale
Tachycardia
Hypotension
High
Collapsed
-ve
Warm, sweaty
with congested
veins
6. Discuss management of crushed wound in

the thigh
Answer:
2.

Antitetanic.
Primary survery (ABCDE): Discuss primary
survey in management of several trauma & multiple
injured patient, p.7, 8 Book general.
3. Secondary survery:
A. Femoral arterial injury (closed, without

devision) contusion & spasm:
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40
Discuss clinical picture (p.90,91) of acute ischemia,

investigations(p.92) & treatment (p.93)of closed
(without devision) arterial injuries.
B. Femoral vein injury causing DVT: Discuss
prevention of DVT from p. 125.
C. Femoral nerve injury: according to time of

presentations:
After the first 6 hours: delayed( secondary)
i. Nerve graft.
ii. Nerve transposition.
iii. Cutting of unimportant branches.
D. Muscular injury:
E.
i. Gas gangrene: Discuss prevention of gas

gangrene from p.74.
ii. Compartmental syndrome: proper fasciotomy.
iii. Crush syndrome: Discuss treatment.
Compound fracture shaft of femur: by external
skeletal fixator (Elizarof).
F. Skin wound: lacerated wound managed:

1st 6 hours: by primary suture: Discuss.
After 1st 6 hours: delayed primary suture:
Discuss.
7. Discuss management of lacerated wound in

the calf
Answer:
2.

Antitetanic.
Primary survey (ABCDE): Discuss primary survey
A. Tibial arterial injury: (closed without devision):

Discuss clinical picture (p.90, 91) of acute ischemia,
investigations (p.92) & treatment (p.93) of closed
(without devision) arterial injuries.
B. Calf vein injury causing DVT: Discuss prevention of
DVT from p. 125.
C. Medial & lateral popliteal nerve injury: according
to time of presentations:

After the first 6 hours: delayed( secondary)
i.Nerve graft.
ii.Nerve transposition.
iii.Cutting of unimportant branches.
D. Muscular injury:
E.
Compartmental syndrome: Discuss clinical picture &

treatment of compartmental syndrome.
Fracture shaft of tibia & fibula: by external skeletal
fixator. (By Elizarof fixator)
F. Skin wound:
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1st 6 hours: by primary suture: Discuss.

After 1st 6 hours: delayed primary suture:
Discuss.
8. Discuss management of cut wrist

Answer:
2.

Antitetanic.
Primary survey (ABCDE): Discuss primary survey
A. Ulnar & radial arterial injury: open & complete.

B. Ulnar & median nerve injury:
Deformities:
- For Ulnar N: Claw hand syndrome.

- For Median N: Ape hand syndrome.
Management:
- According to time of presentations

o First 6 hours: primary repair.
o After the first 6 hours: delayed (secondary) repair
mark both cut edges with black silk suture then
delayed repair by:
i.Nerve graft.
ii.Nerve transposition.
iii.Cutting of unimportant branches.
C. Muscular injury:
D. Wound injury: incised wound
1st 6 hours: primary repair: Discuss.

8-24 hours: primary suture: Discuss.
After 24 hours : delayed primary suture: Discuss
'Summary series
Summary of Special Surgery
Summary of Diagnostic X-Ray in
Medicine
Summary of Clinical Pathology
Summary of ECG
RevisionofSurgery
41
Section 3: Explain
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42
Estimation of free T3, T4 is more accurate than total T3, T4

Total T3, T4 are affected by serum proteins which in turn are affected
by several diseases and conditions
True cut biopsy; Not fine needle aspiration is needed for

diagnosis of follicular carcinoma
As to diagnose follicular carcinoma, we need to see capsular and
vascular invasion ; so we need true cut biopsy
It is recommended to give chemotherapy in premenopausal

females with cancer breast
i. In premenopausal females, cancer breast tends to be aggressive,
with high incidence of recurrence, so it is recommended to
double attack the tumor with hormonal and chemotherapy
ii. Cancer breast is a sysytemic disease from the start, spreading by
microcellular metastases all over the body, so to prevent those
microcelluar metastases from being gross metastases,
chemotherapy is needed
Axillary Lymph node assessment is the most important

prognostic factor in cancer breast
i. Post-operative survival rate depends mainly on lymph node status
Patient with negative nodes: 10-year survival rate 65%
Patient with less than 4 positive nodes: 10-year survival rate
38%
Patient with more than 4 positive nodes: 10-year survival rate
13%
ii. Exclusive theory of spread of tumor:
The tumor invades both lymphatic and blood vessels at the same
time, affection of axillary nodes means systemic dissmenation
Mammography is needed to screen female breasts more than

40 years
i. In females more than 40 years, density of breast tissue
mammography is less echogenic than young females, so breast
mass can be accurately visulaized
ii. Incidence and risk of cancer breast is increasing with age
Cancer male breast has bad prognosis

i. No breast tissue in males, so the tumor from the start is attached
to pectoral muscles (stage III)
ii. Cancer male breast is NON-hormone dependant, so no hormone
treatment
Foot infection is commonly seen in diabetic patient

i. Infection: favored by increased blood sugar
ii. Neuropathy: impaired sensation causing neglected minor wounds
iii. Ischemia: causing acidosis leading to decreased phagocytes with
decreased antibodies
iv. Cellular: decreased cell vitality due to increased sugar contents
and ischemia
High pre-operative fluid intake is recommended in patients

with obstructive jaundice
To protect the patient against hepato-renal syndrome, to give
diuretics to wash toxins to renal blood flow and renal functions
pre-operatively
It is essential to give intravenous Vitamin K to patients with

obstructive jaundice
In obstructive jaundice, bile salts secretion in intestine is decreased
causing decreased absorption of fat soluable vitamins; the most
important of which is vitamin K which is essential for prothrombin
formation
Gas gangrene may complicate lacerated wound in gluteal

region
Because lacerated wound means maximal tissue damage with
vascular damage making it more suitable for anaerobic organism
Cortecosteriods impair wound healing

Corticosteroids:
i. Impair proliferation of fibroblasts
ii. Inhibit transformation if fibroblast into fibrocytes
iii. Interfere with neovascularization
iv. Increase incidence of wound infection, interfering with wound
healing
It is essential not to delay surgery in elderly patient with

bleeding peptic ulcer
i. To prevent hypovolumea which may cause myocardial infarction
or renal shut down (acute renal failure)
ii. Elderly are atherosclerotic, atherosclertoic vessels will not stop
bleeding spontaneously
iii. Options other than surgery as IV antacids will have nothing more
to offer in this patient
Highly selective vagotomy is more physiological than truncal

Vagotomy
i.Preserves motor fibres to pylorus(Nerve of laterjet). So, NO
drainage operation(gastrojejunostormy or pyloroplasty) is
required.
ii.Preserves hepatic branch of anterior vagus, so gall bladder is NOT
denervated with NO possibility of biliary disfunction & gall
stone formation.
iii.Preserves ciliac branch of posterior vagus, so NO disturbance in
gastrointestinal motitity,hence NO diarrhea occurs.
Amebic liver abscess is common on Right lobe of liver than the

left lobe
i. Right lobe is bigger in size.
ii. Source of infection of Amoeba comes from right colon draining
into right lobe of liver; through lamellar blood flow to liver.
Cirrhosis is a relative contraindication for liver surgery

i. Bleeding tendency.
ii. Poor functional reserve of remaining liver.
iii. Diminished capacity of liver cells for regeneration.
Post operative shunts are NOT used nowadays

Because of 3 Disadvantages:
i. Thrombosis at suture line & insufficient reduction of portal
pressure if anastomosis is narrow.
ii. Liver cell failure due to ischemia of liver from shift of part blood
to systemic circulation if anastomosis is wide.
iii. Hepatic encephalopathy due to shunting of Ammonia & GABA
absorbed from intestine.
Patients with live cirrhosis have Haemostatic disorder
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RevisionofSurgery
43
i. Hypoprothrombinemia due to inability of liver to synthesis

Prothrombin from Vit K.
ii. Thrombocytopenia from associated Hypersplenism.
iii. Inability of liver to produce coagulation factors including
coagulation cascades.
iv. Decreased fat soluble vitamins including Vit K due to decreased
Bile salts.
Subdural hematoma is surgical emergency

i. It may cause cerebral herniation: Discuss clinical manifestation of
cerebral herniation from page 186,187.
ii. If neglected, cause Herniation of brain stem causing death.
Deterioration of patient of head trauma in ICU

Enumerate the five causes of deterioration of patient of head Trauma
under observation page 193.
Aspirin should be stopped 10 days before surgery

i. Aspirin is anti-platelet causing bleeding tendency due to
prevention of platelet aggregation & adhesion.
ii. Its half life is NOT less than 10 days.
iii. To prevent postoperative peptic ulceration.
Testicular Biobsy for testicular tumor is done through inguinal

approach
i.To prevent retrograde spread by lymphatics, achieved by clamp to
vas deferens.
ii.To prevent spread of malignancy to the scrotum which necessitates
removal of scrotum which can NOT be done.
Patient with testicular torsion should be treated urgently

i.Testicular torsion causes testicular infarction & gangrene, so
causing testicular atrophy.
ii.Testicular torsion may cause disturbance in blood testicular barrier
with formation of anti-sperm antibodies leading to infertility.
Cancer prostate is usually metastatic to pelvis & lower spine

Because of valveless venous communications between vesicoprostatic venous plexus & emissary veins of prevertebral venous
plexus, so there is possibility of retrograde blood flow.
Ulcers over shin of tibia heal slowly

i.Poor vascularity of any skin covering directly bone.
ii.High possibility of exposure to infection & interference with healing
on surface of tibia.
iii.Most of types of ulcers over shin of tibia are chronic ulcers (due to
varicose, ischemia ) with fibrosed thick edges interfering
creeping of epithelium to cause ulcer healing.
Hematuria is considered as a serious sign of urological

disorders
Most of underlying causes are serious conditions.
i.All malignancies of UT are presenting with hematuria (late sign of
malignancy indicating advanced stage).
ii.Renal injuries are possibility especially those involving pelvicalceal
system.
iii.Severe infection like hemorrhagic cystitis & Bilharzial bladder.
Patient receiving antirejection drugs may develop neoplasm

Antirejection drugs interfere with:
i.Proliferation of B lymphocytes & T-helper cells.
ii.Action of cytotoxic killer cells.
iii.Formation of cytokines (IL2.IL10).
Based on above mentioned data, recognition of abnormal cell

division is function of B lymphocytes, & destruction of abnormal
divided cells is function of cytotoxic killer cells & cytokines.
Causes of disturbed hemostasis

Liver cirrhosis.
i.Massive blood transfusion: means banked blood lacking
fibrinogen & coagulation factors, precipitating DIC.
ii.DIC: consumption of coagulation factors & platelets in the
microcirculation allover the body.
iii.Obstructive jaundice.
Patient with extensive burns needs resuscitation with large

amount of IV fluid
In extensive burns:
i.There is severe fluid loss (insensible loss, evaporation from burned
areas leading to hypovolemia).
ii.To resuscitate microcirculation by hemodilution to avoid
hemoconcentration.
iii.To increase renal blood flow to avoid renal tubular necrosis
(ischemia).
Bilateral orchedectomy is a palliative line of treatment of

metastatizing cancer prostate
i.Bone metastasis of cancer prostate is androgen dependant as
primary tumor.
ii.Of poor vascularity of bone, other types of hormonal treatment will
never be effective in controlling bony pains & pathological
fracture.
- So only way to get rid of source of androgen.
Causes of immediate death in burned patient in closed room

Laryngeal edema & asphyxia.
Carbon monoxide & cyanide poisoning.
Septicemia & septic shock.
Adult respiratory distress syndrome.
Neurogenic shock.
Patient with septic shock carries worse prognosis than

hypovolemic shock
Discuss pathophysiology of septic shock from p.18, 19.
Urethral catheterization in a patient with suspected urethral

injury is contraindicated
Because of
i.Possibility of introduction of infection.
ii.Possibility of conversion into complete injury.
iii.Possibility of creation of false passage.
Stones are more common in Submandibular gland

i.Viscid secretions of Submandibular gland.
ii.Opening in floor of mouth obstruction food particles.
iii.Drains anti gravity.
Cleft lip should be repaired before 8 months
Before dentition, to avoid forward proganthism as cleft lip affect

development of upper incisors.
Cleft palate should be repaired at 1 year

- Before speaking, (as if not repaired constant are speaked by nasal
tone).
- Repair of cleft palate is a major surgery so we should wait until baby
fit for the major operation:
Not less than 10 months.
Weight not less than 10 Kg.
Hb not less than 10 gm/dl.
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RevisionofSurgery

Special Thanks to Prof Amr El-Shayeb

Open arterial injury of incomplete type

2.For arterial injury: INcomplete

72 years old male come to ER 24hours after

- After 24 hours: indicate hypovolemia especially with

A. What is your diagnosis?

Investigations for cardiac condition:

Investigations to assess fitness for surgery:

- Arterial blood gases and serum electrolyte

C. What is the treatment of the case?

Treatment of arterial injury:

a. if transverse tear : measure the tear

33 years old males presented to ER after he

A. What is your diagnosis and differential

B. What investigations would you order?

Investigations to assess fitness for surgery:

- CBC: for hemoglobin and hematocrite

C. Discuss clinical evaluation and preparation

Evaluation of limb condition (viable or not

Preparation for treatment:

Predict and treat possible complications:

B. DVT and pulmonary embolism:

C. Reperfusion injury: especially hyperkalemia

A 28 years old female with a history of mitral

B. What investigations would you order?

Investigations for arterial embolism:

Investigation to assess fitness for surgery

C. What is the treatment of the case?

Under Local Anaesthesia.

2. Fibrinolysins (Thrombolytic Therapy): Discuss.

A 75 years old patient came to ER with

B. What investigation would you order?

Site of the aneurism: supra- or infra- renal (above or

Investigation to detect possible complications:

2. Kidney function test:

Serum urea, creatinine, creatinine clearance.

5. Fasting Blood Sugar.

7. Arterial Blood Gases & Serum electrolytes.

C. What is the treatment of the case?

1. Correction of hypovolemia: Discuss

3. Post operative ICU care: for proper maintaining &

A 68 years old male came to ER drowsy,

B. What investigations would you order?

Investigation for septicemia & septic shock:

C. What is the treatment of the case?

Treatment of Septicemia: Discuss ttt of Septic shock

31 years old female after labor developed

A. What is your diagnosis & Differential

Pblgmania Cerulae Dolens: Painful Blue swelling

B. What investigations would you order?

C. What is the treatment of the case?

Aims of treatment: enumerate

- Heparin: discuss mechanism of action, methods,

duration & control of Administration, antidote &

3.Thrombolytic therapy: plasminogen activation

34years old pregnant female (14week)

B. What investigations would you order?

4. CBC, Hemoglobin and hematocrite:

5. Neck ultrasound & colored duplex scan on

6. Serum Ca and alkaline phosphatase

C. Discuss treatment of this case

*Postoperative L thyroxine replacement should be