A2 notes

Round1
1- difference

btw gangrene and ulcer :

Gangarene: dead tissue with preserved skin

Ulcer : dead tissue with loss of skin
2- Wet Gangarene mean with infection
3- demarcated line : line btw dead tissue and normal tissue
4- In popliteal fossa : tibial nerve, popliteal vein and popliteal
artery
5- sciatic nerve bifurcates in the posterior compartments of the
thigh into tibial and peroneal nerve ( in the lateral side of the
leg)
** if you see the tendons of the muscles the cause might be
either inflamed ((enlarged) tendon OR wasting of muscle
autoimputation :
autoamputation: dry gangrene and loss of a digit due to
profound local ischaemia secondary to peripheral vascular
disease, diabetes or secondary to development of a basal
constricting band the affected part may eventually detach to
leave a healed stump (google )

Round 2

First (?)... G6PD

Round 3
# ccu : coronary care unit
# the most common sensitive organ to low CO is kidney
then brain
# the most common complication of heart surgery is
ischemic brain then renal failure
# blood pressure to normal tissue perfusion is 65-70

*most common abdominal complications of open heart

surgery :
1)ischemic mesenteric
2)pancreatitis
3) acalculous cholecystitis
4) ulcer
*one of the postoperative complications arrhythmia ,and
divided into malignant as MI
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and benign as atrial fibrillation, and benign commonly

occur

*the most common cause af atrial fibrillation electrolytes

disturbance mainly hypokalaemia and hypomagnesaemia#
normal CVP ( central venous pressure) : 4-6
# 4 ccu
1 - ECG ( arrhythmias)
*one of the postoperative complications arrhythmia ,and
divided into malignant as MI
and benign as atrial fibrillation, and benign commonly
occur

*the most common cause af atrial fibrillation electrolytes

disturbance mainly hypokalaemia and hypomagnesaemia
3- CVP and if we have polyuria it's good
4 - oxygenation
# differential diagnosis in CICU in case of hypotension
1- bleeding
chest tube

 2- hypovolemic due to blood or fluid bleeding.

:
Tachycardia, hypotension, decrease cpv and oliguria
IV fluid
3- cardiac tamponed


CO venous retairn
arrest

Tachycardia, hypotension, increase CPV
and oliguria, white mediastinum at chest x ray

** triad of cardiac tamponed

- hypotension
- tachycardia
- oliguria

-increase central venous pressure

*** rapid full injection of potassium will kill patient (cardiac

arrest)

*** as doctor said one of the protocol after operation is take

chest X ray to compare if there something occur

Also Dr said if there acute pulmonary oedema sign in chest

X ray it confirm the tamponed

Round 4
# When you want to describe ulcer :
Site
Margin
Floor
Base
Discharge
# at palpation :
Temperature

Tenderness : if we have tenderness it's either infection or

ischemia
no tenderness : neuropathy
# pressure points in foot : heel and head of metatarsals
# investigations :
WBCs for infection
Blood sugar ( infection increase sugar in the blood)
History of fever
X ray for osteomyelitis
Culture
Kidney function test
ECG
Echo
Chest X ray
# we have to examine pulse, in case of no pulse we do CT
angio

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Round 5
Characteristics of pain :
Stabbing > short, localize, sharp
Burning
Colic
Tearing
Gripping > pulsating

* pulsating pain either Vascular or Abscess cause

* why in abscess? bcz it's transmit from underlying

vessels

* two types of movements in intestines :

1 - peristalsis by 2 types of muscles ( circular and
longitudinal)
2- constricting movement by circular muscles segmental
movement by both muscle against area of obstruction !!
(not sure)
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* pain scale (1-10) : imp in observe the ttt

* pain after 2 hrs of eating it's bcz duodenal ulcer > if it's
immediately after eating it's gastric ulcer

* visceral pain :
caused by ( ischemia, inflammation, destination,
compression, traction)
It's characteristics ( poorly localize, deep, at mid line "
umbilicus, gastric, epigastric" )

* parietal pain :
Caused by ( irritations either chemicals or bacterial, touch,
temperature)
It's characteristics ( superficial, sharp, localize)

* radiation : 2 area have the same continuity

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*Referred pain : share the same nerve supply

* Shifting : pain disappear from primary area and appear in

on other area

*Appendicitis : pain start in peri umbilical area and then in

RIF, why??!
: visceral pain
midline visceral
!
midgut umbilicus

* colic pain.
cholysistis?

irritation peritoneum

Referred pain : pain is not felt at the site of disease but felt
at distant site

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shifting pain : origin of pain is in one site later migrate to

another site and disappear from original site
Radiation pain: pain extension from original site to another
site without disappear from original site

Round 6

Contaminated wounds =never use continues suturing , we

use interrupted ones ...why ?. To drain the pus futurely if
happens ...
Clean wounds =we can use continuous type. .. (thyroid
surgery , lipoma , mastectomy as ex,,)
Multifilaments suturing associated with more infection risk
.... so we prefer using mono filament types ,,,
Every suturing inside the body is done with absorbable
sutures (kol ma kan a6wal el lysis ta3o kol ma kan afdal
atwa8a3!!)
Dyed Sutures more expensive and need more time to be
lysed in comparison with non dyed ones...
Size of needle tip depends on the fatty percentage of the
patient ,,

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The Knot must be outside during suturing on the skin (start

from out to in ),, and buried inside the tissues during
working inside the mouth (start from in to out) ...
(considering the sutures be absorbable here ) ...
Prophylactic antibiotics are given if indicated for 24 hours
only except (immunocompromised people )..

Striper saves time in comparison with hand doing and

suturing, but associated with (om 44 appearance) ...
sometimes it is preferred.

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Round 7
# Causes of Projectile vomiting :
1- increase intracranial pressure
2- pylorus stenosis
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3- over eating
4- cases of delayed gastric emptying

# vital signs in projectile vomiting : hypertension and

bradycardia

# in case of right flank pain of young female you have to

ask about last menses bcz maybe she has ectopic
pregnancy

# differential diagnosis for right flank pain :

Meckel's diverticulitis :
true congenital diverticulum, is a slight bulge in the small
intestine present at birth and a vestigial remnant of the
omphalomesenteric duct

A memory aid is the rule of 2s:[7]

2% (of the population)
2 feet (proximal to the ileocecal valve)

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2 inches (in length)

2 types of common ectopic tissue (gastric and pancreatic)
2 years is the most common age at clinical presentation
2:1 male: female ratio

# in X ray you can see the ureter at tips of transverse

processes

Indelivrin (cause HIV also ) and ipelibtrin both cause renal

stone
Stone can see in CT scan except indelevrin stone
KUB image
KUB : kidney urinary bladder
mini Osco stone
stone radio _obaque shadow

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Round 8
# acute abdomen : recent abdominal pain that hasn't been
treated or investigated before , need surgical intervention
or admission.
# causes of abdominal pain :
1-inflammation :
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Most common : appendicitis, cholysistis, pancreatitis

2-obstruction :
The most common is intestinal obstruction post surgery
(adhesion)
Symptoms of obstruction : constipation , hernia,
abdominal distention and pain, vomiting
3-ischemia :
The most common in abdomen is superior mesenteric
ischemia, common in old, common cause is embolus
from heart (AF) .
4-perforation :
As peptic ulcer or it occur in any organ
* Perforation
omental patch or langerhan patch.
omentum
* omentum : each area of peritoneum covering a specific
organ has a specific name : visceral layers covrring the
stomach = omentum
There should be 2 omenta : one going from lesser
curvature of the stomach towards the liver and the other
going from the greater curvature of the stomach toward the
intestine.

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Non surgical causes of abdominal pain : diabetes

ketoacidosis ,inferior MI ,pneumonia, hepatitis,
gastroenteritis

Round 9
Note from Dr. Haitham qandel:
# in case of gi tumour U can see diarrhea or constipation :
diarrhea bcz tumour cause irritation of mucosa then
induce bowel movement and mucus secretion with stool
# crohns disease : in terminal ilium, thick in CT-scan, pt is
slim bcz this disease affect on absorption
# ulcerative : start in rectum then go to sigmoid... etc,
# signs of ulcerative colitis : dehydration, rash, eye
redness
# parasitic infection : chronic diarrhea
# U can't see the bowel with ultra-sound

# tumour in small intestine v.rare
# diarrhea with mucus in pt who recently travel : infection
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# colonoscopy v.useful ; U can take biopsy by it

# pitting enema : heart disease specially in bi pitting edema
DVT
# constipation in old ages : sometimes dye to drugs or
decrease motility
# problem in kidneys without abnormalities in urinalysis :
acute cases ; like the stones don't cause obstruction yet
# anal fissure : stool with streaks of blood, fresh blood,
painful defecation
# haemorrhoids : fresh red blood , streaks of blood. ,
painless until thrombosis occur.

# grades of haemorrhoids :
Grade 1 :
Grade 2 :
Grade 3 :
Grade 4 :
# mixed blood with faeces : left colon cancer
# in case of right colon cancer : there is anemia and no
blood bcz it mix with stool before reach the anus.

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 left

# differences btw upper and lower gi bleeding :

Upper : melena and special odour
Lower : fresh blood

Notes from dr mohammed bani hani :

10 things you have to ask in dysphagia (,

) :
1_ duration , first thing to ask
2 _ progression
3_site
4 _ liquid or solid (or which precede the other!)
5- vomiting and regurgitation
6 _ appetite 7_is there any pain ( odynophagia)
8- history of trauma
9- continuous

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10- associated gi symptoms

Achalasia most common cause of dysphagia in males (

)
Diagnosis : barium study _ bird beak sign , oesophagus
manometry these two are sensitive to this disease

Round 10
*mastectomy : removal of breast, LNs & pectoralis muscle
Modified mastectomy , without removal of pectoralis
muscle

* most common complications after mastectomy :

1~ Seroma collection between skin flaps & pectoralis major
2~ lymphedema

* 4nerves affected in mastectomy :

1) MC , long thoracic nerve => winging of scapula

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2) Thoracodorsal nerve => pt can't abduct his hands

3) intercostal
4) !

Round 11
* Qs U have to ask it to a pt come with mass :
When he noticed it , disappear or not , onset , associated
symptoms , management , what he think
* Associated symptoms :
Nausea and vomiting intestinal obstruction
Fever strangulation , inflammation , sepsis
Weakness age , previous surgery , pregnancy
Constipation , chronic cough , liver disease
* 3 causes of hernia ( ) :
genetics , environment , personal features
* Direct hernia : medial to inferior epigastric vessel
* Indirect : lateral to it

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* Sometimes we cant determine either its direct or indirect (

they determine it during the operation )
* Direct hernia wider than indirect
* Hasselbach's triangle : A triangular region in the lower
aspect of the anterior abdominal wall, it's described as the
area where a direct inguinal hernia will extrude from
posterior to anterior.
* Boundaries of Hasselbach's triangle:
Medially: lateral border of rectus abdominis.
Laterally: inferior epigastric vessels.
Inferiorly: inguinal ligament.
* Hernia with appendix Amyand's hernia
* Hernia with Meckel's diverticulum a Littre's hernia.
* Pantaloon hernia: Both types (direct and indirect
inguinal hernia)
* Sliding hernia : are those in which part of the wall of the
sac is formed by a viscus.
sac peritonium ,
sliding sac peritonium with other viscus .
* The 1st complication of hernia : incarcerated then
strangulation ( ischemia , necrosis , perforation ) and
obstruction
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* In case of incarcerated : observation , NPO , then surgery

* In case of strangulation : directly surgery
* in case of ( intestinal obstruction )
adhesion ,
cancer or hernia ,

in case of hernia U have to ask about urine and stool , WHY

?! sometimes the pt already has BBH and bcz of strainig
during urination he will have hernia , or has tumor in colon

Round 12
* Causes of lower limb pain :
1) DVT
2) ischemia
3) trauma
4) infection
* Most infection in diabetic pts is skin + subcutaneous
infection < reach the bone in progressive cases

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* If you see cellulites it's infection

* Fever + calf tenderness DVT
*if you cant determine whether its ischemia or DVT << U
have to use Doppler ultrasound

Round 13
a patient with acute flank pain...the first thing to do is???
CT scan WITHOUT contrast
the CT scan can reveal the renal and the extra-renal cause
of a flank pain

Notes about gastric cancer case by dr. Alomary

*What causes of black stool ?

Carrot eating , ferritin intake .
* How to differentiate melena from black stool ? Melena is
-bad smell
- tary

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* coffee ground vomitus +metallic taste~ stomach bleeding

* fresh blood vomitus ~ oesophageal

*mild bleed ~
Severe ~ hypovolemic and maybe shocked

Round 14
* after chest trauma think about : hematoma or fat necrosis
* after mastectomy, we use 2 drains ; one for axilla and
another one for breast bud
* we use drains to observe : bleeding, hematoma and
Seroma
contents and amount
* drains
1) no blood, just serum
2) blood amount less than 50cc
* complications after mastectomy :

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1) hematoma and Seroma

2) nerve injury
3) wound infections, usually at 4th day
* In case of breast CA :
Tender mass
Fixed and solid
Discharge
Peaud' orange : obstruction of the lymphatic drainage
* investigation by ultrasound : less than 45 years old, and
by mammogram : more than 45
We will see calcification
* well defined mass : mostly bending
* for metastasis : CT scan, bone scan, met scan
* before surgery :
- do CBC to check haemoglobin ( must be above 10 ) and
platelets
- Kidney function test : to check dehydration and
hypokalaemia
- Bleeding profile
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* abortion not consider as risk factor for breast CA

* nerves in the breast
1) intercostal 2) thoracodorsal

Round 15
#neuropathy :
Sensory : loss of sensation
Motor : deformity ; increase angle btw 1st and 2nd
metatarsals , hallux valgus
Autonomic : loss of sweating and dryness fissures

# indications of admission in case of ulcer :

1)uncontrolled blood sugar
2) cellulitis :
infection of the deep layer of skin (dermis) and the layer
of fat and tissues just under the skin (the subcutaneous
tissues).

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Symptoms : Affected skin feels warm, may look swollen

and looks red and inflamed. The infected area may spread
and is usually tender.
3) osteomyelitis

# factors affect wound healing :

1) Local : infection ( type of organism , immunity )
Ischemia
Venous insufficiency
Repeated trauma
Lower limb edema
Radiation exposure
Foreign body : necrotic tissue , hematoma , seroma ,
pus
2) Systemic : immunodeficiency
Smoking
Systemic disease
Age
Metabolic disorder
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Hematological disease
Connective tissue disorder
Nutrition
# we start using saline in wound cleaning when granulation
tissue appear
# granulation tissue : new connective tissue and
microscopic blood vessels that form on the surfaces of a
wound during the healing process
Appearance : light red or dark pink in colour, being
perfused with new capillary loops or "buds";
soft to the touch;
moist; and
bumpy (granular) in appearance, due to punctate
haemorrhages
pulseful on palpation
painless when healthy[

# types of drains :

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Open drains (Including corrugated rubber or plastic

sheets) drain fluid on to a gauze pad or into a stoma bag.
They are likely to increase the risk of infection.
gravity , muscle
contraction ,
Closed drains are formed by tubes draining into a bag or
bottle. Examples include chest, abdominal and orthopaedic
drains. Generally, the risk of infection is reduced.
# 2 types of closed :
Active drains are maintained under suction (which may be
low or high pressure).
Passive drains have no suction and work according to the
differential pressure between body cavities and the
exterior.
# inguinal canal : 3 cm

A2 note

Good Luke

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