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 BREASI:
a 2
a g IMUMAIOLOGY AIUD
6 BAs!C GENERAT SUROERY
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I}IYROID: I

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E]IIDOCRINE SUR,GERY:
t
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4G AR,IERIAL gYgIEM
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SWEttIiIGS AND $AIIVARY GLANDS: a

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SURGICAL INFECIIONS TYMPHATIC SYSTEM
. SchcmhsudbdhHnrc rc rlt
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. oallfiq. EFfoob,
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&tACrffioN
DEFINITION: Acule baclerial inflammalion lhal occurs during laclalion
ORGANI$M: 8IAPH.
I

T PRECIPITATING factor ) Nipple abrasions, bad hggiene, bad general cond.

! CLINICAL PICTURE:

Pain Dull achinr 4 Throbbing Attacks of

Pgrexia Mild Conlinous 4 Heclic fever remissions&
exacerbalions
8'rgns l)Enlargemenl, l) Sions of r) Ederna of skin fender swelling
lenderness inflammalion 2l with gielding
2)NO sions of 2) D(TLARY LN8: cenler
inflammalion . Enlarged
. Tender
. Firrn
. Mobile
lnvesl. r zfr TLC, C/8 for the choice of antibiolics
. U/g )sile & tgpe
^EgR, of abscess
^CRP,
. lf no response wilhin 2 weeks ) BIOP8Y
Prophglaclic irealrnenl :
. lasl 2 monlhs of pregnanou ) Massage of Nipple & Panlhinol
. Al lime of deliveru: lf Fissures are presenl) Painl {issures wilh anli-septics
{- Stop Laclalion:
L
o
- - lf infanl>9 monlhs) bg giving PARIODEI
ts
{- - lf lnfanl<gmonlhs) Slop lactation fiorn affecled side , FeedinA from the olher side
o Evacuale breasl * Augmenlin l) Oeneral aneslhesia
o
3.
F (lgm/8hrs) 2) Radial incision nol reaching nipple, areola
& analgesics 3) Deslrog loculi bg {inger
+ 4) COUNTER lNClSlON if in an UN-
Hol fomenlalions dependenl area
5l Antibiotics & dressino

Signs of inflammalion
 ?h l1

Flm-
"J./Pq4wr5 nupCR[..lE lJg{q%l

P hlAts'
Fibrous tissue replaces lhe elastic & fattg lissue ) Aberralion of
Obslruclion of ducl: Norrnal
A FIBROSIS . Unilaleral developrneni &
. Bilaleral lnvolution of
. Affecting sector of breast )"Seclor Maslilis" Breast
EPITHILIOSIS This leads lo cgsl forrnalion:
. Srnall ( Micro-cgst) Sorne consider
. Large (macro-cgst) il as a norrnal
. lf Cgsts coalesce)Blue-dorned cast of BTOODGOOD varianl

. Large cgsl conlain Altered blood 1rej pr

Atgpical epithelial . DD: bluish. greenish discharge from Nipple
hgperplasia
 SUR+-TCr/.r5 6.\W(*NY IJRqW ?Aqv t +

ChJNrcAt
PIC,TURE,

. AAPMT . Cornrnonlg Bilateral . Clear . Enlarged

. Dull aching pain; . $olid or cgslic '. Yellow . Elastic
./ 4 Pre-menestruallg or bg Breast rnovernenl . Freelg mobile lf retenlion Cgsts . fender
/ V Posl-rneneslruallg or bg breasl supporl . Diffuse ) greenish . Mobile
a

#ltrlrilti

I
. For lhe lurnD) friple assessment
. For Discharee) Cgtological \. S;rrrLE MorcAr SI,FGBY
exarninalion & Benzidine tesl
, For Cgst ) Aspiration
ffi''FE
#
'. Analgesics . Biopsg
. Aspiration of cgsls
| ' lea, coffee .
Prim Rose Oil
. lf cgsts are
l. VitaminE
I

Parlodel
I
. Danazol recurrenl ,or Cgsl
. Recurrent cgsls . Psgchotherapg of Blood-good)
r Sclerosing Adenosis Excision
r Cancer
 ilP,q=Tw.J6 hloocxr,qr 5,R(#l ? Aqe I 5
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Docrltu CARC'N6TA W
pAprur.oiA
eAhlAucr,l.{B

toBu[.An PAGEt'S
qltrclN6tA CAtrCJN6TA DISEASE,
INrtT.rnATING tcls INHTTnANNG
/ Comedo r( $chinous r Bilaleral
/ Solid r( Medullarg r Multifocal
/ Cfibriforrn / Maslilis Carc. I Indian file appearance
/ Colloid Carc.
 ilR{dl-Twr5 E{9ocRlNE IJRAW ?h I b
EEhllGt{ oFTl-lEffi
. Benrgn
DOCTPAPITI.or.IA
lumor of the breasl aff
. ll's lhe
. Macro)single pedunculaled mass, mag ulcerale
. Micro) Vascular CT core + hgperplastic epithelium 2EnITII ilirfiEIiIat I

I f [La tIl
PT. Fernale. 2O-3;O Uears Fernale, 3O-5O Uears
Micro I

. EWUtrE
ducls ducls
Female, 3,O-4O Uears with bleeding per Macro NUMBER: Single NUMBER: Single
SIZE: Srnall SIZE: Largr
nipple + Swelling +2 NO GFrRcEt E!@E*ur[ace dsirrn o+rrd SURFACE: urfiace o*rs,
. Bleeding, ) Zonal pressure wil! reveal discharge CONSISTENCY: Firrn SriuD
. Swdling) RETENTION CYSf CUT SECTION: CONSISTENCY: Soft
.. Single, Srnall, Near nipple .. CUI SECTION:
.2 NO > NO pain, NO LNs enlargemenl CAPSUTE:
(Capsule )True + False cap. )
c/o Painless lump Painful rapidlg growing lump
o/E Painless Breasl lump, Painfu! rapidlg growing lurnp,
rnobile: mobile, wilh no LNs enlargemeni
@ pr -) For the discharge : Benzidine lesl wilh No LNs enlargernenl
@ iira,tl,t)For lhe Papilloma: Glaclographg ..({illing defect) Mal'rg. Never lurn malignanl Mag Turn ) SARCOMA

@;r.ro)For lhe resl of the breasl: Mammographg TTT Eneculalion lf srnall :

(Circum-areolar incision) r' Excision with safetg rnargin, Biopsg
lf Larqe (cqstosarcoma Phqlloidesl :
{ Vld,lde local excision or Sirnple masleclomg

Micro-dochectomg & histopathologg ze l2O-9;O cm)

.. probe passes
 lJR+Iw.l5 A{mCFhlE flJts@l ?h l7

DOCTAL
clrrcll.httA

. Discovered accidenlallg afler Bilateral

rnarnrnographg) Bg Core-cut Biopsg
. No rnicro-calcificalions
. ll's a risk faclor for Cancer breasl..
r Managernenl : Multifocal lndian {ile
l) Follow up aPPearunce
2) Prophglaciic Tamoxifen
3) lf lhere's *ve Farnilg Historg)
MRM * reconslruclive surgerg

Biopsg bg self-retaining
needle under mamographg

. Exarninalion everu 6 rnonlhs

. Mammographg everu 2 gears bg
obligue laleral view
row G+RADE
(l gear in HRG)

lE"r-'* I
 lJRq-ro}r5 696ffihlE 5,)?4W ?A vt6
INFIffiNG@CAFCINoD.,IA
lncidence
ti
:t!{tlrts

Most common tupe ..75yo

fit HIHHI
6%
I it ffi rl,
,l

llrvrlrl If
During Lactalion
La

Pathologg .Extensive Fibrous Tissue .Exlensive Malignant cells Macroscopicallg:

Macroscopicallg: Macroscopicallg: . SOFT rnass TNVoLVES 4ESI[E]
.Hard rnass, in{iltrating er .SOFT like Brain
. cut surface)@ . Cul surface) Miuoscopicallg:
areas if Hge, Necrosis ' Spheroidal cells
Microscopicallg: Microscopicallg: producing mucoid
. Malignant rounded cells . Mahgnanl cells, li{tle material
Fibrous tissues fibrous tissue,

Clinical
.@
.
piclure 3i[":', C/Oz Anorexia, Slowlg
progressive pain
' Dimpling..(Cooper's ligarnenr) \ . O/E: Enlarged LNs,
. Relracled nipple..(Milk duct) No siqns of inflarnrnalion
Prognosis Bad Good Good Bad
.. BAD prognosis in
slornach ..
 lJFq-T1un5 nD0cFll.lv ilPhw) ?hqY t

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1

INCIDENCE / Most comrnon maligna

/ Mosl common siie is
.JYfrOFPffiFAtli / 99% in females
/ Age > 20 Uears

neurostt{Gr Sjg+c ,girilil.c g .,iiili.

.r,rrig+c , asil e*E
9
FACIORS
d'Srsii+. at*ii 9 pirrfll 9 d{r.r.i , elc &c 9
. Fernale , Nulliparous, peak of age 60 gears
. Earlg menarche,lale rnenopause
. Posilive familg historg
. Alcoholios, OCPs, lnactive, Obese
. HIGH RtgK FACTORS:
l) Pre-cancerous lesions ..Papilloma, LCIS..
2) Previous affection with Cancer breast

* BRCA I (chromosome 17)

n BRCA 2 (chromosome 13)
, Lu-Frurnini sgndrome (mutalion in gene P53)
n Goddwen sgndrome
(Assoc. with PAPILLARY CARCINOMA OF IHYROIDI

Lgmphatic, blood spread, direct spread

5$asag
S;rrcilNG' TNM * Manchester

FRoGftlGlS Good + bad indicalors ...

. Size
, LNs affeclion
. Invasion
. Melaslaiic polenlial
F Axillarg LN-ve according lo
histopalhological tgpe
 ilK+-TooN5 Y 1JPqW ll0
SPREAD
LYMPHATIC .. BY EMBOLISAIION & PERMEATION..

. Axillaru LNs)
Supraclavicular LNs , Rarelg lo lnternal mamrnarg LNs
. lgmphalic from Lower inner quadranl pierce reclus sheath )
liver nodules
) Mag melaslasize as "SISTER JOSEPH NODULE"
. Obstruction )
Pcau d'oranle, Melastatic nodule, Cancer en Cuirasse
DIRECT
. Skin, pecloral Fascia, Pecloralis major, Serralus anierior, Chesi wall
BLOOD
. Bone secondaries)OSTEOLYTIC LESIONS in
. Through valveless cornrnunicalion belween Poslerior
lntercostalis Veins & Paravertebral venous plexus ..
N.B. ln Proslalic cancer )
Bone secondaries are Osleogenic lesions
TRANSCEOLOMIC ..Relrograde lgrnphatic perrneation..
. OVARIES) Krukenberg's iumor
. NODULES lN DOUGLAS POUOH) Plurnmer's shelf nodules
. PERIQIQNEUM) Malignant ascitis
'T *l
\-;\ q

CANCER BREAST SPREADS BY BLOOD

gPREAg) DI$TANT MICROMETA$TASI g

II(rlcgII
srAgnlq
EARLY
CANCER
BREAST
LOCALTY ADVANCED
Ta, oDg N, Mo BREAST CANCER
MEIASTATIC
 a&q-Toar5 E{pocxx.lE a.Eqw ?[,q ! [
CLn.I'CAt PIGK,FE oF EREAST CArCn
FEMALE, 50-60 YEARS WIIH PAINLESS SWELLING
IN UPPER LATERAL QUADRANT OF BREASI

SyiimE, SlCr}.lS
PAINLESS BR,EAST LUMP GENERAL:
(Discovered bg routine screening) CACHEXIA + SIGNS OF METASIASIS
(LNs: Troiser sign, BONE: fender spine, LIVER: Jaundice, Hepatomegalg)
DISCHARGE:
Waterg, Blood slained, pastg discharge LOCAL:
OCCULT PR,ESENTATION: EXAMINE BOTH BREASTS + AXILLA + SUPRACLAVICULAR LNs
o BONE) Bone ache, pathological fraclure INSPECTION.. PALPATION:
o Lung) Drg cough, hemoplgsis, dgspnea .,ASYMETRICAL
BREAST" I BREAST MASS..Starl wilh lhe norrnat sile
o Liver) Malignant jaundice . Nipple & Areola: l) Site) Upper laleral quadranl
o Axillarg lurnp t) Nipple retraclion
2) Areola)Pagel's disease of Nipple
2) surface) irregular
. Skin proper: 3) Edge) lll-de{ined
l) Skin Nodules 4) Consislencg) Hard in schirrous
o IATE SIAGE 2l Skin Ulceralion carcinorna. sofl in Medullarg
o MASIITIS CARCI NOMAIOSIS 3) Cancer en cuirasse carcinorna
lnfillralion o{ Cooper's ligamenl
o PAGET'S DISEASE OF NIPPLE l) Skin teethering 5) Mobilitg) Earlg mobilitg, fixed
2) Skin dimpling Iatelg.
3l Skin puckering LYMPH NODES:
Lgmphedema: l) Free axilla
U Peau d'orange 2) Enlarged, Mobite
2l Brawng ederna 3) Enlarged, Fixed
Metaslasis:) Sisler joseph's Nodules 4) Supraclavicular LNs enlargernent
 5R{4=Tw.t5 ElPPffhtE fl'.Ph#rl ?hqv t w
I (,FffiCANCER
DUGD{oSIS SrAglNG' PREOP PtLoti, OP
I cxR
TRIPI.E I u/s
aSSESMertr TrrtvloR. HORNIONAt
I

.
TCrn
CT scan ffi ffi
. MR.I . CEA T Estrogen
. cA l5-3 I Progeslerone
I Slain wiih
*
Hisiorg Sono-
Her-Z antigen
Clinical Marnrnographg (Dcls)
ExarninalionJ
Mammographg U/S Can'l differentiale
between CtS,
. TruOcut needle
invasive carcinoma under Local
INDICATIONS: aneslhesia
. Frozen Section t
" Screening in high risk
groirP cYsTrc sollD inlraoperativelg ffi-u{SruD/
. Delecl impalpable
breasl cancer-
II
ASPIRAIION FNABC
. Excision Biopsg
. Mammographg I r+ cr-rrurcAllY
I rueonrnrs
" Evaluale sound breast guided using
gICNS SUGGESTIVE Self-retaining needle
OF MATIGNANCY: Not affected Affecied
' Cluslered Micro- I I
calcificalion FOLLOW IOTAL
(DUCTAL: 2O%) UP DISSECTION
. Slar shaped mass
 "Pl.d*k
5uA{4-:lw.t5 a{DocxhlE f,.M{4rf}l I 17
(,FffiAANCER
STAGE I, !I STAGE STAGE IV
. Cancer breasl is a sgslernic disease HORMONAL THEMPY
. Aim is to CURE mg palient
. Once il is evident) lt melaslasizes - Horrnonal receplors *ve
in lhe forrn of MICROMEIASTASIS
. TTT> TOCAL + SYSIEMIC TTT.
- Bone Melasiasis
I CHEMOTHERAPY
Neo-adjuvanl Chernoiherapg is given) For I TTT. OF COMPLICAIIONS
DOWNSTAGING of Turnor (From Stage lll>ll)
Surgerg is decided according lo response to
Chernolherapg) MRM OR LUMPECTOMY

Maslectomg
I Rernoval of breasl lurnp .- Removal of breast lump
@ . Fernale >Togears
I R.emoval of Breasl lissue Posl-operalive Radiolherapg Cgclophosphamide r Free axilla
t Block dissection of axilla 5OOO RAD Melholrexale I Horrnonal
I Reconslruclion of breasl Local conlrol of Axilla: 5-Fluorouracil *ve
with Mgo-culaneous flap - Clinicallg *ve) Block disseclion
or proslhesis " silicon" - Clinicallg -ve Senlinel LN Biopsg g-t rtp
ti -,f HIGH Grade lumor.... Give ISOO RAD timi
ll -Quadranleneclomg l
larJtr
0tle+ur
{ -HALL LNs are POSITIVE li: -Axilla Clearance
i -ln MEDIAL IUMORS .... lnlernal rnammarg LNs affeclion -Radiotherapg
i
!! rS\i
.
.-... -..-....*....^,,
 lJp.q-{1q.t5 1^w,Pli^r7 xwwl ?hqv tw

TUMORg PATIENT Breast

./ Bilaleral ... Multi-focal ,/
/
Pregnanl '/ Small
Pagel's dis. ...Central lumors
/ Preference
/ Tumor > 4cm
{ Ptevious imadialion
r' High grade (lll) ... Fxed to Ms... Dislanl melaslasis
,/
,/ clg > 20 vo
Conlraindicated

I o;l -Li # f aI! 51lri n

/ ln firsl 2 gears ) Everg 3 monlhs ,/ Complications of operations
/ Nexl2 gears ) everg 4 monlhs ./ Local recurrence
r'Yearlu for !ife) rnarnmographg of ./ Disiant melaslasis
,/

,D
the olher breasl Carcinorna of olher breasl

ETIOLOGY:
AT{UAFEOTA
. lnlra-duclalcarcinoma
. Reirograde lgmphatic spread from schirrous carcinorna
/ Middle aged female
Resislant to usual TII of eczerna
z glderlu female
ttitsiri+,o iilur6 i', rl

. Modified radical
ln nipple )Erosion
. NO itching rnasteclomu
. NO oozing
. NO vesicles
. Well delined lesion
. Breasl lump

lffi
Biopsg & Histopathologg

. Epilhelial hgperplasia, Lgmphocgtic infiltralion

 9.W-TWr5 A{9tr4?[.lE XMW ?hqv t w

MRM + CHEMOTHEMPY A Risk faclors :

AFTER ISI TRTMESTER l) Prosialic cancer
t f, Radiotherapg 2) BRCA 2 mulalion
t f, Chemotherapg in ld
t $ Horrnonal therapg
( -ve homonal receplors) frealrnenl )CA$IRACIION, MRM

DEFINITION:
Painless Enlargernent of MALE breasl due
ETIOLOGY: lo
. DE-novo or on lop of sofl
fibroadenorna Etiologg :
CLINICAL PICTURE: a) Comrnonesl cause is
I b) 9metabolism of eslrogen,LCF
Large breasl mass.
. Spread mainlg bg Blood..( LNs Trealrnenl :
spread is rare & late ) l) SC masleclomg
INVESIIGAIIONB: 2) Suction lipeclomg
' Triple assesrnent) 3) Endoscopic surgerg

IREATMENI:
Simple rnaslectorng + Radiotherapg

* DEFINIIION: Dilaled major milk ducls

.:. has
*
*
M
* CLINICAL PICIURE: Fernale, middle aged, srnoker presenled bg :
l) NIPPIE DI$CHARGE ... uearng, serous, blood slained
2) SUBAREOLAR PAINIESS SWEILING
INVE8TIGATIONS:
l) lf Pt. presenied with sub-areolar rnass) Triple assessment
2) lI Pt. is presenled with Nipple dischaqe) Benzidine tesl, cglologg

l) Earlg) Combination qle!!lbig!!gq

 lJPq:Tw\5 V XMW ?hqY I uo

l) Reason for referra! io breast clinic )

2) )rnore cornrnon in srnokers
3) Cause of Blood slained discharge
4) Cause of Green discharge
. Ducla! changes
. Relention cgsls of
5) Cause of Serosangious discharge )
6) Site of breast cancer )
7) Histological tgpe of breasl cancer )
8) Cause of bilaleral breasl cahcer )
9) Secondarg deposil in carcinorna of breast )
lO)MOT of breast abscess )along (Nipples)

MRI breasl imaging:

. Dislinguishes scar from recurrence
. lmaging of breasl implanls
& recurrenl disease
Managernent of axilla in breasl cancer
CONGENITAT NIPPLE RETRACTION .. Simple nipple inversion:
. Occurs at pubertg.
. Unknown etiologg.
. Bilateral in 25%.
. Mag cause problerns during lactalion.
POLYMASTIA
.
Accessorg breasl.
. Usuallg bilaleral.
. Wlhout nipple.
. MaU occur below pectoral region in groin or even in fhigh but with nipple.
MACROM AZIA
Mild cases can be lrealed bg anti-eslrogen.
TRAUMATIC FAT NECROSIS
. Can occur via blunl lraurna or even indirecl violence i.e. vigorous conlraction o{ pecloral muscle.
. Granuloma formalion with rnarked fibrosis.
. No LN enlargernenl in axilla.
. Mamrnographg is nol conclusive as il gives feaiures similar lo lhose of cancer.
 x,w-Twr5 E{DocFNe ilRqW ? hqv I E
INFI.AMMATION OF BREAST
r) Acule breasl abscess.
2) Chronic breast abscess
s) T.B.
4l .. Obscure igpe of thrombophlebitis affecting veins of the breasl
5)
Mammarg ducl ectasia.
tr Sites of breasl abscess:
. Pre-mammarg )
on top of infected sebaceous cgsl.
.@9I9)deeplopecioralfasciaonlopofinfecledhematoma.
. lnlra-mammarv )
inside breasl during laclalion: can oecur al ang parl of lhe breasl.
-ln slage of milk engorgement: Dull aching pain referred lo shoulder wilh persislenl fever and atlacks of shivering.
-!n slage of acule abscess lhere is pitting edema.
tr CHRONIC BREAST ABSCESB:
. C/O) painless breasl lump and sornelimes dull aching pain wilh no sgslemic sgmploms
. O/E) lhe swelling is irregular.
.TREATMENT) Excision under general anesthesia.
tr TB OF BREAST )
usuallg occurs wilh pulmonarg TB.
FIBROADENOMA
.Benign simple fibroadenorna is less lhan 3 cm.
.Gianl fibroadenoma more than 5 cm.
.PHYLLOIDES IUMOR) occurs usuallg in perimenopausal women in 30-50 age groups.
BREASI CANCER
trFNABC )
can't differentiale belween ClS, ln{iltralive cancer (wrDE BoRE cANNULA )
tr TUBUTAR CARCINOMA
It is a rare bul a well diff. cancer. lt is small in size being aboul I cm in diameler hard and one
seclion has radial appearance. .Histologicallg it forms lubular structures formed of single lager
o{ epithelium. ll spread bg lgmphocgles and it has verg good prognosis.
tr PAPILLARY CAR,CINOMA.. INTRACYSIIC PAPILLARY CARCINOMA
Rare lgpe that is dif{icult io disfinguish from benign inlraduclal papillomafosis.
Well circumsoibed and hislolo$callg demonstrale papillarg formalion it presenls bg
bleeding per nipple and it is of good prognosis.
. lnflarnmaiorg carcinorna can occul in all age groups.
. lnvasive lobular cancer indislinguishable fiom invasive ducl carcinoma.
. fhe second line Hormonal therapg used when famoxifen responders relapse ) Sgnthetic
progeslerone .. "Medroxg progeslerone acelale (provera)" .
. Chemotherapg is the lrealmenl of choice for melastasis
tr Side effecls of Radiotherapg :
. Local burn
. Pulrnonarg librosis
. End arleriiis
tr Axillarg surgerg in breasl carcinoma
. Axillaru LNs melaslasis is lhe besl marker for prognosis
. Trealmenl of axillarg lgmph nodes positivelg influences survival
. NO RADIOTHERAPY is applied if axillarg clearance is performed
tr Lgmph obslruclion of advanced breasl cancer :
. Peau d'orange
, 9kin nodule
r Cancer en cuirasse )
(skin nodule + lgmphedema of breast skin)
. Edema of arm
. Lgmph-an$osarcoma
 l'.Rq-Twr5 hID00RINY gMR't ?h I tg
I

t- fernale in child bearing period presenled

wilh a mass better felt bg tip of {ingers not
lhe flat of the hand , pain and swelling are
related io the cgcle ,Axillarg LNs are
I
enlarged, elastic, fender, mobile
fbruystrb dbase
2- Young Female 20 gears, presenls with well
circurnscribed painless rnass, Firrn in
consisfencg, freelg mobile, Axilla is Free
fbro ademma
3-female 4O gears old presenled with bleeding per nipple on zonal pressure
lrrtra- fuctal lafllbrt/d,
4-old female presenled with painless mass in lhe upper lateral quadranl of
lhe breasl
6atcer brast.
S-Mostlg old female presents wilh unilateral eczema like around areola (or
discoloration), not ilchg and nol respond lo rnedical TIT
PaM dbase.
6-female 3O,4O gears old presented with large firm to soft palpable mass mighl
reach Hulh size with NON- palpable axillarg tNS and skin ulceration might occur
6ystosarcoma /E/bd.
8-Laclating female presented with painful breasl O/E inflarnmatorg reaction
presenled in a Seclor of the breasl. Axillarg LNs are enlarged, elasic,fender,mobile
,4cilte lactatru fi/astttb (nrk etelrgefi/etrt)
9-Lactating female presenls with bad general condition, induration of the breasl
and Axillarg LNs are Hard and Fixed
)/as t itb carc irlor/atos rb,
lo-Laclating fernale presents with breast rnass, hectic fever and lhrobbing pain
Aclte brast dbscess,
ll-Female, middle aged, srnoker presented with creamg breast discharge and
painless swelling (rnostlg sub-areolar)
Dtct atasn
 lJRr+-rwr5 1a.liw*Nv XMWI ?hq? t q

r Earlg deteclion of cancer breast

( Ailar f,2@7)
r Managernenl of Acule breasl abscess
( ,4ilar f' 2@7 )
r Discuss Trealrnenl of Milk engorgernent
( ,4y'rar F' 2@6 )
r Causes of chronic breasl rnass
( ,4ilar f,2M )
r Breast abscess
( ,4ilar f,2CCL4' - r4y'rar ril' ZmO - An sfrafi/s,2@4 )
r Nipple discharge
( ,4/rar f' 2fu5 )
r Breast rnass: lnvesl'lgation
(r4drar F,2M )
Cancer Breasl : diagnosis & ttt
( Atu sl/aus/@5 )
Managernenl of earlg cancer breasl
( ,4ilar ,1r1, 2o2,2d/ - Kasn 2@8 )
r Pathologu of cancer breasl
( ,4/rar )A zma I
r Fibro-adenosis :etiologg , CIP & pathologg
( Alil shafils,2m )
5,W-T0ur5 VSWW Thtqvlm
 er{m@D: xR4-Tw\5 1H'.{W*WXR@I

dpnen
? hEV | ?.1.

DIH'SE
BEh[chl rilArqilA]tr
. CONOENITAL
. ACQUIRED:
. Acuie baclerial
-Endemic
-Sporadic ' Sub-acule lhgroiditis
FRnTAN/ (DE Queruain's Thgroiditis)
-Colloid
. Chronic (TB, $)
Goiler SECONDAF/
. Aulo-immune (Hashimoto)
.Collagen dis. ( Riedel's dis)

. Simple . Neoplaslic
. Toxic . ln{lammation
. lnflammation . Toxic
. ileoplasm . Simple

l) Female with neck swelling )Goiler

2) History & Examination:
. Neoplaslic) inflammalorg )Toxic ) Sirnple (bg exclusion)
3) lf Bimple ) Examinalion of :
. Smoolh surface ) Simple Diffuse Goiler ) m is medical
. Nodular surlace ) $imple nodular Goiter ) III is Surgerg

. stMP[E) EUTHYROTD t{ ',

. NEOPLASIIC) EUIHYR.OID
. Ioxtc) Ioxc
. INFLAMMAIORY) VARIABTE
(HYPER then HYP0)
 lJ(q-Taar5 n9ocPltlt ilPI#) Thav I L1

SMru,qptrER

. Endemic) AbsoluteVlodine uocit Repeated episodes of Slress (Stress) Hge) Necrcsis) nodule)

llrlgll

. PhgsioloAical) Relalive V lodine

At pubertg, pregnancg, lacialion
(VENUS NECrq

Painless Mild enlargemenl of the . Nodular swelling in the neck)cosrnelic disligurernent

Gland . Pressure manifeslalions,
Gland
. Enlarged Tracheo-malacia (Kocker's tesl
EI
MCarclid arlerg pulse (Berrg
. Srnoolh, Sgrnrnetrical ) . Firrn, Asgrnmelrical tesl)
. Mobile, Nol lender ' Moves with deglulilion
. No olher manifestalions . No loxic manifeslalions

l) Function )
Same lnvesligalions 2) Morphologg
as Nodular Goiter, but.. 3)
- U/S)Diffuse Goiler
. NO FNABC
4)Exclusion of :
'
Mal'rgnancg) FNABC

Treatmenl

Total thgroideclomg wilh Posl-op replacemenl therapg

0.2 ngld for several monlhs (l-thgroxin 0.1-0.2 ngd I *Histopathological sample
lhen lapered lo 0.1 mXld for gearc lf smal! sized in a Uoung Pf. )Medical thgroideclomg
. m. of Complicalions

Partial lhgrcideclomg
Sublotal thgroideclomg
To{al thgrcideclomg
tr 2rg thgrolo{gggElq{glg1gus inlernodular lissue ..257o )
(Io avoid recurrence)
tr
Dunhill operalion
tr Pressure on lrachea) Poslural dgspnea
tr Hge , lnfeclion, Cgslic degeneralion, Calci{icalion
tr Relro-sternal exlension.
 1#.14-{ooN,5 A\W*NY qu?q%l YAQK I ?4

- HYPERTIIYROIDIEM.. +Thgroxin due lo thgroid gland hgperactivitg

- TIIYROTOXCOSIS.. +Thgrofn due to Thgroid gfand, drqg induced, eclopic hormone produclion.. elc

ffiffi RAITEffi

NEoNATAt tffi DRrrc-rNp(rcm

I
l) qAS+trroxtlGrS
2) w eoEFVAtN -rrnc/RolDrrts
l)rHffiFACrrmA
2)ffirHffi
l) FnlciloNtNG sEcoNDAF$/
CAFCINortTA
2) SrxrfaoVAFll
3) TSH srlenEflNg IDENortA
oF Ptfl,rrA{/ GI.AND
 1JK4-T1U\5 hleoCFN? il?4w T h{4V | 15

0 I I ilil

EIIOLOGY:
Aulo-immune..flEII) Osec. from 4 sec. from
Iupe V Hupersensitivitu
0n iop of Normal Gland 0n top of long standing SNG

0,c,D . Sudden Onsel . Gradual onsel

, Rernission & Exacerbation . Slowlg progressive
CLINICAL PI )TURE:
Tgpe o{ Fernale at ffi age
palieni
subjected lo Traurna,
Dre{nahcu, lacialion
clo: ,foxic sgmploms . foxic sgmptoms
,,gEE
LATER'' , Auloirnrnune manifeslalions . M Artoirnrnune manifestalions
. Youngl Pl.) CNg
Dominanl
Sp rnanifeslalions @8 rnanifestations
manifes{alions . old Pt.) cvs
olEl
,,GLAND"
. Firrn, well defined edge
. Non lender , Freelg mobile
. Ihrill
INVESTIOAIIONS:
Laboralorg AT3,T4 + VISH
r - ve Antibodies r - ve Aniibodies

U/S : Mild diffuse enlar[emenl Mulliple Nodules Solitaru Nodule

Thgroid scan :
(Diffuse A Uprake) (OVER-active inlernodular lissue) (Low uplake of
surrounding lissues )

TREATMENT:

Main Line is lf Pl. < 45 Years:

Sublolal Thgroideclomg lpsilateral Tolal
afler Preparalion Lobeclorng afler
l) Neornercazole (10 mg x 3 /d)
preparation
2)lnderal (80-l60mg/d)
lf High risk Pt. (Hearl failure)) ll3l (Hemi-lhgroideclomg)
3)Valium (s-15 mg/d)
N.B. IF MEDICAL ITI FAILED:
. (45 Years & Large) Surgerg :: Medica! ITT is used ONLY
g.rr.)ll3l for PREPARAIION
' >45
(Lugol's iodine 2 weeks before surgerg)

No role for FNABC)As incidence of malignancg in a loxic goiter is exlremelg rare

 Uo

ChJN

ff 6d 6dlb JiIe o) *,ri, f ot6p j *otr J.rL e

rls.p 1 I Jfll <; a1lu! r+tt Jnfi
Diplopia t rl,Jt*te J-trt t #J6xll oi$6f SCT ederna .rtll.-irn

i
u'lN!)t 9 u'JJlaq$
6Jly't
Ihgroid paradoxl-J
!. -nrlir o "i Fine lremors t $,4too 6ie1J.rie
lmitabilitg oy' ;lUts I oe*ll 6),ae,st+,h

f6hiL 1 ? q,Ei^ t jli *r 6i,eJ.Jrie

t 6rU.f Jo ft 6ppU.ioist b
- ACOP HFU
Polguria eJ$Jl.f Jdl t ay' & ,r'6 6sy' Jlt> j JL1
"rU"p -o19

I 6/#t ,s, J/tl'"..,1$g

r ls il lrue or false?
. Nafzrger lesl , Ruler tesl . PULSE: (Tachgcardia, Waler Hurnmer pulse,
mag be irregular)
tr Darlgmph's sign . B[00D PRESSURE: Asgstolic,9Diaslolic
(Rim of sclera) . IEMPEMIURE: Oin Thgrotoxic Crises
tr Stellwa!'s sign
(lnfrequent blinking, lremors)
tr Joffrog's siln
lack of wrinkling on
looking upwards . ABDOMEN )
HSM
. UPPER, UMB: )Aoopacg (Clubbirrgf
E Von Gravie's sign
Lid tag
. LOWER UMB ) Pretibial mgxedema

Etr Rosenbach's sign

Fine lremors on 4fentle closure
tr Mobius Sign . IA![{D!QD. Anti-thgroid
Failure of convelgence drugs, Liver melaslasis
. PALLOR) Malignancg
. cYAltogtg) Rsc
 1,^?4:lw=t5 A{DOCBhIE ilPq%l ? hq, t 7;?

IN FII=GIIANCrI
FIRST TRIMESTER:
INDICATIONS:
g Propgl lhiouracil SOmg x?8 hrs.
INDICATIONS: INDICATIONS:
V 2rg fhgroloxicosis EI lrg lhgroloxicosis in (lf crosses Placenla io less exlenl)
Mlrg lhgrotoxicosis (<45 gears) g
M Huge Goiler. Pressure Pt. >45 Uears after failure Add Propranolol (lnderal)
EI Pne-operalive preparalion in 2rg
lhgroioxicosis. Toxic Nodule rnanifeslalions, RSG of rnedical TTT. SECOND TR.IMESTER:
EI Failure of medical TTT of EI High risk palients g Surgerg.. Subtotal thgroideclomg
lrg thgrotoxicosis IHIRD TR.IMESTER,:
M When Pt. is HqPerthuroid: A Anfi-lhgroid drugs+ L-Thgroxine
Neomercazole lO mg tds (To avoid thgouracil lransrnilted goiter)
* Propranolol "lnderal" 80-160 tr # Radiotherapg
mgl dag (Cardio- Proleclive) (Bela rags.. Deslrogs major Parl
of gland without affecling the DUR.ING T.ACTATION:
M When Pt. is Euthuroid
Give neomercazole
adjacenl slruclures) tr Propgl lhiouracil
Preparation before surgerg: EI tO Milli curie
Smg x3ldag for I gear l) Thgroid funclion lesls
N.B.
M Effecl appears afler
2) lndirecl LargntoscoPg 3 monlhs lN Cutr.oneN

ry'
@ Diazeparn rnau be added 3) NeomercazolelO rng lds
in severe CNS affeclion
*Propranolol (lnderal)
g drugs wailing for
Anti-thgroid
EI Follow up) Serial TBA spontaneous remission
measurement. until palient is Euthgroid
4) When Pt. is Euthgroid tr # Radiotherapg
I )Neomercazole Smg tds
till the evening prior lo I EI
g
ggmpiomalic relief I
tr Sur"gerg mag be done after pubertg

operalion+ Lugo!'s iodine I weigl* gain I

\ I u eUeping pulee
lor 2 weeks (9 Vasoularitg)
I

I gerum
el rs. r+ |
Operalion: ,
Subtoial f hgroideclom g THYROTOXCOSIS EXOPHTHALMOS
(lnderal) mag be given Posi-Operalive: M Anfi-fhgroid drugs * L-Thgroxin g Posilion, Proteclion
withoul Neomercazole for 4 dags Propranolol for few dags M lf surgerg is indicated )Subtotal g Diuretics
especiallg in R8G& Conlinued fior fhgroideclomg is done afler g
l-2 weeks after surgerg lo anoid Laleral Tarsorraphg
Poet-operalive Thgto,ioxio crisea
slalionarg Exophthalmos for Ci ms g Orbital De-roofing
 1JK4-Tm\5 ww*NV,.lF(lW i*.q B I

cprreR
*'' *"+"q. ;:{+jl-*flE .:
fu'*i; "' B;'**.' ti-
:[:;.-..

"wlmnAsnrlAr,@rrRe"
PU'Nql}G
Rises wilh
. Gland is presenl in chesl
I Nodule presenl in Chest

deglutilion
. SeDaraled frorn rnain (land
I Connecled lo rnain gland bg
. Arises from Eclopic thgroid lissue
band of lissues
Descends again
{hrough lhoracic
. Takes blood supplg frorn
Takes blood supplg from

rnediastinal vessels Thuroid vessels

goiler

CIINTAUHCTURE, It Mag be sirnple, Toxic, or Malignanl Goilre

TYPE OF PATIENT: Male with shorl neck, slrong slrap rnuscles (MEDIASTINAL WPE)
clu
T
Mag be asumplomaiic
T Hislorg of cervical goiter which has disappeared
T
Severe pressure rnanifeslations : , RSG

l) Trachea )Dgspnea . Reidle's thgroiditis

.
2) Esophagus ) Dgsphagia .
Malignancg
Mgopathg of slrialed rns. 0f esophegous
3) RLN ) Hoarseness of voice
olE:
I INSPECTION) Engorgernenl of neck veins, dilaled chesl veins
T
PALPATION) Lower border isn'l palpable
T
PERCUSSI0N) Dullness over rnanubrium-slerni
T
SPECIAL SIGNS)
"Patient elevates arrn above level of head) Facia! nlelhora due to venous conoesfion "

a is the invest'rgalion of choice

T lsolope scan . RSG
I PIain X-rag ) shadow in superior mediaslinum........ . Ihgmoma
I Flow Volume Ioop pulrnonarg funclion lesl . lgmphoma
. Aorlic aneurgsrn
. INS ++

g Idea! lreatmenl ) Subtota! thgroideclomg from Neck "piece meal"

g lf toxic ) Subtotal thgroideclorng after preparation with TNDERAL onlg
g Avoid ) lnjurg of RLN , Fragrnenlation if malignancg is suspecled
 ?hq I L1

Autoirnmune disease: Abs against Thgroglobulin

& Micrcsome )Destruclion of Follicles 9 61115
&li.rrr'
i,ri DEffiS
(ffi)
THy'trolDrns
4AFibrosis Viral or Cornplicalion of Mumps
Middle aged Female ClO ol manifeslaiions of loxiciig
(HASHITOXICOSIS) then Goitrous Mgxederna
+Other aulo-immune
manifesialions Pain in Gland, Knee. Liver
Enlargemenl of fhgroid
O/E: Gland is Latge, Multi-nodular, Firm, MrcRoscoPrc
Asgrnmetrical. and Moves with deglulition
Mag be associaled with:
@
ffi
' Reiro-periloneal {ibrosis
. Mediaslinal {ibrosis
. $clerosing Cholangiiis

>ACIDOPHILIC o/s T[tlrFotD sScAD.l

COID Nodule
' Lgmphocgtic in{iltralion Multiple
(Features of Chronic Thgroidilis)
nodules .
. 9Thgroid function . ^ESR Anlibodies)- ve
Thgroid
(Mgxederna) .
.AEgR Isthmectomg Thgroid Scan) @[I
. Anti-Thurogllobulin Abs +ve
. Anli-rnicrosornal Abs +ve
. L-Thgroxine + Corlisone
. Surgerg if Lar"ge, Mal'rgnant PREDNISOLONE
 1L\P.4:locrr5 E{D,CF^IE ilRqW ?AqY I rc

Well-formed acini * askanazg eells PRIIJIAI{/

ADEhb- MeUrr.qFy
Cancnr.nne Ahnctl|ortlA
thlotffi
'. U/8 ) Solitarg Nodule eAlalrrdt!/,
Thuroid Scan > COLD Nodule ffi
(Can'l differenliate belween follicular
adenorna, Follicular carcinorna)
ChJN'CAL
a Hemi-Thgroidecfomg g Rapidlg growing swelling in lower part of froni of Neck
g Open biopsg & Paraffin seciion g Earlg painless, Painful latelg (referred lo ear)
V ln{illrative manifeslalions
A Meiaslaiic rnanifestalions
SIGNS:
Z GENERAL) Cachexia. rnelasiasis
g TOCAL SIGNS:
g Hard gland, Earlg mobile & fixed lalielg
A Trachea fixed lo Gland, Posilive Berrg's sign
g LNg+ + (Delphian. Cervical LNs)
 ilRt+-Twr5 flW*NY WW P *hV I ?i

Exlernal radialion of Neck in children, Genelic faclors (Goodwen's $, Onco$ens)

Fernale 2O-4O gears wiih Delphg [Ns

Solitary lhgroid swelling in Neck pilrtu;1ri :
e
{
(D
I ll-defined rnass in{iltraling surroundings +
-
Io
E
Microscopic : o
wilh vascular Cf core J
CL
o
J
o
(s
. loss of polaritg, signs of Milosis
v
)
ETI0LOGY: SNG, Follicular adenorna, Hislopatholo$cal surprise F
o
+
Fernale, Hislorg of 8N0 eilher:
. o
Left wilhoul surgerg) Follicular carcinoma
. o
+t
Hislopathological surprise during subtolal
thgroideclomg bl 8N0 Uq
-o
{+
Fernale 40 grs.)mpid progressive swelling in Neck Bolilarg
Painful

. Mggrylg. )Brown Unicenleric mass Pulsating e

E
' Ulgrgsss&,
l) Follicles wifh rrilrble degre rentialion.
0steolgtic
-o
UU

. =
o
Loss of polaritg + signs of rnelaslasis
12.
9
e
-
o
(C
o
o
-ct,
Old Age, rapid progressive swelling in Neck
(D
F
L
-
. Ugg@qlq1)Greg Unicenleric mass
PRESSURE MANIFESIATIONS s.
. Miuoscopic:
* RLN )
Hoarseness of voice o
l) Clusters of * Carolid )Absenl carolid
2) pulsation (BERRY SIGN)
Separated bg Fibrcus lissue
. Loss of polaritg * silns of melastasis
 ilR4-Tw\5 htw*ht,ww l'l,*V I 1L

DlreT{Cus: Dlffi ONurrrxeNntrp

. Funclion)Thgroid funclion : N0RMAL
. MorDholoAu) U/S TUMOR & GLAND IF INOPEMBIE:
(Solitarg Nodule, . Surgical debulking
. Tolal Thgroideclorng + .
Cgsl with papillarg projection) Pallialive Iracheoslorng
Cenlral Nodal Disseclion
' Morpholoqg & funclion :
. Post-Op L-Thgroxin
lsolope scanning )COLD Nodule
. FNABC
R.eplacemenl &
(ln follicular) Hemilhgroideclorng & Paraflin) radioaclive iodine
IF OPEMBLE:
s3rrerNg: LYMPH NODES Tolal lhgroideclorng * Posl-
. CT, MRl, U/S operative Radiotherapg &
. CXR, abdominal U/S . CHILD) No Disseclion Chemotherapg
. Bone scan (done after lotal lhgroidectomg) . ADULT$) Prophglactic
Disseclion of cenlral group
FNE{DEnA]TTE
of LNs
0rgan profile "CBC,KF[,LF[,ECG" . lf One LN is Affecied)Block
Disseclion of LNs of neck

. Posilron emission tomographg (PET) RADIOACTIVE IODINE

.. To delecl RECURRENCE ..
Follicular carcinorna
lrcaled bg thgroidectorng
+ Post-op Athgroglobulin Level
. Deslrog ang rernnanls of norrnal thgroid iissue,
Ablale ang rnelaslasis of lurnor
. STEPS:
Wait for manifeslalions of MYXEDEMA lo appear..
l) Give srnall dose of Radioaclive iodine
) Total bodg scan
2) lf there's *ve rnelaslasis) Large ablalive
dose of Radioaclive iodine
3) Posl-therapu scan afler few weeks

FOLLOW UP .. 5 gears post-operative..

. Everg 3 months do the following :

l) Clinicalexarninalion
2) Thgroid scanning
3) Iumors rnarkers
lf palient wilh residual turnor afler tolal
thgroidectomg) Serum lhgroglobulin > Zngl ml
 ilPq-Twr5 ww*Nvwwl '"J c1., I ffi
tvleWcAFclNo,lA r;*
ETIOLOGY:
)'a*
. Sporadic ) Falal
C-Cells

. Farnilial ) MEN ll = SIPPLE's $ \z\

CLINICAI PICTURE:
TYPE 0F PAIIENT: OLD Aged patienl

. Rapidlg progressive swelling in ..Secrelion of serolonin.. . Dgspnea

. Diarrhea . Dgsphagia
lhe lower parl of fronl of neck
. PAIN: earlg painless, lalelg painful 'Bronchospasm , Hoarceness of voice,
. Flushing . Horner sundrorne

SIGNS:
tr GENERAT) Cachexia, Melaslasis
tr IOCAL:
. Earlg mobile thgroid swelling, latelg fixed
. NECK lgrnph nodes )Enlarged , Hard
. lnfillralive) Trachea, Carolid sheath (+ve Berrg's sign)

SPREAD:
. LYMPHAIIC SPREAD) Mediaslinal LNs
. B[0OD SPREAD) liver, Skull nodules, ascilis

INVESIIGATIONS:
. SCREENING ) Calcilonin, Calcium
. DlAGN0Slg ) Ug/FNABC/Calcilonin (>0.08 nglnl) *ve Farnilg Historu + ,lt Calcitonin
. $IAGING) CT, CXR, U/S, Bone scan
, = IOIAL IHYROIDECTOMY
Pre-OPERATIVE) CBC, KF[, [FI, FBS
. EXCIUDE PHEOCHROMOCYTOMA)
even if Normal Gland

TREATMENT: !! Jrll 9! brtull

. fofa! lhgroidectomg * Cenlral Neck Nodal disseclion
. SPOMDIC CASES) All the Paralhgroid is Preserved
. FAMILIAT CASES)
l) Ireal
(Combined Alpha & Beta Blockers ) Adrenalectomg)
2) Preserue YzPmalhgroid gland.. (for fear of hgpo-parathgroidisrn)
. Trealrnent of Complicalions
' Posl-operative Follow up everu 3 monlhs
 crFq-Twfi a{Docw ww ?hEV t ++

f
./'

I
i:,

i
t'v\

PARATHYROID ADENOMA PITUITARY TUMOR PANCREATIC IUMOR

t.JlEN - llA

MEDULTARY CARCINOMA PARATHYROID ADENOMA PHEOCHROMOC\TOMA

tilEhl - llB

)1

ffi{*llD! vldl,6'. thytld

,qtah3 b d&lhr,lDrEd ffilmt

MEDUTTARY CARCINOMA PHEOCHROMOCTTOMA NEUROFIBROMA +

HIRSHSPRUNG+
MARFANOID FEATURES
 ilEI4-Tw$ 1a"]lW*WWW
.TRAPPING of inorganic iodide fiorn Blood
.@[!9! of iodide bg peroxidase enzgme inlo lodine
.@ru!E!qAM! binding of iodine wilh lgrcsine
bg Tgrosinase lo forrn M0N0- iodo lgrosine, Dl-iodo lgrosine
.COUPUNG of rnono-iodo lgrosine lo forrn lg, T4
\^J€
) unile wilh lhgroglobulin) Stored in Follicles

l- THE TIIYR0GIOSBAL DUCT; is related to cenlral part of

bone (rnoving of thgroglossal cgst up wilh tongue protrusion)
2. IHE T}IYROGLOSSAI CYSI;
-
MrU be present al ang level of lhgroglossal lracl in lhe midline from forarnen caecum to lhe suprastemal
nolch excepl in lhe reglion of the lhgroid carlilage where fhe figro$ossal lract is pushed io one side
-
Trealed sur$callg bg rernoval of the lracl with cenlral pad of hgoid bone (as infection is inevltable)
3- rlmoclossAr FtsTU[A:
-
Alwags acquired (following infeclion, inadequate remova! of thgroglossal cgst)
- lt is lined bg columnar Epithelium.
-
ln long standing lhgroglossal {istula, fistula is silualed lour dorrrn in lhe rreck.
4- PENDRED'S $: due lo de{iciencg of peroxidase enzumer in which lhe patienl is deaf, mule, but NOI blind.
S IINOUAL IHYROID
-
MrU represenl the onlg thgrcid lissue.
- Forms a rounded swelling at the forarnen caecum, cause irnpairmenl of speech or respiralorg obslruction.
-
lt is besl lrealed bg full replacement wilh L-thgroxin or excision.
& MEDIAN ECI0PIC IHfRO|D) usuallg rnislaken as lhgrcglossalcgst

l- ln simple goifer, lhe mosl imporlanl faclor is dietary deliciencg of iodine (Ihe dailg requiranarl100-t25 qg)
2- Vegelables of brassica familg, PAS, Ca, lhiocganate, Carbirnazole and lhiouracil are goilrogenics.
3- ln diffuse hgperplastic goiter)lhgroid hormones level are normal (euthgroid).
& A colloid goiter is late stage of diffuse hgperylasia.
5. MUIIITIODUTAR GOITER,
- Onlg rnacroscopic nodule is found.. (Micrcscopic changes will be presenl throughoul the gland and
mag be one forrn of a clinicallg solitarg nodule.
- Irlodule mag be colloid or cellular, and cgslic degeneralion and hemorfiage arc oommon
0- Regading thgroid funclion lesls, no single tesl is conclusive & lf TSH is normal)lg, T4 arcn't needed.
7- Regrding FNABC:
- Ihe invesligalion of choice in discrele lhgroid surelling, Simple & quick, with excellenl patient com$ance
- Cannol differenliale Belween Follicular Adenorna and carcinoma
8- Regardin! isotope lhgroid scan,
-
Most useful in loxic adenoma of thgroid
-
Cold nodule )Under aclive nodules (usuallg Malignanl nodule)
- Warm nodule )Acllve nodules
- Hot nodule )(her aslive nodules (usuallg lhgrcioxi,c nodule)
9- lndicalion of surgerg in isolaled thgroid swelling are: foxic adenoma , Pressute sgrnPlorns, Neoplasia, for
Cosmoslic purposes
l0- Regdin! largngeal paralgsis :
-30 Yo of cases arc idiopalhic, 3-4 % of palients have congenilal paralgsis of one of the vocal cords
() Do lndhecl laryngoscope before ang opemlion per.forned on lhe thgrcid gland for medicoJegal putposes )
ll- Invesligalion of choice in Sltl0 )
U/g
lf a dominant Nodule > 1.5 cm) FNABC (exclude malignancg)
 1,)?4-TW\5 A{DoCENV WW ttu

PRIMARY THYROTOXICOSIS (Grave's disease): is an auloimrnune disease thal develops in a previouslg

healthg thgroid gland where the gland is enlarged or shows mild enlargemenl.
2- Thgroloxicosis should be suspecled in :
- Children with growth spurt, Behaviora! problerns
- Un-explained tachgcardia, arrhulhmia, diarrhea, loss of weighl
- Resislanl heart failure
g- Effecls of Thgroloxicosis on Bone:
. THYR0IOXIC0SIS ) 0steoporosis
. After operation) B0NE HUNGER.... (Osteoporolic bone wilhdraw Calcium from blood, manifesled bg Tetang)
Pretibial rngxederna:
- ls a thickening of the skin bg a rnucin-like deposit.
- MaU be cganolic when cold, Associated with clubbing of lingers and loes.
TREAIMENT OF THYROTOXICOSIS:
Disadvanla(e of anli-thuroid dru[s Advanlales of surgenl
a- Trealrnenl is prolonged a- the goiler is removed
b- Failure rale afler 2 gears is 50% b- the cure is rapid
c- ll is impossible to predicl which o- lhe cure rale is high
palienl willgo inlo rernission if surgerg is adequale
d- Some goilers enlarge and becorne
vascular durin( lrealrnenl
6- Regarding ITT. schedule for diffuse loxic goiler
a- 0ver 45 gears) radioaclive iodine
b- Under 45 gears * large goiter )surgerg
)
c- Under 45 gears + smallgoiler anti- lhgroid drugs
7- Surgerg is the TTI of choice in loxic nodular goiler as il doesn'l respond lo drugs rapidlg or lo radiolherapg
8- Ihe lsl line of TTT of Grave's disease is mainlg rnedica! for hope of perrnanenl rernission.
9- Patients on anti-thgroid drugs rnusl do CBC periodicallg for fear of AGRANUTOCYTOSI$
l0- Post-thgroideclorng slridor mag be due lo:
a. Bilateral RLN injurg.
b. largngeal ederna.
c. Iracheal collapse.
d. Deep neck hernalorna.
ll- lndications of surgeru in Grave's disease include:
a) Large goiter which is uncornrnon wilh Grave's.
b) Failure of conservalive rneasures.
o) Suspicion of malignancg.
12- PEDIAIRIC GRAVE'S DISEASE: surgerg is rnore preferred because radio-iodine is poientiallg carcinogenic
and causes lale mgxederna and antithgroid drugs aren'l wilhout side effects.
13. THYROTOXC CRISES:
- An ER. case manalled in lCU.. (lV {luids, lV hgdrocortisone, Digoxin for hearl failure, Lugol's iodine & propranolol)
- MaU follow an unrelaled operalion, lnadequale Pre-oPeralive preparalion
- SUPPR0TIVE TTT for dehgdralion, hgperpgrexia, restlessness is essenlial in Thgrotoxic crises
14- EXOPHTHALMOS is a comrnon fealure of Grave's disease (Radioactive iodine lherapg is better avoided in ttT)
15- SECONDARY IHYROTOXICOSIS (Plumme/s diseasel :
- Develope on lop of multinodular ;loiler
- ln Plummer's disease lhere're aclive inlernodular lissue wilh inaclive nodules.
- Cardiac sgmplorns are rnore prominenl in Plurnmer's disease lhan in Grave's disease.
 lJRq-Twt5 ilpocru7ww ?AhY t 11

Rarelg caused bg enlargemenl of eclopic thgroid lissue in lhe rnediastinurn.

Asgrnplomalic and rnag presenl as dgspha$a, Palienls attend lo chesl clinic and diagnosed as "aslhma"
ln severe cases lhere rnag be obslruction of superior Vena cava.
Recurrenl largngeal paralgsis is nol cornrnon.
TTT: Have lo be rernoved rneal.

I. HA$HIMOTO IHYROIDITIS:
- Presenls as rnulti nodular goiler, fealures of chronic lgmphocgtic ihgroiditis are comrnon on hislologg
- lrg mgxedema wilhoul deteclable thgroid enlargernenl represents the end slage of the pathological process.
- Complicaiions: Ihgroid failure is cornrnon, lnuease lhe risk of lhgroid lgmphoma.
- Invesligations.. Aulo antibodies against thgroid peroxidase, thgroglobulin.
- ldeal TTT. of hashirnolo's thgroiditis is THYROXIN .. (DOESN'T ALWAY$ require thgroidectomg)
2. RIEDLE'S T}TYROIDITIg
- Thgroid iissue is replaced bg {ibrous lissue.. (Mediaslinal fibrosis) ..
- MrU be misdiagnosed as lhgroid carcinoma
- Ihgroid scan shows no uplake over lhe swelling.
3. DE QUER.VAIN'S THYROIDITIS
-
Due lo viral infection
- ln tgpical sub-acule presenlalion of De-Quervian thgroidilis lhere's pain in lhe knee, liver rnalaise, and firrn
irregular enlarlernent of thgroid.
- lnvesl'rgalions: Thgroid aniibodies are absenl.

l- Ihgroid malignancg is rnore in females lhan in male.

2- LATERAL ABBERANI THYROID... A melaslasis in arrival lgmph from an occuli thgroid carcinoma.
g- SPREAD: Papillary carcinorna)lgmphatic roule, Follicular carcinorna)blood & Anaplaslic
carcinoma)Local in{ihration of surrounding tissue
4- Melaslasis lo ceruical [N occurs in 50-60%.
5- PAPIIIARY CARCINOMA
- The rnosl cornmon lrg mal'rgnant lhgroid lurnor, Slowesl growing lurnor & mag lurn lo anaplaslic forrn
- Dependent on T$H slimulalion.
- Has a lendencg io become rnore rnalignanl wilh age.
- Not associaled wilh hoarseness of voice.
6- FOTLICULAR ADENOMA presenls clinicallg as a solitarg nodule, Best TTT is LOBECI0MY
N.B. (Distinction bel. Follicular adenorna and carcinorna can onlg be made bg hislopathologieal
examinalion, ln adenoma lhere is no invasion of lhe capsule or pericapsular blood vessels)
7. FOLTICUTAR CARCINOMA
-Thgroid cancer with mulliple bone rnetaslasis
-lf suspected) Hemi thgroidectorng is needed io diagnose it.
8- FNABC {indings are diagnoslic regarding papillarg carcinoma, bul nol a conclusive evidence regadin!
follicular carcinorna.
9. ANAPI.ASIIC CARCINOMA
- Usuallg affects old males & cang worsl prognosis.
- Iotal thgroidectorng is often impossible for anaplaslic carcinoma.
IO. MEDULTARY CARCINOMA
- A lurnor of C- cells derived frorn neural cresl with characlerislic amgloid slrorna and A calcilonin.
- MrU presenl wilh (Earache, hoarseness, sfridor, Enlarged cervical LN, Diarrhea due lo serolonin)
-
ln thgroid carcinoma, Mediaslinal node involvernenl is a feature of medullarg catcinorna of lhgroid.
- The level of calcitonin falls after lhe resection of the lurnor.
II. PHEOCHROMOC\TOMA
- MrU be found at aorlic bifurcation.
- Rule of len ) lO% bilateral -lOTo exlru adrenal - lOTo multible
 lJPt4-Twr5 hrDocRNYww ?hqv t%
l. Youn! prelnanl female presenls wilh mild diffuse
enlargemenl of the thgroid gland occurs for firsl lime
in pregnancg and gives hislorg for the sarne condilion
with previous prelnancg which fades with deliverg.
DrTtse srnVle prter
2. Young! fernale with N0 Historg of lhgroid disease
subjected to Psgchic lraurna, presenled wilh
diffuse enlargemenl of lhe gland, Toxic C/0

Difuse to\tc lotter

3. Middle aged fernale with Past hislorg of thgroid disease presenled wilh toxic
sgmptorns, 0n Palpation: Ihgroid was Nodular
Toxb Nolttar Wrter
4. Female with one palpable nodule in her neck- thgroid scan shows hol nodule.
Toxb Thyrolit Ndtle
5. Middle aged fernale wilh past hislorg lo thgroid disease with or without exposure lo a
stressful condilion presenled wilh hgpertherrnia, arrhgthrnia up to corna
Thyrotoxic 6rbes
6. Obese rnale, complaining of dgspnea, wilh hislorg of neck swelling which disappeared
recenllg , and pressure sgmploms appeared.
Retrostertal Wtter
7. Middle aged Fernale with enlargemenl of lhgroid gland, thgroid scan shows cold
nodule & inter-nodular lissue
//as fiinoto's tltyrordrt b
8.01d female with hard thgroid nodule, pressure manifeslalions, Frozen neck,
relroperiloneal fibrosis.
&rd/e's Tltyrorditrb
9. goun! female with solitarg lhgroid nodule & no toxic or pressure manifestalions
Paf'tta7 carcthor/a
10. Old female with pas"t hislorg of SNG, Rapidlg progressive swelling in neck,
picture sirnilar lo a skull abscess.. Thgroid scan shows cold nodule
follrfular cdrutlottld
ll. Old male with rapidlg progressive swelling in neck, absenl carotid pulsalion &
hoarseness of voice.
,haVlastb cdrcrloftia
12. Old age patienl with rapidlg prollressive swelling in neck, *ve farnilg historg
presenled with Diarrhea, Bronchospasm, Flushing (Carcinoid sgndrome)
,ilAnrury carcfuottld
 ilP.q-Twt5 ww.iEN0 l"Rhw ? Aqv I n

aa

- Give an explanation for: Papillarg carcinorna of thgroid should be

lrealed bg lotal Thgroideclorng
Kasr,2W)
- Managernenl of Thgroloxicosis, Trealrnenl of Prirnarg
thgrotoxicosis
( r4ilar rl/,2o/2,2o//,-zml Au s/uns,2m/)
- Managernenl of solilarg lhgroid nodule
G4il slhns2@2,2@5, r4ilar f'2@5
- r4ilar rl,L 2w.Z@4, 2fu5 )
- Manalfernenl of ihgroid Neoplasia
( ,4n sfians,2@5 - r4ilar il'ZO// )
- Thgro-glossal cgst : eiiologu , tupes and ClP , Trealrnenl
stldt/s,2M, r4ilar f,2@5 - Ay'tar ril,2m )
(r4rh

- Multinodular goiler: investigalions, Cornplicalions

04/tar f,2M, rAur f'2M)
- Toxic goiter: Tgpes and Trealrnenl
04/rar f ' 2ob, 2@5, 2@4, r4y'ur f' 2a/)
- Huper-paralhgroidisrn: Diagnosis & Investigations
(Alur fiZM, r4y'ur f,20b )
- Relro-slernal goiter: CIP
- Ihgrotoxic crisis: lnvesligalions
- Cornplications of lhgroideclorng
ctBq'41ar5 VWW ?AqVt+0
SUR(

rllrclraet Safrut
lAB.BCh - /////uersify
 ww*tv lJ?wl ? hEv t +7.

r Cushing sundrorne
! Pheochrornocglorna
r Hgperparathgroidisrn
 1fr14-Tw\5 ENDoCFIE ilRqWt ?hqe t ffi
Wn{GlShbnoMe trCUSHlNG SYNDROME: Chronic t
of cortisol levels
trCUSHING DI$EABE: 4 Cortisol secondarg lo pituilary lumor

tr ETIOTOGY

tr Plluilarg adenorna 80% of cases tr Adrenal tumor

tr Eclopic ACTH sgndrome tr lalrolenic: Prolonged Corticosleroid
tr

tr CLINICAI PICTURE:
FAT DISIRIBUIION:
. Moon Face (Face)
nl'$;,*,,,i,:::.",", . Buffalo hump (upper back)
'. Supraclavicular Fal pads (above clavicles)
Trucal obesitg
abdomen, ecchgrnosis . 4Waiet-hip ratio >l in rnen, O.8 in wornen
. Thin skin
. Hirshulism, 4 Facial hair Cardiovascular, Renal , Endocrine
. Hgperlension
'il:iH#*i:".. . Diabetes mellilus
. Edema 1l

. Menslrual irregulaillirs, amrJ,omh"r.

infertilitg

tr INVESTIGATIONS
I

?EARLY) Loss of circadian rhg[hm

?t-IiIE) flevels of cortisol
(dexamelhasone O.5rn/6 hours for 2 dags)

lnhibition'of ACTH Corliso! level$ unchanged

secrelion, O Corlisol levels
I CUSHING SYNDROME
NORMAT

ZIr
=
PITUITARY TUMOR {z = ADRENAT TUMOR
CT Scan sella lurcica, MRI CT abdomen, MRl, U/S,
Selestive adrenal venous
sampling
tr TREATMENT
? PITUITARY TUMORS:
trlrans-sphenoidal rernoval of lurnor
trHgpophgseclomg or piluilarg irradiation followed bg replacement therapg
?ADRENAL TUMORS:
tr Sur$cal removal followed bg suboplimal rcplacement therapg wilh low dose slercids..
(Till olher adrenalgland recove!'s from suppression)
?MEDICAI THEMPY FOR PRE-OPEMIIVE PREPARAIIO!{ .. C-metgrapone
 lLlPq-{wr5 A\lDpC4€hlV lJRhWl ?A v I ++

tr DEFINITION: Turnor of chromaffin tissues secretin! Catecholamines

tr ETIOLOGY:

tr Adult tr child
tr <lO7o Bilateral tr 50% bilateral
tr lOTo malipnanl,lOTo tr Mau be oarl of "MEN ll"

E Forrned of Embrgonic Chrornaffin cells around abdorninal

aorla that Normallg atrophg during Childhood
E Maior sites of Exlra-adrenal Pheochromoculoma

tr CTINICAL PICIURE

. Sueening of Hgpertensive palients for Pheochromocglorna :

Recenl onsel of relinopathg wifh DM

*
Sgmplornatic HTN Vasomolor phenomena or DM
HTN (e.0. Postural HTN

td - Iachgcardia, Palpitation
- Swealing, pallor
d - Anxielg , Trernors
d6 - Arrgthmia, precipilalion of angina
. HYPER,IROPH IC CARDIOMYOPATHY
. FEATURES OF "MEN II":
- Medullarg carcinoma
\r t - .Hgperpamlhgroidism
..U."....
. \- - Neuroftbromalosis

tr INVESTIGATIONS
. LABOMIORY ... 4 Urinarg VMA, Calecholarnines, Plasma Catecholarnines
. MDIOLOGY ... Abdominal U/S, CT scan, MRl, Seleclive adrenal vein sampling

tr TREATMENT:
. ADRENALECIOMY of diseased side afler Pre-operaiive preparalion bg Alpha
blockers 7-lO dags followed bg Beta blockers for 3-4 dags before operalion
N.B. avoid using HALOIHANE in aneslhesia lo avoid arrgthmia
 5"Rq*Twr5 rNDoCEtl' XRhWI ?Aqv t +6

H ,trOlDlSM
ADENOMA: Compensalorg tr After prolonged Ectopic secrelion of PIH
- gz%ofcases hgperplasia due to secondarg bg small oell bronchial
- Middle aged female prolonged hgperparalhgroidism carcinoma
- Affecls I gland hgpercalcemia
tr Olher causes: (e.9. CRF,
e.g. Hgperplasia, Carcinoma, Malabsorption)

tr CLINICAL PICTURE:
MOOD..
( MORE !N PAilENTS >60 YEARS)
BONE I - Apathg, loss of
- Bone pain concenlralion, Depression
- Pathological fraclures rl
- Ostitis fibrosa cgslica
STONE..
GIT ( MORE rN PAT|ENTS <60 YEARB)
- Anorexia, Nausea, Vomiting -Recurrent Renal slones
- PU, acute pancreatitis - Nephrocalcinosis

tr INVESTIGATIONS:
FOR LOCALIZATION IN RECUR,RENT CASES
O Serum calcium except in 2rg tr ffi...MOSTACCUMTE
hgperparathgroidism tr CT scan
V Serum Phosphorus tr TCnn
O Serum PTH
X-MY: multiple bone cgsls, reabsorplion

TREATMENT
tr PRIMARY HYPERPARATHYROIDISM )
Surgical removal of enlarged gland
- Adenoma) reseclion
- Hgperplasia) removal of 43 ol gland & implanlalion of l/3 ln deltoid .
tr SEOONDARY HYPERPARAIHYROIDISM
- t alpha hgdroxgl Vitamin D3
- Calcimimelics
tr TERTIARY HYPERPARATHYROIDISM
- Total parathgr autotransplanlalion of parathgroid fragment
equa! lo normal size in arm Muscles
 1JR{4-TW\5 ilPq%l
^IDOCRNV

Regarding PARATHYROID HORMONE (PTH):

- A peptide hormone
- f Phosphorus excrelion in urine.
- PTH serurn levels are Ain chronic renal failure.
- Require vilarnin D as a Precursor.
ETIOLOGY OF HYPERPAMT}TYROIDISM:
Hgperparalhgroidism resull from single adenorna (the most cornrnon cause) or mulliple adenorna,
Carcinorna is a rare cause.

CIINICAI PICTURE OF HYPERPAMT}TYROIDISM :

l- Hgperparathgroidism associaled wilh mulliple bone cgsls, can Presenl with renal slones.
2- As regard hgperparathgroidism, lhe commonest presentalion isasgmplomatic
hgpercalcemia.
3- Clinical fealures relaled lo hgperparalhgroidism
a- Bone pain, multiple bone cgsls, palhological fraclure
b- Renal slones.
c- Abdominal Groan
d- Psgchic rnoan
4- Chvoslek's srgn is twitchin! of the facial rnuscles produced bg lapping over the
prorninence of facial bone in fionl of lragus of the ear in a person has lelang.
5- Pancrealitis is a recognized complicalion of hgperparathgroidism.

I NVESTIGATION$ OF }IYPERPAMT}IYROI DISM :

l-The biochemica! findings related to hgperpatalhgroidism:
r J Serurn alkaline Phosphatase
.1 Ca in urine.
2- Radionuclide scan is the besf wag of preoperalive localizalion of paralhgroid adenorna.

TREATMENT OF HYPERPAMTHYROI DISM :

l-
Hgperparaihgroidism can'l be cured bg using anli- parathgroid hormone drugs.
2- TfT. of hgperparathgroidism
l'e: Surlery
2ry : rnedical
3ry: surterg
ilR{+-{wr' ww,PNY XMW ? AqY | +6
tblichaet
lr',B.Edh Arn s/uns unirersl;4
 cJ,,Eq-Twr.t5 f/-tp4B{ ? Aq I 60
htpOCFNE

Liporna
Neurofibrorna
Hernan$orna
Vascular rnalforrnalions
Derrnoid cgst
Fistulas
Sirnple ganllion
Miscellaneous lopics
 l./{Pq-Twn5 a.Doc*hlE 5JR4W ?AEV t d

@Site:
@@ @ SlfE: Forehead DDiagnosed bg MRI ODANOEROUS) @Related to Spina! cord
@Sile: Ihighs,
shoulders
@ glTE : Back, shoulder, @ Firm DDD: Osleo-arthritis, COMPTICAT!ONS: Long!, flal bones BUTIHHITN
Bullocks @ Nol allached lo skin Baker's Cgst - Respiralorg
@Diagnosis: MRI
@OE : becornes
@ Attached to Skin
@ Well de{ined slipperg
@
@
NO slipperg edge
Lirnited mobilitg -
obslruction
lnlussusceplion
@CP:
6ifi rnore {irrn on
Muscular
edge conlraclion
Pressure
@ Mobile rnanifeslalions

swelling, of gradual onset

:IC
MISCELLANEOUS 'F

@ Neuro-Lipoma SUBMUCOUS> Respiralorg

@ Dercum disease Obstruclion & lnlesiinal
@ Complicated lipoma lnlussceplion
R,ETRO-PERITONEAL>
@ MICRO$COHCPICTURE: Premalignanl
Aggregation of Fat o"lb)@, DCTRADURAL) Pressure
separaled bg fibrous liesue, contains Blood vessels @ Palient: Fernale, post-
tNVESTIGAIIONS: ... Clinicallg diagnosed... rnenopausa! patient manifeslalions
BPECIFIC: Excisional biopsg, X-rag, Spira! CT spinal cord @ Site: lower limb
Treaimenl of choice is Enuclealion of tumor frorn its @ Clinical oiclure:
@ Relro-periloneal lipoma
Small, rnulliple,
@ SC lipoma in fhighs, Bul^locks
Painful swellings (Slighrlg higher incidence)
 il84-T0ur5 wwtxNr' a^Pqw ? hq, t 61-

DEFINITION:
Mal-arrangemenl of Normal tissues

CONGENITAL OTHERS
. Pigmenled skin Iesions
Hernangiorna Vascular . Neuro-fibromas
. Lung!, brain hamarlomas
Slrawberrg rnalforrnalions
Hernangiorna
Low Flow High Flow Sgndrornes
.Slurge weber
.Klippel Trenaunag
Capillarg Venous Lgrnph Arterial A-V Fistula . Kasabuch Merrill
I I Cersoid
Porl Wine Salrnon
Cavernous Cgstic Aneurgsrn
Hernan$orna Hggroma Congenital Acquired
sfain Patch
prrS .g.url (Cavernous ,=rrJ pf,1i (traumalic)
t-sgufuib.[r loJ +rb ,=lifr: Loi Lgmphangioma)
r rrr i.t Venous
malformalion
 lRq-Twr5 A.DoCFNE 5tM4W ? AqV I m
@DEFINITION: Tumor like rnass
forrned frorn Nerue sheaih

Caf6 au lait
patches PTEXIFORM NEUR.OMA @Congenilal disease
MOST COMMON TYPE @Site: Scalp, face, lrunk
@ Cgstic swelling in lhe face @Consistencu: Sofr @Site: Limbs
rYPE(l): @ Palpation: Sensalion of @Clinical picture:
- AD, Chrornosorne 17
bag of worrns Hgpertrophg
. CTINICAL PICTUR.E:
Tenderness
+ Caf6 au lail palches
+Pheochromocgloma
(if a part of MEN llb $)
- Special characler in fgpe(l): C/O: painless swelling, of gradual onsel, progressive course
Alnlra cranial iension o/E:
TYPE(ll) ACOUSilC NEUR,OMA:
- Chromosorne 22
- Associaled with Acoustic Nerve
lumor
- CtlNlCAt PICIURE: Painful ,
leading lo Deafness & vertigo @ Not atlached lo skin
@ Moves across Nerve aLoUiJJI iirrl,ii
Caf6 au lail palches

COM Ptl CATI ONB :_Mag lurn Mal'rgnant) "Neuro-fibrosa rcoma"

TREATMENT:
- lf sin$e) Excision
- lf Multiple: "Let lhe patient die in peace nol in pieces" !!
, DEFINITION: Benign furnor of Endolhelial cells

. INCIDENCE:7OTo growing during lhe first gear

. CLINICAT PICTURE:
* Erylhernatous palch with irregular surface
*
MOST COMMON SITE: Face
*
Appears at birth or shortlg a$er birlh, 4 in size in lhe first 6-12 rnonlhs
*
lnvolulion starts afler I gear: (5O% bg 5 gears, TOyo bg 7 gears)
*
The remnanl of after-involution is better lhan scar d surgerg
COMPLICATIONS:
* , Ampglopia, Blindness, Squinl
TREATMENT:

MNesrAlN r-iglriri Lr.lgc

t Appears )
NO sponlaneous lnvolulion
I CLINICAL PICTURE: Deep purple lesion, NOT RAISED, Pressure causes blanching
:: Mag be parl of SIURGE WEBER, $ ... if associaled with similar lesions in meninges ::
COMPLICATIONS :

. Trealmenl :

. Decolorized compressible swelling

"KASSABACH'g MERRI $"

Appears )
ttlO sponlaneous lnvolulion
INVE$TIOATIONS: Arteriographg, CT scan U/S) Hgper-echoic
TREAIMEIIIT: lesion in liver
AI'IGIOORAPIIY)
Cenlripelal
arrangement of dge
 lJ?{44wr5 ww,PNY ilRq%l ?hqv t 55

. Mosl common sile

€. gCAtP (lemporal , Occipiia! relion)
.w.
N. C/O: Headache + cosmelic disliguremenl
* O/E: Waler harnrner pulse, lrregular swelling with norrnal
overlging skin, Pulsaiing with machinerg murmur on auscullalion
' !.Eyes!!Et!ons.!
l) Doppler, Duplex
2l ECA an$ographg
3) Xrag) Rarifaclion of bones
. Trealmenl :

(Semisitting posilion, Hgpolensive GA . Pre-operalive Ernbolisalion , ligalion of ECA )

r APPears in Neonales
Nurnber Single
M
Site Rool of neck in Posterior trianfle,
suoerlicial lo slernornasloid ms.
Size large
Shape Rounded
Surface irregular
Edge il! de{ined
Consislencg Lax, Custic
Special I

characlers T

. DD : Branchial Cgst

frealment:
 ilRq-Twr5 A{rcruV ffiqw Thq* t 5b

lmplanlation
Sequeslration Tubulo-epiderrnoid Teralomalous derrnoid cgst
dermoid cusl

DD of Derrnoid cgsi: Sebaceous cusl (epiderrnoid cust)

crrsr (enOennmD q/sr)

. Bile: Angwhere in skin relaled lo hair bul
. Appears after adolescence )Grows slalionarg with NO sDonlaneous lnvolulion
. CIP
* Slowlg growing SC swelling attached lo skin al a point)
sebaceous rnalerial which can be Squeezed

. Cornplicalions :

! (ulceration of sebaceous horn)) BIOPBY (D.D. SCC)

MffiAnol.l
I DEFINIIION: An Acquired derrnoid cgsl
g/sr
t EIIOTOGY

I PATHOTOGY Site: ln the tip of fingers

I
CLINICAL PICIURE:

endings)

I COMPIICAIIONS: as anu cgsl..

!
TREATMENT
 ilPq-Twr5 ww*NV IJP^W ?hqv t 67

. Infeclion )rupture Since birth . Rupture

. Inadequale excision of . lncornplele
cgst excision or
incision
, Opening is near midline or lo
the Left side . Parliallu deep to sternornasloid
. Viscous discharge or pus rnuscle giving Mucoid discharge
rich in Choleslerol

N.B. Branchial cgst, Thgroglossal cgst ... See Pedialrics surgerg

DEFINIIION: Chronic cgsl conlaining rnucoid malerial, relaled lo a lendon

EIIOLOGY: Mucoid degeneralion of {ibrous lissue of lendon sheath
C/O: Painless swelling al dorsurn of hand or around ankle
o/E:

Moves across lendon

Mobilitg V bg Pulling on lendon

coMPUCATTONS:

INVESTIGATIONS:

TREAIMENT :
 e.B4-TooN5 hlDoCFlNtr ilRhwl ?^qv t 56

M roPlcs
@ Port wine Cornmon associalion wilh Port wine stain @ Hemangioma *
@ 2rg varicose veins @ Capillarg vascular rnalformalion Ihrombocgtopenia
due lo A-V fislula @ Leplo-rneningeal AV rnalforrnalions @ Vascular lumor Ieading to
@ AV Malforrnalion in Exlremiiies 9Platelet & other bleeding
disorders
@ Complicalions: DIC

@ Weak poirrl in lhgroid membranep @ Hernialion of Lung apex lhrough Sibson's

@ Cgstic swelling in the Neck @ Cgstic swelling in Supra-clavicular region
@ Becomes hominenl on Straining @ Prorninenl on slraining

@ Sile:
On one side of longue
@ ORIOIN: Sub-lingual gland iijglLuLtll iiy gaJJI , [l+JI ii 14rtr a
@ Cgstic, Translucenl Exlends begond the edges of lhe wound
@ Blood vessels ovel il, Mucous rnembrane @ Site : Face, neck, fionl of Chest &
@ Crossed bg Wharton's ducl abdornen
@ lf ruplured) Pass belween lhe Muscles @ Comrnon in Negros
io lhe neck (PLUNGING TYPE) @ Have inherited lendencg
@ Trealmenl : Marsupilizalion (deroo{ing1) @ Acule: 1';o; ) Chronic: Uirf.li

@ Pre-patellar : Housemaid
of the back of kna,rr
@ Occurs in rnidline
@ Olecranon : Sludenls
@ lf ruptures) Severe pain (DD : DW)
@ Over head of shoulder : Porlers
@ Over big toe : Bunion

@ Locallg malignani lurnor in a Mutipara fernale

@ Cornrnon with OARDENER $

Site:
I
@ ,
- Al site of previous sur$cal incision J
at
- From the reclus shealh, Rl >Li
. NEVER IN MTDLINE
@ Best invesi'rtalions : MRI
@ Treatmenl:
- Surglical excision with safetg rnargin 2.5 cm *
Post-operative radiolherapu lo avoid recumence
 ilRq*TwN5 ?h Y I E
'NDoCF[.lVflR{1W

Acuie Bacterial Sialoadenilis

Salivarg slone
Salivarg fistula
Salivarg turnors
 5er4-Twt5 hlpoC^RNE 5WW ?Aqv | @

Sffi inflammation of salivarg gland (PAROTID)

* Organism ...... STAPH , pneurnococci

.r Predisposing faclors... Posl-operalive dehgdralion, Poor Oral hggiene, Obslruction bg Slone
& Route of infections ......Direcl from lhe mouth, Blood born.

HECTIC fever , T
* Severe pain on side * Gland:
of the face . Enlarged
* fon ealing or on . Firm, lender
ingeslion of lernon . Raising, lobule of lhe ear (Don't wail for fluctualion)
or acidic iuice * DUCT is inflamed * Duct) Erudalion of Pus

.r GENERAL.... Chronicilg , Baclerernia, seplicemia, Pgernia, Toxemia

* LOCAL... Slone, fistula

* CBC: 4ILC, 4EgR, ACRP

* c/g
* Plain X-rag) 9TONE

.r Prophglaclic ..avoid PDF faclors

* General) Resl, Analgesics, Antipgretics, Anlibiotics :OConcenlration in saliva)
* ... ,;J,; g figif+a 6rii Lrs pgrp Ulroi 6-0r:
l)
Blaire incision under G.A.) Hihon's lechnique ) C&S * Drainage
Suroical drainaoe of subrnandibular Abscess:
l)
lncision 2 qn parallel io lower border of mandible below& infronl of angle of
mandible )Helton technique
* *
2) Complicalions of draina!e.... Fislula Facial N. injurg Freg's post-operalive $

Condition following surgerg or injury of the parolid gland or fMJ

PAIHOGENEBIS: Cross regeneration of Parasgmpathetic &
Sgmpathetic fibers
CLINICAL PICTURE: Flushing, Sweating of Skin innervaled bg
Aurieulolernporal N. whenever salivaiion is slimulaled
 xRq,-Tw.J5 rNDocF[.], *R@l ?AqY I bl

lncidence
. Submandibular > parotid (50:l)
- More viscid secrelion , 40oncenlralion ol Ca*z
- Ducl ascends upwards ... lnadequale drainage
- Ori{ice lies in lhe floor of moulh ... Could be blocked
faclors
. lnfeclions(ex: Chrcnicsialoadenitis)
ofren's $)
... MAINY ASYMPTOMATIC ...
. Episodes of pain afler eating followed bg relief in the side of Face

. Submandibular slone (radiopaque)) appear with x-rau (Closed mouth)

. Parolid slone (radiolucent)) appear with Sialographg
. U/g) Echogenic stone * acousiic shadowing
frealment
Submandibular )submandibular sialo-adenectomg
Parotid Gland )
Superficial conservalive PAROTIDECTOMY
glone in Duct) according to place:
l) Slone from ori{ice of Parolid Gland) Mealolomg
2) Blone in ducl) Removal under loca! aneslhesia
3) lf Recurrerrl) Submandibular sialo-adeneclomg

@ Ett"t"gs;l
- Trauma, inflammalion, Neoplasm
@-IUGI
- Exlernal) requires TTT
- lnfernal) requires no TTf
Clinical
. lF EXTERNAL) Waterg discharge from opening * Eczema of skin around opening
Trealmenl
T Submandibular fislula) submandibular Sialo-adeneclomg
I PAROTID GI-AI{D
- CON8ERVATIVE: Parasgmpathetic drugs for I week
- Avulsion of auriculolemporal N. or superficial conseryalive parotideclomg
- lf fails) fotul conservalive parolidectomg
PAROTID DUCI:
- MAS$EIERIC) Excision with end lo end anaslomosis
- PRE-MA$8EIERIC) re-implanlalion of ducl in Buccinalor
 4ilP.14:loN5 A'DoCxhlE 1,,Mh#}l

r 4Gland size ...flumor

I VGland size ...4Malignancg
I Mosl lumors are BENIGN
a More common in parolid

I MUCO.EPIDER,MOID CARCINOMA
(Wharton's lurnor). (Adenolgmphoma) . Mosl common lgpe
(Papillarg cgsf-adenoma-lgrnphornalosurn) . Sheers of Columnar + squamous epilhelium
ADENOID CYSTIC CARCINOMA
ttr
2T at tvt [0 rt [l) rvl tll iI 2 I ] . Most cornrnon rnalignancu arnong Minor
ll tI lrttll 117t ,l I
salivarg glands
lncidence lOTo ol Parotid lurnors,
I
More comrnon in Males
Old aEe, smokers (Mgo-epithelial + epithelia! cells)
Macro. Mullicenlric * lncomplele Capsule Cgstic, encapsulaled lumor ACINIC CEIT CAR,CINOMA
Micro. Epithelial cells * rnucinous rnalerial Colurnnar eoilhelium * Lurnohoid lissue . Serous acini, ONIY lN PAROTID GLAND
Malignancg . Benign .. Malignanl lransformalion ADENOCARCINOMA ...
Bad prognosis
occurs after lO uears (rare in 2-3%l CAR.CINOMA EX.PLEOMORPHIC ADENOMA
c/o Painless, slowlg growing swelling in the side of lhe face UN DI FFER.ENIIATED CAR,CI NOMA
Sile Parolid )Superficial parl Parolid )
Superlicial parl,
M
Size Variable Sgrnploms
Shape lrreqular . Pain: Awith maslicalion
Surface Lobulated . Swelling on the side of face
Consislencg Firrn or cuslic.. (NI:M:EIElIl-rl m . Dislurbance Of funclion .... Facial N. palsg
Mobililu freelq mobile Signs of rnalignanl turnor ... SWELLING
Special . Firm lo hard
characler . lrregular, Nodular surface
lnvesligalione . CTscan I Cfscan . lll-defined edge, lnfillralive lo skin, vessels
. Tc99 ) COLD spol (Avascular) I Tc99 ) HOT spot . LNs **
. Free needle biopsu
lnvesl'rgalions:
Trealrnenl SURGICAL ITI ....( see Ialerl Conservalive supet"flicial parolideclomq . For diagnosis) fc99 (COLD) + Biopsg
. For staging) CT, FNABC
 ilR+-TWr5 ,N90C8N' *fr@l ?hqv I v)

PARTID GLAND: IF OPEMBLE:

. Superficia! conserualive parotidectomg . Total radical parctideclomg
. Tolalconservaliveparolideclorng . folal block disseclion of neck LNs
(preserualion of facial N.) . Posl-operafiveRadiolherapg
gU BMANDI BUI.AR GI.AND GLAND: IF OPERABLE:
gubmandibular sialadeneclorng
3 nenes could be injured:
l) Facial N. (Ceruical & mandibular Br.)
2l Lingual N. COMMANDO OPERATION
. Tolal radical submandibular
sialadeneclomg
. Hemi-mandibuleclomg
PARIID GLAND:
. . Block disseciion of LNS
Buper"{icial conservativeparolideclomg
 5,R4-TW'V wu[r*N?ilRhry ?hqv I b+

t. Lipoma is a universal lurnor.

2. Plexiform Neurofibrornalosis NEVER affecls
TR,IGEMINAT NERVE
3. Branchial cgst is best differenlialed from cold
abscess bg conlaining cholesterol crgslals.
4. CYSTIC HYGROMA can be the EARLIEST
$WELLING OF THE NECK lo appear in life.
5. Cervical LNs are "300" oul of the 80O lgmph
nodes in the bodg
6. T}MOGTOSSAL FISIULA:
-
MaU follow infeclion, inadequaie remova! of lhgroglossal cgsl.
- lt
is lined bg columnar epitheliurn and never be congenilal
Thgroglossal cgsl Mag be presenl in ang part of the thgroglossal fracl.

t. MNUTA is lhe MOST COMMON indicalion for rernoval of sublingual salivarg gland.
2. Mosl cornrnon salivarg lurnor is PLEOMORPHIC ADENOMA
3. Mosl comrnon sile for acule baclerial sialoadenilis is PAROTID OLAND
4. Sjogren's $ affecls 4 glands) 3 salivary (submandibular, sublingual, parolid)* Lacrimalgland
5.

' ll's Stones are lhe . lf's Slones are lhe . EOTI of sativarg slones arise
MOST OPAQUE MOSI MDIO-IUCENT from Submandibular Gland
' lt's secrelions are . lt's secrelions are lhe . Gland secrelions: Viscid
mosl MUCINOUS mosl SEROUS + ACalcium concenlralion
. ll has lhe TEAST . ll has MOSI IUMOURS . Ducl ascends upwards:
TUMOURg . ll's lurnors are Most Orifice lies in floor of rnoulh
. ll's Tumors are mosl BENIGN
MALIGNANI
 ww/Pw1frqw ?hqv I 6
l. Middle aged male or fernale complaining of
painless swelling in shoulder accideniallg
discovered. Clinical exarnination shows lhal it
is lobulaled and attached lo skin bg mulliple
poinls but mobile over deep slrucfures.
Sttbcttanarc lrpna,
2. Palienl complaining of lim painless swelling in the forehead 't have a slipperg edge.

Sfu filtU lryna,

4. Palienl presenled with painless swellings lhal move onlg across lhe neFves of gradual
onsel slowlg progressive course associated with dark brown palches on lhe back. Ihe
patient lives positive familg historg to lhe same condilion.

Qeteralful ilerofibronatosrb Ylil fuklrhg llatset s dbasd.

5. ChiH presenls with dark puryle lesion not raised above lhe surfiace. Pressure causes
blanching of the color. Molher sags that if's presenl since bidh.
Pofi fftrle stam
Adult male presenls with slowlg growin! painless subculaneous swelling wilh black
spof. On squeezingil discharges sebum.
Sebaails cyst
Female patieni arcund 2O gears old presents with a slowlg growing painless swelling at
lhe laleral side of lhe uppel part of lhe neck protruding benealh the anlerior border of
sternomastoid .

Bratcltra/ cyst
8. An adull male presenls wilh painless swelling rnostlg al lhe dorsum of the hand, lense,
cgslic, rounded relaled lo a tendon and its mobilitg decrease bg pulling on lhe lendon.
SrnVh ldrdtotl
9. ltlewborn presents wilh large single cgslic swelling al poslerior lriangle of lhe neck.
Trans-illuminalion lesl is posifive.
6yshb lrygrona,
lO. Patienl presents wilh cgslic, bluish ,translucenl swelling wilh prominenl blood vessels
on ils surfiace on lhe floor of the moulh.
foMa

t. Adult male C/O of painful swelling in the sile of lhe face, Awilh lernon ingeslion.
.+xte Baterral shlo afuiitrb,
2. Adull male presenied wilh painless slowlg growing swelling in the side of lhe face
elevaling lobule of lhe ear. On examinalion lhe swelling is irregular, Iobulated, freelg
mobile, no ceruical LN enlargemenl.
PlnuaVhrb d&tllfi/a
 ?ifr+IwJ6 6lD0CFt'1tr lrRqBY ?hqv I b

I Give an explanalion : Slones of lhe Parolid salivarg

gland ate rare and less cornrnon than lhose of the
subrnandibular salivarg lllands
(Kasn 2@n
I Salivaru neoplasrns
( Kasn 2d/ )
! Manalernent of salivaru slones
( r4ilarf'2W )
r Managernent of paroiid abscess
(Kdsr'2M )
r Liporna : fgpes, Diagnosis, TTT
Kasr, ZO@,Au shans,2@4, r4lur rl/, ZooZ)
r sebaceous cgst : Cornplications, Pathologu,
Manalernenl
Kasn 2@Z Ail siaills,2005, ,4y'tar f, 2@Z 2@4)
r Derrnoid cgst
( ,4trar f,2@6, ,4y'tar;,29p( )
I Cgstic hggrorna
G4h siafils,2M)
r Neurofibrornatosis
O+i/ sfiafils,2M )
 1Rq-TWr5 A{DoCFhltr XMW ?hhv t 10
a
a

Definition aaaaaaaaaaaaaaaaoaaaaaaaaaaa

iologg (Org, PDF, Roule

* Organisrn ..................r........
* Prgdisposin! factors ....t........ . Definition
* Roulg of infgctions ... . ... .. . . .. . .
. Etiologg
. Palhologg
. Clinical piclure
* Sitg .................r.... . Complicalions
. lnveslitalions
* Patho gngSJS
a

......................

HECTIC fever , Tachucardia

. Pain: Dull aching then . Swelling) Hot, red ,lender
Throbbing . LNS) Enlarged, elastic,
. Swelling of lissues lender, Mobile
. Loss of function aaaaaaaaaaaaaaa

a
Cornoli
* Genera! >Baclerernia, seplicemia, Pgemia, foxernia
* Loca!: Chronicilg, Pus loculus, Spread
lnvesti
* CBC )Leucocglosis in mosl of infeclions
* c/s
* Plain X-rag
* lnvesligations according lo sile...
D Trealrn
* General) R.A.A.A... Resl, Analgesics, Anfipgrelics, Antibiolics (AUGMENITN)
* Local
I Hol Fornenlalion
I Aclivg lrgalrngnl: ...................
 SJRq.-TW]'S rNDoCFX.ltr ilRhw ?hqv I ?r

Definition ... Localized suppurative inflammation

iolo{u (OTI- PDF, Route
*SKIN, ABSCE$S) Sraph (coagulase *ve), ABDOMINAL ABSCESS> EOoli.
NECK
* PDF) Bad general condition, Slasis, Bad hggiene
* Roule ) Direcl, Blood, Lgrnphatics, lhrough nalural Passages.
Peripheral zone) rSlrlro!
Hgperemia

lntermediale zone)69!5 ff '(J ra

Granulalion tissue
Cenlral zone) 6+rh? iiJ{io
Mimo-organisrn# dead WBCs

CP (Sgmptorns,

. Pain : Dull aching) Throbbing, . $wellinS) Hol, red ,lender

V bg elevalion of the part
. Surelling of lissues
. Loss of funclion
tale fluctualion
O Breast
Special signs according to tgpe : O Proslale
Breasl, brain(4l0T), Lung (pus on poslural drainale), o Parolid
Liver, peri-nephric, Sub-phrenic , cold abscess O Perineurn
o Pulp space
icalions
* General ) Bacferemia, septicemia, Pgemia, Toxemia
* Local :
@
@ ANTIBIOMA
@ Chrcnicitg, Spread, Sinus, Fistula

& CBC ) Leucocglosis

* c&s
* Plain X-rag, CT scan, MRI
(According lo site of abscess) :: INCISION & DRAINAGE ::
O Under general aneslhesia
O lncision )(long, dependenl, never crosrs a skin
* TTT. Of Predisposing factors creaser parallel lo imporlanl Slructures)
* General)Resl, AAI (flugmenlin) O lntroduce {inger lo break ALL septae
O Packing for 48 hours
* Local O Dressing everg dag unlil co@
. Resl, Hol Fomeniation ) @
OFor importanl strrtfur"*
. lncision & Drainage .................
. tf Amoebic liver abscess, Brain, Cold abscess )
Aspiralion
. Chronic abscess: tf Thin walled) lncision & drainage , !Ilh!g@!!gd) Excision
 xfrq-Twr5 E{rccFhlE ilPAW ? Aqv I lt
I

Non suppuralive infeclion of loose Non suppuralive infeclion of

Conneclive lissue :qD dllrh s r+ppi Superficial Lgmphatic vessels r)A>i
olal\ rEonn oiVeubtq o:qp q d\irJ\

OENERAL)FAHM .... LOCAL)Pain, swellinq, disturbance of funclion

o Tender O Firg red swelling in face &
o Duskg red exlrernilies
o Hot area wilh induraled edge
o
* Post-strept GN (after skin inf.) Seplicemia *
* Scarlel fever *
Facia! ergsipelas) Cavernous
* slRs (coMMoN coMPIcATloNs) sinus lhrombosis
* Lumphederna, R.heurnalic hearl *
Recurrence) Block lgmphatics
A/M + Rest *Hol fomenlalion
Palient is isolaled
( lf no response >48 hrs)euspecl abscess ) (As disease is highlg contagious)
Give Erulhromucin if Pl. is

Infeclion of ) Perifolliculilis
ORGANI$M: Slaph. Aureus ..()Nemoloxin)

ciultrn iln: (Boil subsides leaving thick indurated arca)

TREATMENT) lmprove general condilion (Control DM,

*
nulrilion, Vitamins) + MA Resl, fornenlalion
- Antibiotics )
Flucloxacilin or(Augmenfin)

I
o ORGANISM: Slaph aureus) Necroloxin )lnfeclion of SC lissue
o
o
o
ffi [ffi :HHl
PATHOIOGY:
:,X,I'lii#li'mn
lnfeclion slarls in follicle)
hair Spreads to SC fissue)Loculafed abscess
) Each bursl on Surface individuallg
o CIINICAL PICIURE: Multiple puslules appea? on surface
o COMPLICATIONS: Chronicilg, CAVERNOUS SINUS IHROMBO$I$
o IR.EATMENT: - Resf, AAA (Flucloxacilin), lrnprove leneral condilion
- lf Pus is formed:
.
.
.
'
Cruciale incision& Debridemenl of necrolic tissue
Glgcerine Mg sulfate lill sloughing occurs
Dressing until healthg lissue is fomed
Skin Graft
E
tirlt+f
 cJ'JF.q-Twr5 ,NDocElNltr IJRqW\ ? hqY I 71

ffiNq
)EFINITION:
DEFINITION:
O Bilaleral diffuse Cellulitis of floor of mo
)RGANISM:
ORGANISM:
O Mixed infection (e.g. SIREPT... moulh
TOUTE OF SPREAD:
ROUTE
O Due to Direcl spread frorn infecled
of longue or submandibular sialoade
CLINICAL
)LINICAL PICTURE:
,?\ ,.t/ar \n^..^-^
O J..^-L^r!^ O- h..^--^
C/O)Bevere dgsphagia & Dgspnea, surrtruarru,r
o o/E:
-CERVICAL: Swelling in submandibular region
EI{TiERGEilCT
TREATMENT:
O EARLY)massive doses of Antibiotics (Amoxicillin,
Melronidazole), Resl in semi-sitling posilion
O SUBMENTAL CURVED incision of skin & Deep fascia
O TRACHEOSTOMY if needed

DEFINITION:
O Nemosis of a nail edge which is embedded in skin
& SC lissue of nail sulcus Betrore

ETIOTOGY & PATHOLOGY:

O Sile : BIG TOE
O Etiologg : Faultg nail lrimming, wearing lighl shoes
, Nail abnorrnalities as Hgpercurved nai!)
IREATMENT:
CONSERVAIIVE
O Gauze soaked in anli-seplic lo separate Nail {rom Nai! bed
O Correct trimming (square trimming)
O Avoid tighl shoes
O Keep fooi clean & drg
OPERATIVE
O DEFINIIIVE IREATEMNI) WEDGE EXCISION
O Excision of Nail with periosleurn
O lf Heavilg infecled ) Left lo hea! bg 2rg inlenlion
 1fr4=Tw\5 hlD0cB[lpf/,M@ Th 17+

rtal mrF F
r)
I

Definilion Acule speci{ic infeclion leading to 4 Acule specific infeclion leading lo spreading of
nervous excilalion due lo release of gangrene wiih excess gas formalion
neuroloxin.
Organism Clostridium fetani : CI.WELCH ll (Sacgharolqticl,
.Gram *ve Ct. HI$TOLYTICUM (Proteolulic) :

'. An-aeorbic . Gram *ve

Spore forming . An-aeorbic
. DRUM STICK aDDearance . 9pore forming
Secreles Neuro-loxin . Secreles Aloha-foxin
PDF . Aorganism contenl ) Conlaminalion in {ield & slreels s>\io
. VO2 conlenl) Deep laceraled wounds, lschemic limb, shock, Compadmenlal $

. Lack of proper sierilizalion of cal gul & inslrumenls p\il\ qe aibAl

Roule r) WOUNDS, endogenous
2) Posl-operalive ielanus
3) Telanus Neonalorum
Pafhologg: Oroanisrn release EXOT0XIN: . SACHCAROLYTIC GP.)
. ANTI-CHOLINE ESTR.ASE) fonic acls on CHO of dead muscles) Gases)
rigidifg of muscles at NMJ Elevale sarcolernma) Cul blood supplg
.
OExcilabilifg of motor neurons . PROIEOLYTIC GP.)
al AHC) Clonic conlraclion acls on Proleins) Arnmonia) H2S) mix
.
LOCAL) Minimal inflammalorg wiih lron of Hb) IRON SULPHIDE "Black
reaction. color, Bad odour"
. GENERAL) RBC hemolusis, de(eneralion
clP..
IP l-21 dags l-2 dags
gYMPTOMS . General) FAHM (low grade fever . General )
FAHM (slighl fever or even
excepl during convulsions) subnormal femperalure)
. Local )
pain, swelling, dislurbance . Local) Pain, BIack swelling wilh offensive
Of funclion (Convulsions) odour, loss of funclion
S!GNS GENEML: GENERAL:
Slage of lonic conlraclion : Jaundice, MOF
IEG, Risus sardonicus, LOCAL:
.
Opislhotonus, dgsphagia, dgspnea, Wound crepi+us, Black color, foul
slridor odour (Burnt sweel or Spoiled eggs)
Slage of Clonic conlraclions: . Sulures appear afler lension
Clonic Spasm on lop of tonic . Loss of sensalion & Ms. conlraclion
spastic muscles
LOCAL) Red, hol , tender wound
Complications MORTALIW 45% MORTAUW >25%
. Hgperpgrexia , Exhauslion leciihenase is lhe mosl dangerous loxin
. Asphuxia, ResDiraloru failure & HF Severe loxemia, MULTI-ORGAN FAILURE
!nvesl'rgalions . Smears from Wounds) organism . cT, MRt (THE BEST)
' Organ profile, ABGs ' TLC ) Leucopenia, anernia
. CBC) Leukocglosis ' 4Bilirubin
. CSF) Normal . Smear from discharge
. SPATULA TESI .. bed-side test . Plain x-rag) fissue gases
 ? h{qV I 75
OFffi

r) R.esuscilation & Moniloring

l) $kin incision 2) lsolalion in dark roorn, Nulrition bg NG tube
2) Open Deep fascia 3) RESPMTORY PROBLEMS) 02, lracheostomg
3) Ms. Debridernenl
4) Wash with H2O2
5) lf <8 hrs) Close skin looselg wilhout deep fascia
6) lf >8 hrs, excess necrolic tissue or heavilg
conlarninaled) wound is lefl opened .. lnjected in the proxirnal porlion
eutralizes circulaling loxin
2)

. Conlrol of convulsions bg Valium, barbiturales

Patienls who is
previouslg immunized in
the last lO gears
v r) lnitial dose (O.5 ML)
Give Boosier dose of
lelanus loxoid (o.5 ml lM)
. ln severe cases > VENTILATOR.
. Conlrol of Hgperpgrexia bg Cooling
Tetanus toxoid
IIG (25O units lM)
2) 2 doses given with 4 Cornplele . Vaccinalion bg DPT
irnrnunizalion course
weeks inlerval
anlibiolics
. 2,4,6 rnonths
. Booslet al 18 muscles
. HRG should be vaccinaled
everg 5 gears
 5)P.q=Tw)5 A.DOCXhIE A,EaW) ?Ahq t 7b

r) Skin incision r) Isolalion

2) Open Deep fascia 2 ) Resuscilalion & Monitoring
3) Ms. Debridernent 3 ) !V fluids . BIood lransfusion
4) Wash wilh H2O2 4
5) lf <8 hrs) Close skin looselg without deep fascia
6) l+ >B hrs, excess necrolic lissue or heavilg
contarninaled) wound is lefl opened
It's lhe least imporfant step
2) ... lO million lU/dag

T Sterile instrurnenls, sutures . Massive tgpe)H'Eh amputaiion above all a{fected

I lsolation rnuscles
T Polgvalent Anti-gas gangrene serurn . Localized tgpe)excision of muscles, dusling wound with
T
Antibiotics ... Penicillin G penicillin powder, drainage of wound
 xfrq-Tw.t5 ENDocFhlE l.M@l Aq I ? T1

Definition: Non-specific infeclion ihat follow surgerg or Hospital admission

tr Stah. aureus
tr MRSA
tr Sierpt.
tr tr
tr Age Foreign bodies Poor lech.
tr Enlerococci
tr tr
tr Pseudornonas
tr Obesiig lschemia Long time
tr Malnulrilion tr Hemalorna
tr lnrrnuno- tr Unlidg wounds
cornpromizalion

@ lnfection < 30 dags afler

surgeru
. Pain . Wound : red, hol,
@ lnvolve skin & SC onlg
. Ewellin8 tender, wilh
. Dislurbance Of oozing pus @ Purulenl DISCHARGE
function: . LNs : Enlarled, @ lsolaled Organism
lender, elastic,
mobile

tr CBC) Leucocglosis
tr c&s

. Non-lraurnalic wound in Glf, uilnarg, Respiratorg tmci

. Risk o{ SSI <2%
. gurgerg inlo lracls with No significanl spillage
, Riskof 8Bt 2-5%
I Open aocidenlal wounds , Gross spillage from GII
I

ffi Perfioraied viscus accompanied bg high

Risk of 38! up lo 4OTo

g NO Prophglaciic anlibiolics in clean surgerg

V lN CLEAN CONTAMINATED) Aniibioiics are $ven 3O min. before skin incision
& Repeated intra-operative with insertion of FB (e.g. Mesh)
g lN DIRTY WOUND) Antibiotics are Curalive
g CUMIIVE TREAIMENT OF WOUND INFECTION:
- Drain, anlibiotics, Dailg dreesing
 ffi+Twr5 1a{iw*NY

Definilion aaaaaaaaaoaaaaaaa aa aa aa aaa aa

PDF, Roule
.r Organism:
* Predisposing factors )bad hggiene, bad general condition, manual
working, housewives
Route of infeclions

' SWELLINGS:
- Hol, red ,fender
. SWELLING: according to sile..
-Ederna al dorsurn.of hand . LNS:
-Pulp space )distal phalgnx Enlarged, elaslic, tender, Mobile
- Acule parongchia )Nail fold
. DI$TURBANCE OF FUNCTION:

Corn
* General )Bacterernia , septicemia , Pgemia , Toxemia
* Local : Accordin{ to tupe of infection :
/ Pulp space infeclion )Thrombos:s, Osteomgelilis
/ Acule parongchia )Subungual abscess
* lf FB is suspecled )X-rag
l) General aneslhesia
* tf recurrent )Blood sullar for DM 2l Bloodless field
I gl lncision al site of seleclion
(never cross skin crease,
BEFORE SUPPURATION AFTER SUPPURATION avoid rnidline incision in
.F Oeneral )
Resl, analgesics, lncision and drainage digirs)
anlipgedtcis, antibiotics , Hot 4) Rernove pus
Fornenlalion 5) NO DRAllllg) Tullgrass
* tocal ) 6) Drg dressing changed after
a) Posilion of resl lsl dag, lhen every 2 dags
b) Position of exercise if sliffness
 xMq-Twr5 E lDocFhttr lJkhw ?^qv 1 fi

DEFINIIION:
lnfeclion of lissues surrounding Nail bed

EIIOTOGY:
. Organisrn Baclerial Fungal
' PDF
Bad lrimming of Nail Hands frequentlg emerged in water
Thorn driven under nail ,!otl\ z\l tl>u\
>rd\.! J\ 6Nt
ClP:
' Sgrnploms General) FAHM Itching
, Signs
local) Swelling of Nail fold Nai! becomes Whitish

Genera!) Hectic fever, tach cardia

Local) ... Cgstic
, uellow & U-shaped
coMPUCATTONS
IITIVESIIGAII0NS Cullure on Sabouraud's agar
TREATMENT: As Scheme *....
rNCrSroN : tr Drgness of hand
tr Oblique at lhe anlle of nail Ouler tr Topical antifungal
fold, excision of lhe % of nail lf failed :
is all around
tr Nail fold is laid open & Nail
Exlraction

shaped from ihe cenler of lhe free

edge)

DEFINTTION: lnfeclion of space belween subungual epithelium &

lheir periosteurn
r ETIOLOGY: Prick benealh Nail
I
CLINICAL PICTURE:
-Severe pain, Litlle swelling
-Maximurn Tenderness) Benealh free edge of Nail
IR.EATMENT: Rernoval of small "V" From center of fiee edge of Nail
 cilR+-TCrIr5 END0CRNtr ffihW PA6h |&

1.1 "*

Conlents
l) Fat
2) Fibrous septae )
3) Food: D'rgifd arlerg) Thrornbosis) Osleorrgelitis
of ienminal phalgnx exeepl ils epiphgsis

@ lncideRce;
@ Etiologg )Prick
@ CLINICAL PICTURE: as scherne * ....
@ Cornplicalions )
Osleomgelitis of lerminal phalgnx excepl its epiphgsis
Treatrnenl: As scherne * ....
- Anterolateral ineision on lateral side of dislal 43 ot
distal phatgnx Or al point of maximurn lenderness
- For severe cases )Counier ineision
- For sequeslreclorng )
 w+tw'J5 a{DocFI{E 1.8@l ?AqY I a

sgnovial sheath ol >le 6i.

..uilie ,i>9>e!or>d
on l4i sgnovial shealh rf.
PUIP l8 FREE q6,gS\iili'Jt

.lniib\ a\oi3
shealh drrO "
op

CULDO$AC trri s t>i en a,ip

MDIAL BURSA
Ihenar spaceJl + $li .
IhumbJl0iilhe
lendon of flexor pollicis lonlus 5N c .
ULNAR BURSA
FID(OR REIINACUTUM d\oiA .
Aidlr\lnll oldihe$t .
Space of parona n o! FOREARM I >q,i .
Mid-palmar spacell re Jui .
Medial 4 lingers g\lllexor tendonjlSur .
tjtluj c FLEXOR REIIIIIACULUM Jt *llsr .
Space of parcnaJtop FOREARM

CLINICAL PICIURE: as scherre * ...

l) Tenderness over infecled sheath Especiallg
2l (affecled finger is semi-flexed with limitalion of movemenl)
3) SPECTAL STGNS:

) srTil.T?, q swelling
'rn,
of Little finler, Semiflexion
parl ot
dislal paH
rn, digtal of rcreari
forearrn &
2) swelling of fhumb,
(fenderness over infecled burcae belween lhenar eminence, distal
lransverse palmar crease & Hgpottnnar Me.) parl of forearrn

COMPLICATIONS:
$loughing of lendon, Adhesions, Osteomgelilis, arthrilis
TREAIMENI: As schenre + ....
fransverse incision over proxirna! Cul de sac Catheter ) Betadine )
l) UTNAR BURSITIS) lncision : Along radial border of Hgpolhenar eminence
2)RADlAt BUR8ITIS> Along Ulnar border of thenar erninence & Slop
proximallu 1.5 inch distal to the dislal eease of wrisl (to avoid injurg of
Molor branch of median N.)
 x*#l ?hEV I 6L

ht
hlDoc8hlE

o t*t & ?d web

O friangular region al base of lingers sPaces
(Dorsal & Venlra! surfaces) Connecled lo
O From Free border lo palmar crease
O Contain fal, vessels, neles, @space
lumbricals & irrlerossi.

3'd & 4h web spaceg

Connecled ro Elmai space

c[r$CArWrtrFE:
As scheme + ....

.. {ingers can't be approximaled

@rinrdtnorts:
As scherne + Spread to deep mid-palmar sPace & adjacent web space

ffi As scheme + .....

. lNClglON )Transverse incision over web space I crn from free mar$n
. ln severe oases )
courrler incision

s#l
O Anlerior{ )Palmar )
O hnterior | {lexor lendon of medial 3 {ingers
O lPosleilor l)Fascia coverin! inlerosseii
O lLateral l){ibrous band from palmar
irrlercsseii to 3d melacarpal
o MAla[gl) {ibrous band fiom palmar

As scheme + ..... (Obliteration of palm concavitg)

coMPUCAilONg COIIAR-STUD ABSCES9: 3 points ...

l-
8ub-culicular whitlow (loculue in SC tissue)
2- Leulus in superficial palmar space
3- Hole in oalmar aDDoneourosis conneclino lhem
TREATMENI . lncision: Transverse incision . !4p!q; Transverse incision over space
at line of oease ovel site of . Posilion of funcfion: semi-flexion of {ingers
rnaximurn tenderness . lf complicaled bV web space infeclion)
. HELTON's TECHNIOUE: Counter incision from web space
Palmar fascia is divided
 lJP.q-TW-t5 X,WW ?hqv t 81
^DoCR[{V

l. ldea! anlibiotic surgica! prophglaxis should start before skin incision and
conlinue for one dag after surgeru.
2. lndiscrirninale use of antirnicrobials can lead to the developmenl of antibiolic
resislant microorganisms.
3. The rnosl important cause of posl-operaiive wound infection is presence of
dead space.
4. Fournier's lanlrene is caused bg bacteroids, califorms & peptoslreplococci,
bul nol clostridia.
5. Bacteroids a?e a parl of norrnal flora of oropharunx, colon & vagina, bul nol
urinarg fracl.
6. The main organisrn of endotoxin release in multiple organ dgsfunction is E.coli.
7. The mosl cornrnon anaerobe in Colon is B. FRAGILIS
8. The rnost frequent cause of Endotoxic shock is E.Coli.
9. The mosl frequenl organ:sm associated with neck abscess in children is $laph.
Aureus.
lo.Adequate wound debridemeni is the most imporlant measure in management
of coniaminated wounds.
ll. Cenlral venous pressure {CVP} rnag be decreased bg Grarn-negalive sepsis.
12.CLOSTRIDIUM TEIANI: has a drum stick appearance, is slrict anaerobe, and
Produces h'rghlg resislanl spores.
l3.A palient who has recovered from lelanus requires a dose of loxoid
l4.Gas gangrene infection is caused bg anaerobic spore-bearing closlridia, has a
veru shorl incubalion period, Cornmon lo occur in deep wounds of lhe thigh,
but nol associaled with high fever.
ls.Trealment for clostridial mgonecrosis (gas gangrene) includes Adminislration of
Anlitoxin, Wide debridemenl, and Adrninislralion of hgperbaric oxggen
l6.The rnosl lelhal loxin of Cl. Welchii is LECITHINA$E (cr - loxin).
17. Fool infection in diabeiic palients is predominanllg caused bg rnixed
organisms.
ls.Midpalrnar spcace infection is mosl oflen due lo direct spread from inlrathecal
whillows.
l9.Ihe hand infeclion which carries the highest risk of osteorngelitis is distal pulp
space infection (felon).
 1fr+Tw'{f_ A.WCPhltr lRI#l ?hqY t e+

l. Patient complaining of lender, duskg red hol, non suPPurative area with
induraled ill-defined edge al medial aspecl of lhe leg. lnguinal LN are enlarged,
elaslic, lender, mobile.
Gelhlrtb,
2. Pallent oomplaining of tender, duskg red hot, non suPPuralive area wilh
indurated well delined edge al lhe face, slighflg raised
En1srplas,
3. Old patienl complains of suffooalion, severe dgspha$a, and severe dgspnea.
On examinaiion edema of the floor of lhe rnoulh, lhe longue is pushed upward
and bach,uards.
l@fi| I dtqttta
4. Manual worker presenls with $a,elling in nail bed. Dull aohing pain. On
examination nail bed is induraled gellowish cgslic.
,futepnilFlk
5. Youn! male cornplaining of neuosis of the big nail sulcus with persislenl
irrilalion of his nail.
hgnyyt tu- tarl @tyclrun1fiu H,
6. Patient farmer preienls wilh conwlsion. fhe relalives $ve hislory lo
severe
headache 12 hour ago. On examinalion the patient has a swollen wound and
severe pain al sile of wound.
Tetarus.
7. Palienl presents withdeep laceraled crush wound, lhe wound is black &
edematous with foul odour and waterg diecharge.

fias gdillroile,
 ilPq-Twr5 ww/PNYlMW lffi

of

Discuss Aetiopathologu , ClP and TTT of acute

Puogenic abseess
( Kasn 2d/ )
r Gas gangrene
( ,4r'tar f,2M- Arfl sfiams,zfu )
r ClP and TIT of Tetanus
b4th sllafils, 2d/ )
r Short account on : ergsipelas
sfiafils,2M
O+i/
I Factors affecting wound healing, cornplicalions of
wound healing
( r4lur)/,2M -r4ltarf,2M,2@5 -
Kasn 2@7 - Kasn 2d/ )
Genera! principles in rnanagernent of hand infection
( ,4y'rar f, 2@Z 2@4 - ,4y'rar ,il, ZooA)

Tenosgnovilis of lhe finlfers of the hand

G4i/ sfiafils,2M )
Managernenl Pulp space infection
( Kasr 2@7)
'
Delection of wound sepsis afler surgerg and ils
rnanalfernent
( Kasn 2@n
"(g I NY I |..Aqil6 alrd?ftlM grwY?ttrE
"v-

tUbhael
AAF tth .. Altr snrversrttt
 xfr+rw*1 6m,rhu xfr#ll ?hEv t *

r Polg-fraurna lized patienl

r Acute wounds
r Wound Healing
t Hernorrhagic shock
r llernomhage
 5R4-Twr5 dwUWlJRhW i ,ii I 81

INCIDENCE:
)r Mosl cornrnon cause of death among middle aged paiients
)1 3'd Mosf cornrnon cause of death among al! groups

resffioF .

Will die anuwau Will suruive ONLY lF theg WILL survive angwag
whether theg received timelg medical whelher theg received
received medica! al-lenlion in the GOLDEN medical altention or not
altention or nol HOUR, "{irst hour"

lf resources are Iimited ) YELTOW CODES arc lrealed {irsl L{

TRlr.iODAt DlsrRlBonohl ... re OF DEJtr+t -H

Within rninutes
Due to injurg to vital Due lo hemorrhage,
slructures or maior fraclures
 flJR+-Tour5 ENDo(xhlE ilPqW ?hq? | 10

OF
PffiEf.tr

HFJTDToTOE e><A.,ilNIFION
@ A: Airwag patencg & support mandible @ A: Airwag @ Head
@ B: Adequale breathing (look, feel, listen) @ fr Breathing @ Neck
@ C: Circulation ) Gonfrol ang bleeding @ Q Circulalion @ Neurological ...
@ D: Drugs "Analgesics" @ D: disabilitg @ Chest
@ f, Exposure @ Abdornen
@ Cover wound wilh slerile dressing
@ DRE
@ Avoid flexion of spine lo avoid dislocalions
@ Limbs

M ls patienl able lo speak or not? g $fiPleslsron#

EI Is airwag patent or nol ? sbg @ Allergies
aitwag , @ Medications
@ Past Medical Historg
!nspeclion - Palpation -Ausculialion @ Last Meal
gHOCK @ Event of injurg
(Hemorrhagic. cardiogenic, Neurogenic)
AVPU evaluation
OFGFitrlffiAFrB,
(Alert, voca!, Painful slimulalion , Unresponsive) EAslcuFE gJ'PFo'Fr
LAB : HB%o, Glucose, KFT, ABGs , PO2,PCOZ
a Foleg's ICalheler @
RADIOLOGICAL : X-rag ,CT ,MRl .U/g , Duplex
Resuscilaiion & moniloring ... d NG tubeI
@

g Radiolortical assessrnenl @ INSIRUMENTAL : Endoscopg, Centesis

T[{EN.. DEFINffi\'Effi&
 ilR4-Toqr5 a{DocRNr rlxt wt ?nqe t 7

W "GCS,,,
'-l :r^ arra,,-
S fu Ug'=F.lr aii+{ r-.llol'rll g r-llg,,iu
Ug
U+rirql plgl +Iiii 9 r.lLip

Orienfed, Norrnal
Exlension to painful stirnulus Flexion lo painful stimulus Flexion *
us$hll
Localize painful
drrSc sr$bll rr{Sr Withdrawal slirnulus
De-cerebraled De-corlicaled srt+ll

REsttrohlsE
Merarcud
EBB Pl{AgE l<24 hours)
)rOEnzgrnalic activilg & OZ consurnplion
ffil\IE
OSecrelion
E Lactic acidosis al tr Aldoslerone) 4Na, HzO
CATABOLIC Pl{AgE (g-to dage) reabsorplion
11 Fat, Prclein rnobilization rr CA) V.C., Tachgcardia
11 4Urinary Nilrogen excretion
AilABOtlC PHA8E (tO-eO dags)
tr ADH) H2O retention
trResloralion of Fal & prolein slores
!r GH, Prolacfin, ACTH
 AB+TUD{r, E\m,fbEAE#t

DEFINITION: Discontinuitg of ang bodg structure bg Phgsical injurg

os(

Due lo Heavg
arac
blunl lrauma
Due lo qi olerp Producing sevene
Due lo friclion pressure bg lissue damage
with a rough sharp object
oUui! lncision bg
blunt objecl sharp cufling Wound is Untidg,
object irregular
frealmenl:
(Clean, tidg devilalized edges_
Antibiotics
t Betadine cut)
anliseplic

.. See Orthopedics ..
Ecchgmotic skin patch Collection of blood
due lo btunt lrauma freatmenl:
Trealrnenl: o Fomenlalion (cold) Warm)
Fomentalion o Antibiotics
(Cold ) Warm) o Aspiralion if large
 ci,Rl4*TC0r5 ftlgpc*tlE ilRqWJ ?AqY I T
oFnlooxp
ENBAT
@lipucAnoNs
OF HEJUTNC
Hgpovolemic @ SPECTFTC
Septic (TB, gas gangrene) O Contracture
Neurogenic @ NON-gPEC!F|C O Chronic ulcer
(Seplicemia) O Keloid
@ Crush injurg Staph. Telanus
@ Compartmenlal $ Strept. Gas-gangrene O Disfigurement
@ lnvesligations : Pseudornonas O Lgmphederna
lr Hgperkalemia
* CK > IOOO U/L
*
Mgo$obinuria
Complicalions :
Acule renal failure
Trealrnenl :
B Resuscitation & Anti-
Management of Polglraum alized palient
shock rneasures
..(see before)..
n Alkalinization of urine
. Fluid
Management of Wounds
. Diuretics (lV mannitol)
..(see Vascular surgerg)..
. Vilamin K
fr Fasciotomg
 cilP+:fmr5 ENDOCFNV 1JPqW ?hq, I T

3J+JI
tito0lb
@ IRRIGATION WITH SALINE
@ PRIMARY SURVEY ... ABCDE ...
@ SECONDARY SURVEY
@ DEBRIDMENT
& Examination from head lo toe * Skin )Excision ol l-2 mm of edges
* Resuscilalion * Fascia )Fasciotomg
* lnvesligations * Muscles )Excision of dead muscles
t Moniloring * Bones ) Deconlaminalion bg cureltage

@ SYSTEMIC THERAPY
* Nerve )Mark wilh black silk lhen delaged repair
* Blood vessels ) (nT=!oni,.,,,,'u,Ir) Ligalion or repair
rr
* Skin closure ) According {o slale
Accordino to slalc of wound
worrnd

Closure withoul Delaged closure

Tension or gra$]ing

@ IMMOBILIZATION & POST.OPEMTIVE CARE

* Observafion
* Antibiotics
* Anti-letanic serurn
* Anti-Gas gangrene serum
 fuxp DEFINITION:

NfENTION: EsririrroJl r'S

fl/F4-ToohlS g{rucxlNE lJ?qw

NG,
Mechanisrn bg which bodg reslores integritg of injured part

t{EAtlNqSrAH: x4
?hh6 115

@ tidg wounds, slrong scarc

@ Seals l-2 dags INFLAMMATORY PHASE (lsf 4 dags)
Vascular response (hemoslasis * Vasodilatation)
@ Heals l-2 weeks
Cellular response :
@ Full power 3-6 Ms
Following bg Neulrophils, Masl cells
SECONDARY INTENTION: <lpral! r-r h Wound
tAG PHASE (3rd -Sth) Conlraction
@ Unlidg wound with gapping edges
Endothelium, Collagen , MPs
@ Weak scar tigfr ii+tr
PROLIFEMTIVE PHASE (sth -2lst )
@ Takes much rnore lirne Wound
Epithelial regeneralion
TERIIARY INTENTION: Granulalion lissue forrnalion (healthg, unhealthg) Conlraclure
.l.rLiGil Ufyfg Lir.#ai iir'i6 3i-i{ ii rfr rg ii?Lt
Conneclive lissue repair
Wound is lefl open for 5 dags then requires a Wound Conlraclion
delaged prirnarg sulure after being clean.
REMODELING PHASE (> Igear)
TUp" lll Collagen )Tgpe I
FACronS AFrECTING HEATI}G'
@rtlpucArloNs oF r{EArrNG,

@ TUp" of wound (Tidg. untidg) @ Age of patient

@ Site of wound @ Obesitg
lnfeclion, iijglUuLtll 1,i [r,Ul iir..rfil
(Wounds over flexures )lension) @ Medical condilions
hernalorna @ Scars
@FB @ Malnulrilion Dehiscence @ Hgperlrophic scars
@ Vascularinsufficiencg @ Medicalions
@ Keloids
@ Smoking
@ Marjolin ulcer
 wp.q-rw$ 1aJlw*Nexww ?hqY t fu

HE State of peripheral circulalorg failure due to sudden blood

loss or shift from peripheral circulalion.

V Blood volurne due lo :

fl Whole blood loss
g Plasma loss
g Waler & elecirolgte loss

g Delerioralion of
Phgsiological rnechanisrns A Mu[i-organ failure
To reslore blood volurne funclions of
Fail if blood Loss > 15% brain, kidneg,
Hearl, lung
(lf Treatment fails)

nGrunei,

OF COMPLICAIIONS

clo: tr Exlernal Hge tr Anuria

tr Weakness, fainling tr lnlernal Hge tr
tr Palienl feels Cold ,fhirslg ARDS
OlEz tr Burns
tr Altered rnenlal slalus tr lntestina!
tr 9BP, Weak lhread pulse, 9PP obstruclion
tr Hgpolhermia
tr Tachgpnea, air hunler
tr Skin becomes pale,
tr Capillarg refilling > 2sec
tr Oliguria )Anuria & Renal failure

ORGAN PR.OFILE DETECT THE CAUSE COMPTICATIONS

Exclude bleeding lendencg
f prJl lJt+3

CBC, ABG, Electrolgfes, PH,

tr Head CT scan
KFT. LFI tr Abdorninal US
 1Tr. OF
ilE+TW
ew A{poCXt\tE ilR(#l ?Aqv t T

ArHcFrrAt(td{r)
E ABCD
tr Airwag )patent E STOP HEMORRHAGE
tr Breathing )Mainlained E RESUSCITATION:
tr Circulalion)Slop bleeding tro/2
tr Drugs )Morphine lo relieve neurogenic shock tr RYIE )evacuale slornach
tr 3 ANII - : Anlibiotics, Anli-Gas gangrene, Anli-Telanic serurn tr LINE >2 Cannulas for fluid
E FIRST AlD replacernenl & Samplint
tr Elevalion of tegs ..
tr lmmobilizalion of fraclures
tr Warming

FLUID REPLACEMENT: MONITORING SUPPORT

tr Slart with Crqstalloids tr Viial data
Until blood lgping, cnoss rnatching are done "Pulse, BP, Ternp. Respiration"
t) Norrnal saline tr ABGs , ECG
2) Ringer (+K*t tr Urine Oulput
3) Ringer laclate (+ Buffer) tr Cenlral venous Pressure
N.B. : tr Pulrnonarg arterg wedge pressure
O Crgstalloids mag be given alone )Pf. with
Hgpovolemia due lo waler & Electrolgte imbalance
tot m oF cAusE
O # Glucose 5% )leads lo dilutiona! hgponalremia earlg delection of Lt side HF in tr lnjured vessel)surgical repair
tr Colloids: old pafients. tr Burns) fluids, wound care
l) Plasma subsilitues Arlerial Line )Monilor ABP, m OF COMPtlCATlOttlg
2) Dextran essessrnent of ABG tr DIC) fresh frozen plasrna
tr Blood ) in hemorrhagc Shock if HCI <gO 7" SECONDARY SURVFT
After stabilizafion..
 ilRq-Twr5 flW47NY 1'RhW ?hqv t r

Bleeding:
g Venous blood : dark, profuse
a Arlerial Blood: red, spurling, oscillaling
V Capillarg Blood: red, oozin! -ht
't'

Accordin! lo tirne of Hernorrhage:

g Prirnaru Hernorrhage : al sarne lime of operalion
g Reaclionarv Hernorrhaqe: within 24 hours
V Secondaru Hernorrhaoe : within 7-14 dags ... main cause is infeclion

Normal Sgstolic BP
ODiaslolic BP

Capillary re{ill
Replacemenl bg
Ringer laclale 3 times
delicit

MHernalocril SO %
g urine oulpul SOm7hour
gCVP rises lo lhe upper /z of norrnal range
lf CVP is risin! & Patient is NOT imprcvin! (Shock + zfCVP)
) search for:
a) fension pneumolhorax
b) Cardiac larnponade
c) Heart failure
frealrnent
l. $loD hemorrhaoe: (posilion - pressure - packia$ e.g.
- Elevalion of the limb above the heart level , Balloon larnponade
2.@Accordingtotheclassofhemorrhage...seebefore...
3. Optimize oru{en deliveru: 4O% oxggen is $ven for class ll and IOO% for classes Ill and lV.
4. General care of lhe patienl: absolule bed rest and analgesia
(Morphine is contraindicated in head injurg and in oases of respiralorg and liver insufliciencg)
5. @gI!Dg:
- Urine output, core lernperalure, hernalocril and cardiac moniioring
- ECG for earlg deleclion of shock-induced arrhgthmias is important).
- ln class lll or lV hemorrhage )
as above + CVP, ABGs and PH
 ilRq-Twr5 nDgcRNV il?4ry Thh'* I fl

"MOST SERIOUS WPE OF SHOCK',

,,MOST
DIFFICULT WPE TO BE IREATED"

ETIOLOGY:
Etr Or(anism: MOST COMMON ORGANI$M lS GRAM -VE BACILLI
E Source of infecfion: Perilonilis, Cholangitis, UTI
E Predisposin{ faclors: Exlrernes of Age, DM, Irnrnune-comprornisalion, Malnulrilion

CLINICAL PICTURE ... 2PHASES ...

. Reslless & confusion . SKIN) Cold, Clammg

. gKlN) Flushed, warrn, drg . VITAL DATA:
. VITAL DATA: tr Oliguria
x Fever >38 tr Sgstolic BP<90 mmHg
tr Tachgcardia tr lachgcardia
tr Tachgpnea 11 Tachgpnea
. . vcoP
^COP

$FS
(sYsTEMrC r NFLAMMATORY
g
g
Evidence of infeclion ... *ve Blood cullure
Refraciorg Hgpolension
+ Ang 2 wltefia of the following ...
RESPONSE SYNDROME) V Hgpervenlilation (RR,>20 breaths/min)
Etiologg: V ABG (PCO? <32 mmHg)
a ffir@ A WBCs <4000- >12,000 cd!s/mm3
g Polg-lraumalized patienl
g Major burn
g Acule pancrealitis
g Neglected hgpovolemia

CRITERIA FOR DIAGNOSIS:

a) Iemp >38c , <36c 80% MORTATITY
b) HR >90 bpm g MOF
c) RR >20 breath/min g Dtc
dl WBCs >12000 , <4000 lmmS

INVESTIGATIONS:
tr FOR GENER.AL CONDIIION:
tr CBC: 0TLC, V Platelets
tr ABG, Electrolgles, Blood sugar
tr FOR EIIOLOGY: lsolalion of organisrn, C&S, Localizalion of seplic focus
tr FOR COMPLICATIONS: KFT, LFT, ECG, Coagulalion profile
 ilRI4-T1a.t5 ,NDocE[.], ilRhw ? hhv I r00

TREATIVIENT.. ADMISSION TO ICU THEN ...

RESUSCITATION ERAD!CATION MONITORING

CIRCULATORY SUPPORI
OF INFECTION tr Vital silns
tr FTUID REPLACEMENT: E Urine output
RINGER LACIATE
tr Eradicalion of sepsis E ABGs, CBC,
tr DRUoS
E Parenieral anlibiotics Coagulation profile
(if Patient rernains HYPOTEN$IVE
despite {luid replacernenl)
tr CVP, Arlerial line
Dopamine, Dobularnine tr Prophglaxis against
REPIRATORY SUPPORT DW, slress Ulcers
tr O2 bg mask
tr lf PO2 < 60 mmHg
) Mechanical venlilalion
RENAL SUPPORT
Hemodialgsis in ARF
PROGNOSIS: 80% MORTALITY
DIC? Fres.h frozen plasma

ffiffioF
g
Cmuoqpt{CstlodK
MOSI COMMON CAUSE Ig MYOCARDIAT
INFARCTION
CtINtCAt PICIURE:
CONGESTED NECK VEINS + ACVP
TR,EATMENT:
g TTT oflhe cause
A Dobulamine (inolropic agent)
EI Most imporlanl lrealmenl of
Anaphglactic shock is lV

ffileSHocK
EflOTOGY:
hgdrocorlisone
M Mosl importanl causes of
. High spinal aneslhesia,, Transaciion of spinal
Endocrinal shock : DKA, Addison,
Mgxedema
cord
CLINICAL PICTURE:
M Ang prolonged hgpovolemic shock
. BMDYCAR,DIA
)seplic shock
. WARM SKIN
EI Ang prolonged hgpovolemic shock
. LOW BP
in elderlg )cardiogenic shock
 g
re
suruive in slored btood from
1JP4-Tw.t5 1a{lw*Nv lJRhRl

llfi
?hqv I u

Blood group mismalching can be accepled in LIVER lransplanlation

Donor & recipienl are onlg malched for ABO compalibilitg
a All componenls for slored whole lend lo Vovertime excepl Polassiurn
a Donaled blood should be roulinelg screened for Hepatitis B, C, HIV
g CMV is screened :n high risk groups (Ex: lC palienls)
g Best guide for blood transfusion in hernorrhagic shock is " CVP "

a
Transfusion of 2500m1 of blood
FEERITE a
al one lirne or 5000 ml or more
tr
over 24 hours
tr TTT : stop lransfusion, Anfi-hislaminic, Hgdrocorlisone

AII^BCICREACTIoN. fficAr
tr Delaged hemolgsis
tr C/P: urticarial palches up lo Iargngeal edema.
tr TII; Anlihislaminics & corlisone, slop the lransfusion. tr Post-lransfusion purpura

HEitolr/rlcREAcrloN: tr a-lron ovedoad (Hemosidrosis).

tr ETIOLOGY: lncornpalible blood transfusion tr b-fransmission of diseases as:
tr CLINICAL PICIURE: . AlDg.
. Brucelloeis.
. CMV (Ihe MOBI C0MMOttl)
Fever & r'lgors . Fever & rigors. . Malaria(onlg bg RBCs)
Chesl, lurnbar pain. . Hgpolension, Tachgcardia. . Viral hepatitis.
Dgspnea. . Cganosis. . Sgphilis.
Headache. . Ol[luria.
. Renal failure.
tf patient is under anesthesia or comatosed
lncompalibilitg is suspecled bg:
. Bleeding tendencg (oozing of blood) trWHOtE BLOOD: Hernorrhage,
. Progressive uneplained hgpolension, fachgcardia. operalive replacernenl, severe
tr TREATMENT: burns
. Slop lhe transfusion irnmediatelg. trPACKED RBCs: severe anernia
. lV fluid(ringer laclale* corticosleroid). trPI.AIELETS:
. Alkalinizalion of urine bg NaHCoS
I'u or 2's lhrombocglopenia,
. Mannilol20% l0O ml (forced alkaline diuresis).
platelet dgsfunction
. Repeal palienl's blood lgping & matching.
trFRESH FROZEN PLASMA:
Noll+M burns, rnalnulrilion,
coagulopathies
Complication of maseive blood lransfusion
. Acidosis, Hgperkalemia, Circulatorg overload, trCRYOPR,ECIPITATE:
Hgpothermia, Cilrale toxicilg, Bleeding lendencg hemophilia, DlC, Wt/D
Z-Ait embolism. TFIBRINOGEN: DIC
3-Thrombophlebitis at the site of injeclion. trLEUCOCYTES: Severe
4-Complicafion of lranefusion of stored blood leucopenia, Agranulocgtosis
Acidosis, Hgperkalernia, f O2 affiniig
 lJRq-Taq'$ E{Docxhly XMR'I ? hqv I WL

r Hernoslasis
r Bleedinlf disorders
r Bodg Waler
r Sodiurn, Potassiurn, Calciurn
r Acid base balance
r Nutrition (Enieral, TPN)
r Posl-operative cornplicalions
 cilRt4-Iwr5 A{D0CEI{E IJP^W ?AqE t w

Cornrnon pathwag:
EI Vilamin K is essential for aclivation of
V Faelor l, 2,5,10, l3
g Assessed bg PT, PTT
Factor 2 ,7 ,g ,lO
Iheg are prolonged in Liver disease, Vitamin K
Exlrinsic pathwag:
g Faclor 7
rnal-absorption (obslructive jaundice)
g Assessed bg PT
M Cournadin effect can be reversed bg Vitamin (
M Anti-thrornbin 3, Pr.otein C, S, Faclor 5 leiden
V Affects Oral anfi-coagulanls
have anli-coagulanf effecl
V Prolonged in Liver disease,
(Measured in a recurreni DW in a goun! patienl)
Vilamin K malabsorplion
(obslruclive jaundice)
tnlrinsic palhwag:
g 8,9,11,12
g Assessed bg PTI
g Affecls Heparin
lnlrinsic pathwag
tr I
Half-life of factor is 8 hours ogq ++lJl
tr Mosl cornrnon cause of defeclive
hemostasis is fhrombocglopenia

CLOTTING CASCADE:
O 4BT (platelels) , 4PTT O INTRINSIC PAIHWAY
O EXTRINSIC PAIHWAY

o Long acling
o acls on factor Xa Wthin few Within few
minules seconds
o Given once dailg
o Eliminated via kidnegs
o Causes no bleeding lendencg:
NORMAL PTT(better in
vil
tx vil
xt
Reduce lhe concenlration
xil
Vitamin K dependent clofting
INTR!NgIC EXTRINgIC
faclors
Half-life : 36 hours PATHWAY \. PAIHWAY
Crosses lhe placenta (Should be ^'
avoided in pregnancg) v
Doses should be reduced in Liver
disease
lt (Prothrombin)
Controlled bg lNR, (aboul 2-3
! (Fibrinogen)
iirnes double the norrnal value)
xlll
 lRq,'IWr5 A\$gCRtl, flRqW ?AqY I w+

NG,D
g Deficiencg of faclor 13) A , Faclor 9) B
g Sex linked
g Bleeding during circurncision
g Posl-lraurnatic bleeding (e.g. Hemo-arlhrosis)
g INVE$TIGATIONS: value of faclor = 5-2OTo Normal value
g TREATMENT: lnfusion of deficient facfors, FFP, Crgoprecipitate
!M lnjeclions ::

g De{iciencg of Factor I
, Aulosomal dominanl
d CLINICAL PICTURE: Echgmosis, Purpura, Bleeding from orifices
g INVESTIGATIONS: ABT, 4PT, APTT, De{iciencg of factor 8
a TREATMENT: lnfusion of Deficient VW factor

V Mosl cornmon cause : SEPTICEMIA

g CtlNlCAt PICTURE: PARADOX.. Thrombosis Bul bleeding rnag occur
g INVE8IIOATIONS:
-VPlatelels, 4PT,PTT, VFibilnogen, 4FDPs
V IREAIMENT: TREAIMENT OF UNDERLYING CAU8E, FFP, ugoprecipitate

REJECIION LIVER TRANSPTANIATION

Chronic reieclion is the
g lndicalions :
a) Primarg sclerosing Cholangitis
[[[![[[[p[fupeof rejection
b) Biliarg alresia
Hgper-acufe rejeclion is rnosl cornmon
in lransplanl of KIDNFf c) Fulminanl hepatic failure
g Acule rejeclion occurs within 6 months d) End stage liver disease
a Chronic rejection occutts in the form of lschemic
g
secondarg Hepalitls B,C
Hgper-acuie rejeclion is almost I\IOT
librosis
PREgEItIT
g Acute rejection occurs in 30-50 % of
palienl, reversible is possible bg
sleroids
V Chronic rejection is irreversible, needs
re-transplanlalion
g ABO malching is a musl, wtrile HtA
malching is nol a musl
Irnrnune-suppressive drugs:
g Cgclospodne inlerferes wilh
produclion of cgtokines
V OKIS ie more sneci{ia
 lRq-TwV 1a{lwC*NY,',RqAl ?hqv I w

Total bodg waler = of Bodg weight We1

rcF (As) EcF lt/3)
40% of adult 20% of adult
bodg weight bodg weight

lnterslitial fluid lAq Intravasoular fluid (t/g)

lO% of adull bodg weight 5% ol adult bodg weight
Waler balanoe is maintained bg adjusting waler intake & waler loss..

LOgS

. lnsensible water loss (t2Oornl)

- 8oOml)perspiration lhrough skin
EXOGENOUS ENDOGENOUg - 4o0ml) Expiration through lungs
(2500 ml) (soO ml) . Urine (l600rnl), 0lT (2Oornl)

M Osmolaritg of BLOOD depends on PROTEIN

M Osmolaritg of ECF depends on Na, Cl, HCO3
EI Osmolarilg of ICF depends on K, Organic phosphorus
.BODY O$MOIARIW = 300 mosrno7Kg ..(Double Na leve!)
'ADH is conlrolled bg Plasma osmolarilg , ALDOSTERONE is
Conlrolled bU Na*, K+, Renin

. VTNTAKE:
- V availabilitg
- Difficullg to swallow
. AOUTPUT:
Fever, Osmolic diuresis
rlprallEpJiir
fhirsl, weakness, Oliguria
Hgpoiension, Tachgcardia
. AINTAKE:
- Pre-operafive waler enema
. TURP $
- Posl-operalive over infusion of Glucose 57" lV
- Neurosis
MODEMTE: 4udne volume, OBodg weight
MARKED: Brain edema, Nausea, vomiling

TREAIMENI R.eplace bg Na free waler .MILD TOXCITY: V waler inlake

.BEM!IA!!!!BE Dialgsis
.EBA!UEDE@, Mannilol, Cortisol,
Hgpertonic saline (lf lhere're CNS
manifeslations)
 crffi4-Twfi ww*wflMw ?Aq I ttu

g Major exlracellular calion

V Normal leve! " 135-145 mEq/L
g Mosl comrnon sile is BONE
V Main route for excrelion is Kidneg (reduced after lrauma)
a Main regulalor is Aldoslerone

ETIOTOGY
DITUTIONAT (MOST COMMON TYPEI RETATIVE HYPERNATREMIA:
.. Waler inloxicalion .. EI Mosl common cause is WAIER
EI 4lntake.. Post-operative infusion of DEPLEIION, Na wilh inadequale
Glucose 5%, IUR.P $ replacemenl
EI VOuQut.. Rena! failure ABSOIUTE HYPERNATREMIA
NON. DILUTIONAL EI AINPUT .. Post-operalive
.. Shock .. adminislralion of Saline
EI V dietarg inlake EI $ALT RETENIION.. Cushing $, Conn
EI 4Plasma, GlT, Rena loss $, Hgperaldesteronism

CLltrllCAL
MIID CASES (VECFI: gpertension, Tachgcardia,
H
PICIURE Enlarged Neck veins, Ederna,
Hgpolension, Tachgcardia, Oliguria,
Emptg Neck veins, Sunken eUe, DrU CNS manifeslations ending bg
longue, Drg Skin seizures, Corna
ADVANCED CA$ES (OICFI:
CNS manifeslalions
EI lF REIAIIVE: as waler inloxicalion EI Active lrealrnenl:
g AB$OIUTE HYPONATREMIA: Sodium-free waler
- Mild lo rnoderafe) 0.9% NACI (Correlaled wllh duralion of hgpernalremia)
- $evere) 5% NaCl ..(oNa lrnEq/hour) M m. Of Cause
N.B. lf more: demgelination of Nerues
EI TII. Of Cause
 ilRq-Twr-5 ANDoC4qhE ffiqw ?Aqv I w

V Main lnlracellular calion 198%)

A N. level 3.5-5.3 mEq/L , Dailg need : 60rnEq/L
g Non-diffusible lhrough cell rnernbrane
g lnsulin, 82 slimulanls, alkalosis)K lransfer inlo cells
g 9O% oI {illered K* is reabsorbed through PCT
g 4K levels in
(Succue intericus = inleslinaljuice )
sarne conc. As PLASMA )if
leaking occurc: rnelabolic acidosis with N. anion gap)

ETIOLOGY MMost cornmon cause is

RENAT tOgS VBnd rnost cornrnon cause is Renal failure
g EIDfiRACETLULAR, SHIFI:
ElDiurelics Tissue damage (Hemolgsis,
MAntibiolics "Carbenicillin" Rhabdomgolgsis, Acidosis,
MCrohn's disease, Cushing $
insulin de{iciencg)
GrT tosg

EICrohn's disease with {istula

EIK losing tumor "Villous adenorna "
Mlnlracellular shift: Alkalosis, insulin

o Asthenia o Asthenia, Alonia, Arrgfhmia, Apathg

o Alonia (ex: paralgtic ileus ) o Conslipalion
o ARRYTHMIA

g ECG: V ECG:
. Flal or inverled T wave . Prolonged PR
, Prorninenl U wave . Wde QRS
. Depressed S-T segmenl r zfr S-I segment
g lnvestipalions for lhe cause g lnveslioalions for lhe cause
@ Trealrnenl of cause
V >7 meq/L )Dialgsis
EI RULE OF 40
- Urine oulpui musl be >40 mlhour
-=---E
a) Sodium licarbonates lV
- <4O rnrnol K* added to I L {luid b) lnsulin regular infusion
- lnfusion rale should be al rale <40 c) Olucose 25%
mmoUhour
d) Calcium .. anlalonize
E ESTIMATE K+ DEFICIT
Polassiurn effecl on heart
(4.5 - serurn K* concentration) x IOO
in Norrnat PH of an adull
EI DECIDE OML OR IV K*
 ilR4,-ToAr5 E{DoCFNY rJ,l?4W ?hq* | 08

V N level : 8.5 -10.5 m7dl

V Mosl cornmon sile is BONE$
g Serurn calciunr exisls in 2 forrns:
- 50% ionized) ACTIVE FORM
- 50% Non-ionized ... l4O% of which is bound to albumin)
V Albumin's half-life in circulalion is 15 dags
g Delerrninalion of Prolein level is essenlial
in analgsis of Calcium levels

I
T r1 IIrIrl Ig 1[' l7t : Il2: :IglITD: ill7t
ETIOTOGY
' Mosl cornrnon cause is Mosl cornrnon cause is
after thgroideclomg
. Alkalosis Hgper-parathgroidism
. Hgpoalburninemia Thgroloxicosis
. Acule pancrealilis

CLINICAT
PICIURE:
BONE, MOOD, STONE, GIT
. Carpopedal spasm, $lridor, Convulsions
LATENT HYPOCALCEMIA:
:: see clinical picture of
. CHOVESTECH SIGN: tapping over branches
hgperparalhgroidism : :
of Facial)twilches in facial Ms
. TRAUSSAU SIGN
lnvesli- . Measure serum Calciunr . Measure serum Calcium
gations
. lnvestilations for cause:
- HVDerDaralhqroidism
:: see invesl'lgations of
hgperparalhgroidism : :
-Bone secondaries) Bone scan

TTI V lO% : l0 ml lV slowlt MEDICAL TREATMENT

g TTT. Of cause g lV fluids , Bisphosphonales
TREATMENT OF CAUSE:
fl Hgperparalhgrcidism
M Patient with Hgperparathgroidism :: see lrealrnenl of
,exposed lo slress hgperparalhgroidism ::
EI CLINICAL PICIURE: V Bone secondaries:
- Polg-urea, Sevete dehgdration - lf operable) R.adical reseclion
M TREATMENI: - lf inoperable) Palliative
a) Ringer Laclaie reseclion, chernolherapg,
b) Radiotherapg
c)
 ffi(rTwt5 E{Docxht, ilEqw ? AEe Iq

ACIDP/ISE
, Producls of melabolism are predominafelg ACIDS (CO2, organic acids)
. Mainlenance of slable PH is achieved bg BUFFER 8YSTEM
CE
. Mosl imporlanl buffer is HCOS ... (easilg manipulated bg lungs & kidneg)
. HCOS is controlled gtOWLY bg KIDNEfS ... Change is MEIABOUC
PCOZ is controlled RAPIDLY bg TUNGB ... Change is RESPIMTORY
. Blood Pll , Elecfrolgles are assessed bg ABG
. NORMAL VALUES:
PH:7.95 -7.4
HCO. : 22-26 mmoUl
PO2 75-l00mmol/L , PCO2 95-42 mrnol/L
PH = Pka + Log HCO/H2Co"
Bicarbonale, Carbonic acid ratio is 2O:l

. ln ang melabolic or respiralorg disorder...

OMPENSAITON will reslore Normal arlerial PH PARTIAILY

Metabolic acidosis) Hgpervenlilalion (VPCOJ

Metabolic alkalosis) Hgpoveniilalion (APCOr)

Respiralorg acidosis) HCO, produclion bg kidneg

Respiratorg Alkalosis) HCO. excretion

Eliologg: vPH, V HCO3 4HCO3 4PCO2 VPCO2

4Production o{ H+: ^PH,
loss of H+: lmovE[il.ATtoN ^PH,
HYPERVETII.ATION
-DKA, Mgocardial -VOMITIN0, diarrhea CN0 depression, Hgslerioal,
infar"ction -Paradoxical aciduria Ms. Weakness Hgperpgrexia
-lacllc acidosis (CHP8, Pgloric slenosls) (Mgathenia
-Seplicemia, seplic -Diurelic therapg gravis), COPD
shock (Ihiazide, loop diurclics)

HCO" Loss: O HCO,:

-Renalfailurc -44 inlake of
-aa-
-Diarrhea, inielinal arrlacids (NaHCO")
{istula
- Urelro-sigmoidostomg
Clinical 4Raie, depih of - C.P. of cause - Cganosis 4 Respimiorg rale
piclure: Breathing - lfsevere) Ielang - lrrilabilitg (Tetang, Respiratorg
..KUSMMEL'g BR.EATI{" anesl)
TTT. -m. Of cause -m. Of cause Mechanical Palienl respirc irrlo
-lf severe) NaHOO, -!V saline venlilalion a Paper bag
(Bodg weighl x 0.3 -lf severe) Arnrnoniurn
x Base deficient) chloride Slowlg
 Xeq-fwg ,NDoCFNE X,V^W ?hqv I m

UEq GJ
METABOLIC DISORDER, RESPIMTORY DISORDER

VPH, V HCO3 4 HCOs vPH, 4 PCO2 VPCO2

^PH, ^PH,

CornDensalion: Cornoensalion: Cornpensalion:

-0PCO, -oPco2 -fHCO' (Buffer
(Hgperventilation) (Hgpoventilaiion) sgslem)

-VH* lRenal lossl -VHCO. (Renal) -VH* (renal lossl

MIXED DISORDER euiq lJlllft COz, HCO3 Jl eJ

RESPIRATORY, RESPIRATORY,
]VIETABOLIC ACIDOSIS METABOTIC ALKALOSIS

VHCO3, 4PCO2 aHco3, vPcoz

. Represenls Anions NOT usuallg measured

. Value: 10-19 mmo7lilre
. Calculalions: CAfIONB (Na, lq - ANIONS (Cl, HCO3)
. MEIABOLIC ACIDOSI$: Other alkaline juices :
- Due to VHOOa.. NORMAT ANION GAP 1XCO, srii)
. Succus entericus
(RF, diarrhea, Inteslinal fistulae)
. Bile i
- Due to 4 H* .. 4ANION GAP lncia tusi)
(DKA, Lactic acidosis, Septic shock) ANa,ACl, AH*, No HCO.
 c*fr.4:lw.t5 ww*NY 1.R@l ? h{10 | lll

INDICATION$ OF ENTEMT NUITRITION:

V In Palienls where ORAL inlake is inadequale :
(Cornalosed patienl, Severe dgsphagia, Neck surgeru, Burns)
PATIENT REQUIREMENTS:
M Stp FEEDING: Whole food bg mouth (fluid formuta)
EI Tueg FEEDING TECHNIQUES:
- NGT: Rgle'e tube
- GASTROSTOMY) Liquid diel, Juice, Milk
- JEJUNOSTOMY) Partiallg digested or elernenla! formulae
OOMPTICATION$ OF EIITEMI NUITRITION:
-MECHANICAL: Malposition, displacemenl, BIockage, Breakage, Leakage
-INFECIIVE: exogenous or endogenous
-GII: Diarrhea, bloating, Nausea, vomitin!, abdominal cramps, conslipalion
-METABOLIC/ CHEMICAL: Elecirolgte imbalance, malnuitrilion

TUTAt T{OM
INDICAIIOIUS OF TPN:
M Blocked GlT... Slricture, Neoplasm, Exlrinsic rnass
M Shorf GlT... Short Gul sgndrome
EI Fistulated GlT... Enteroculaneous {istula
EI lnflammed GlT... lnflammalorg Bowel disease
EI Unsuilable condition... GIT can'l cope as in severe traurna, hgper-catabolic slate
PAIIENT REQUIREMENTS:
EI Suqical patient needs 40 KcallKg bodg weighl,24OO Kca7dag
M Energg given:
(lgm CHO=4Kcal, lgm Protein=4Kcal, lgm Fat=9Kcal)
EI Ratio in a well-balanced diel is .. (CHO 5OTo, Prolein 157o, Fal g5%)
M Requirernenls are liven in 2-4liters of Fluids as following:
- CHO) Glucose 5O% + lnsulin
- Prolein) Varnine or Tolarnine
- Fat) lntra-lipid l0%
COMPTICATIONS OF TPN:
- Nutritional & melabolic cornp!!ca]!ons;,
(Hgperglgcemia, Hgpokalemia, Hgponalremia, Hgpercsmolar coma)
- Cenlral venous Catheter comPlicalions: (Hemolhorax, Pneurnofhorax,
Nerue injurg, Cenlral venous calheler infection & Sepiic thrombophlebitis)
 1.R4-Toq..t5 1^m,RNY 1JWW ?hqv I w

tr GENEML COPLICATIONS:
- Fever (Most cornrnon 4O%), Bed sores, Confusional slale
tr LOCAT WOUND COMPLICATIONS
tr OTHER gYgTEMg COMPLICATIONS
- ResDiralorv ... $ee Cardiolhoracic surlery ...
- Cardiovascular cornplications:
Hgpotension, Hgperlension , DVT
- Gasiro-inteslinal cornplicalions:
Posl-operalive Nausea, vorniling!, lnleslinal obslruclion, jaundice
- UrinargcomDlicafions:
Renal failure, Acule relenlion, UTI

DAYS (Reactionarg- Lung Urine- wound) -

EI 0-l )Reaclionaru : Ebb phase of inflammalion
fl 2-S ) Atelectasis of Lun!
V 3-S ) Thrombophlebitis at the site of cannula
fl5-7)DW,UTt
V > Tdags) Wound infeclion or sub-diaphragmalic abscess

FOR UNCOMPTICATED PATIENTS) 3 LITERS OF FLUIDS

EI 5OO ml saline
lO.9% NaCl)
g 2.5 Lilers iYo Dexlrcse (Glucose)
V K* is liven afler 48 hours:
- Saline is replaced bg KADALEX (Contains 27 mmolK+ll)
- Polassium Chloride supplemenls
N.B. Correclion fluids irnbalance should be lo avoid fluid overload

CONTM-indications:
EI Biliarg operations
M Coma
EI CNg problems
EI Respiralorg depression
Withdrawal effects:
Agitation, Vomiiing, Diarrhea
.riiill gJorJl.cl+i Ef pto!rJrk
 cJJR{+-TooN5
1r"l{[rr'*Nv ARqW ?hqt t v

l. Focused abdominal sonograrn for iraurna

(FAST) assesses for blood in pericardial sac,
hepalorenal pouch, pelvis & spleno-renal
pouch, bul NOT in relroperilonea! space.
2. Small inlesline is the rnosl commonlg affecled organ in penelrating injurg of abdomen.
g. The rnosl irnporlanl slep in lreatrnenl of septic shock is drainage of septic collecfions.
4. Allowing blood which is readg for lransfusion lo remain for 4 hours in warm environrneni
encourages bacterial proliferation & septicemia.
5. Donaled blood is nol roulinelg screened for CMV.
6. The mosl cornrnon problem resulting in hernoslasis is lhrombocgtopenia.
7. Warfarin has half-life of about 36 hours.
8. Warfarin crosses the placenta & should be avoided in pregnancg.
9. Half-life of faclor Vlll is 8 hours.

l. Newborn infants have the lrealesl proportion of total bodg waler (total bodg waler
decreases steadilg wilh age).
2. Females & obese persons have a decreased percenlage of TBW.
3. ln a healthg adull, exlracellular osmolarilg is lhe same as inlracellular osrnolaritg.
4. Norrnal saline conlains 154 mmd Sodiurn & 154 rnmol Chloride.
5. HARTMANN'S $OLUTION conlains calcium bicarbonale.
6. The major anion in lhe inlracellular fluid is PHOSPHATE .
7. Sodium urinarg excrelion is reduced after lraurna.
8. lnlracellular concenlralion of K* is 150 mEq/1.
9. The averuge dailg need of K* is aboul 60 mEq/I.
lO. The rnosl serious consequence of K* irnbalance is cardiac abnorrnalilies.
ll. Magnesiurn is lhe 2^d rnosl abundanl inlracellular calion.
12. Ihe cardiovascular effects of hgpomagnesaemia are similar lo those of hgpokalemia.
13. The rnosl significanl inorganic plasma buffer is bicarbonale.
14. The 3 mosl important buffers in bodg fluids include: bicarbonate, phosphale & prolein.
15. Ihe ideal infusion fluid for correclion of hgpokalemic alkalosis due lo pgloric obslruclion is
norrnal saline.

Locallg invasive lurnors include basal cell carcinorna, rnixed salivarg lumor, bronchial
adenorna, adamanlinorna & osleoclaslorna.
2. Genelic predisposition to cancer is relaled lo inueased chrornosomal fra$litg & defect in
DNA repair enzgmes.
3. Thgroid, breasl & lung cancers are cornrnonlg melaslasizing bg blood.
 leq4w-tS ,ND0CRNY l"RqW ?h I r[4

Clinical picture of seplic shock

KasnZM ) aa

Managernenl of septic shock

G4ilar trl, zoll
Patienl wilh seplic shock have a worse prognosis than
those with hgpovolernic shock
(Kasn 2M )
Discuss Etiopaihologg and clP of hgpovolernic shock
Kan 2o// - 5u sfiams, zoo/, znz - Alur rlrL zo/, zml
Tgpes of Hernomhage and their rnanalernenl
( Kasn 2@7 )
Factors affectin! wound healing
,4ilar rlr1,2W - A**
( f,2@6,2@5 - Kasn 2@f )
Cornplications of wound healingf
( Kasn 2d )
r Cornplicalions of Blood Transfusion
Kan 2@f 2M-,4lr sfiarrls, 2W, zfu
- r4y'ur f, 2@f Z@4, 2@/, 2fu5, 2M -
,4y'rar rl/, zmz 2@6, 2@4, 2@5, 2@/1
r Cornplications of spina! anesthesia
Kar, z@r- ,4y'rar ril,2@2,2@/,2m -
,4y'ar F,2@22@6,2Ut4 )
r Cornplicalions of general aneslhesia
( Ailar f,2@O - Ay'rar rl/, Zm/ )
r Enurnerate posl-operaiive cornplicalions
( Ailar f,2@7)
r Posl-operative pulrnonarg cornplications
( ,4ilar f,2@4 - r4y'rar rl/, ZnC)
r Post-operalive fever
(Kasn2M )
Brain

Ji,gi;ietr r'ell

Arms

SLrtertor !8lia taYa

',-.,i2('ot .iefia Q'!a

lleoa',lc ', elr

Hepaiic c0ta1 'jerii

i-iver

?e.tall ie::l

!i,aa':e,,.

Lo!"jea ;!Cv :i':S rels

rilbrtael Safwat
/1ABBClt - slaws
 leq-fw$ EFTDtrXNE g,^?4W ? hh ! tq
DEFINIIION: Lack of blood flow due to
eudden occlusion of previouslg patent arterg
with NO lirne for collalerals fo open.

Severe, in lhe rnosl peripheral part of limb

Pallor
l) Marble white
E Young age tr OLD age
2) Mottled ,pp. After 6-12 hours tr lncidence: FlA, Fernoral l4o%) tr PDF : ETIOLOGY

3) Fixed blue slaining of skin ........ tr PDF: . Alherosclerosis E Open

. Mitral slenosis with AF . Slasis,Hgper-viscosilg
E Closed
IR.R,EI/ER.SIBLE . Lefl alrial Mgxorna (Diarrhea, polgcgthemia)
lalrogenic
Etr
Pulselesness dislal lo sile of embolisalion . E lntra-arterial
@
Mural lhrornbosis tr LIMB :
drug lnjection
@ Paralgsis . Frorn Larle arteries) / Acule bui less drarnalic clo:
Earlg in arterial, lale in venous obslruclion Alherosclerosis, aneurusrns / Pale, white E Historg of
Paraslhesia (Anesthesia) . Veins) Venous thrornbi, / TROPHIC CHANGES lraurna
LATE, bul reversible after TfT for few monlhs VSD, ASD, Eisenrnenger $ // ANGTO> +VE tr Bleeding
Progressive Coldness tr LIMB : COLTATERALS o/E:
/ $udden onsel / Pasl Hislorg of tr Shock
/ Pale, while, lnlerrnitlent tr Hard signs vs.
/ claudicali Soft signs
//
tr s acc.
To affecled arterq :
. Brain )TlA, Stroke
VIAEI-E THRPtTBIED lffi .
.
Relina )Arnaurosis Fulax
Fixed color changes Mesenleric vessels
)Gangrene
: . Spleen ) Loca! pain
. Kidnegs ) Hernaluria
 a&q'-tw.$ 6{Doc^PI.lE IJRqW ? AqY t Ytn

Srrpor rMpIGnoN oFETpl.Oq/ oFffi

g ECHO, ECG)Deiect AF tr Muscle Necrosis :
g X-rag ) lnjuries 4TLC, 4CPK, Acidosis
V PRE.OP
V US ) Aneurgsrn tr Hgpovolemia :
g INTRA.OP 4Hb, Crealinine, BUN
)For fhreatened limb

g Block of main A +VE collalerals

arterial lree

FERIPHERATffi
H/AFD StqlUS vS sEoFT sltGIUS

tr 6Ps tr Hernaloma non pulsaling, non-expanding

tr Pulsatile Hemorrhage tr Nerve injurg
tr Pulsalile Hernaloma tr Wound is near a rnajor vascular slructure
tr Palpable thrill, bruit tr Delaged capillarg refilling time

Urgent lnvestigations
 lLlq.q:l}r/,.r5 1^9rr/PNY IJRqW ?AEi; I Wl

PREoffi nfrnAcrffi Podroffi

g Hospitalizalion
g
g
Oxggen, d'rgiialis
Anlibiotics
oFCAGEE OFGOME
d Morphine
d Heparin : SOOO units lV eryleoust/l T{roMBoclls tr Gangrene
tr Anli-coagulants Eleclive BYPASS Arnpulafion
tr Anti-arrglhrnics tr Volkrnan's
contraclure
Tendon lransfer
tr Crush $
lV fluids,
eMgo;StJl ffi AI{IERLIIL $[rt,FI/ Alkalanizalion
tr lf wiihin 6 hours: of urine
URGENT EMBOLECTOMY (Fogerrg catheler)
l) Fernoral arterg)
Cornrnon femoral VIAETE T{FEATEDb lffi
lransverse arteriotomg
2) Aortic bifuricalion) Bilateral Femoral MCS Urgenl ANGIO
+URGENT
AMPUTATION
arteriolomies I
tr lf Late : Follow up clinicallg and R.EVASCULAR.IZATION
Fasciolomg SURGERY
angiographu
(To prevent cornpartmental $)
tr S'rgns of adequale emboleclorng: tr Streplokinase Pulse sprag or lV
. Pulse fell No wlFno\lErllntr tr Loading dose, followed bg
. Color, ternperalure I rnainlenance
. Fleverse bleeding URGENT tr R.ecenl) Recornbinant Tissue
. lnlra-Op angiographg Re-vascularization plasrninogen aclivator
 1R{4:locllt5 .^*,,*NYilPq*' ? hq t w,?-
TIT oF FERIF|{ERAL AnrrmrAU INJ,F!/
n PRIMARY SURVEY: ABCDE .... Airurag, breathing, circulation, Drugs, eXposure
fr SECONDARY suR.vEY : Head lo loe Exam, AMPLE Hislorg , lnvesligalions (An$o ,Doppler)

MOFAIilEFRACTT'RE
WAII fior 20 rninutes

Pulse relurns No pulse

DEAL WITH THE FRACTURE D(PLORE & DEAL

ODEN ch.m
lrrigate wilh saline &
Wound debridrnent
tr Skin) Excision of l-2cm
t{tfttourrE(R I{ITHTEAR
tr Fascia) Open lense fascia
tr Mg.) Excision of dead Ms. Spasrtt CortnstoN PAXTIAT, Corinere
tr Nerue) Mark with black silk I I r) Repair in
tr Blood vessel ) Deal as Painting Or Excision of the <l/2 >l/2 obligue mahher
Clo.sed injurg wilh tear... conlused circumference circumference 2) Mobilize arterg
lntra-arterial 3) Cul branches
segmenl and I I
papaverine 4) Baphenous
saphenous graft Repair with Treal as
proline sulures vein grafl
Cornplete
 lJ?q,-Toqr5 E{D0CXNE ilRhW ?hh? t w7

cqnoN penrPl+*ALffiDlslEASE
DIAEEf,IC
PRESENILE
AIHEROSCLEROSIS
BrrItcFRS
ffiffi ffi'S
chrNrcAr srAgEs (Fs,trAllG)
.ASJMTMdUS
TYPE OF PAIIENT WPE OF PAIIENT I. UICER, RESISIANT
trAiherosclerosis )
Male>S0 Uears wiih risk trAlherosclerosis )
Male>SO FOR, HEATING:
faclors (DM, HfN, Obesitg) gearc wilh risk faclors (DM, HTN, trTender ulcer Between
trBuroer's )
Male 2O-4O Year. Heavg smoker Obesitg) Toes, dorsurn of foot
gYMPIOMg trBurper's )Male 2O-4O Yr , tr Edge ) Punched oul
tr Cramp-like PAIN, bg walking, V bg & resl
,1. Heavg srnoker tr Margin )Black,
i tr Prcgression ) shorter claudication dislance, I-REST PAIN rnumrnifted
4Period of rest tr Severe pain lhal awakens Pl. tr Floor ) Granulation
tr Affection of other sgsierns from sleep tr Base ) Diflicull to
, r CNS : TlA, slroke tr 4bg REST, AT NIGHT, palpate
. ryq HF ELEVATING LEG 2. GANGRENE
.
Kidneq : Pain. hernaturia, hgpertension tr Vbg Hangn! foot down
.
@!!g!.;. Leriche sgndrome tr NEI/ER above Ankle
OENERAL EXAMINAIION tr Drg gangrene ...... (Wef if
CI.AUDICANT LIMB tr
Vilal s'rgns : HF, lnfection)
. Bgslolic Bruit )(Aneurgsrn) 2. ABSENCE OF PERIPHEMT
. Conlinuous Bruil )(arterio-vehous fislula) PULSATION
LOCAL EXAMINAIION) LIMB IIII LAYERS
 1Rt4-{our5 E{DocxhrE 1,^Phwl ?A6F I W

tr CBO)Anernia, Polucvlhernia
(Anernia eggravaled ischernia)
tr FBS >DM
PFEOFENffi\IE lFITF)MRA tr KFt >Alherosclerolic kidneg
DOPPIER
,-l
W tr
tr
LFt
ECG
) lrnpaired
)IHD
. i..
, r.al1-r4l iiqLit .ADVANTAGES:
- Site of slenosis tr CXR )Promineni aorlic knuckle.
Biphasic flow ABP!
. Normal >l - Exlenl of stenosis calcified atherorna
(Collaterals)
. O.5 : CLI - Collalerals tr L:pid profile
ln diabelics ) - Run in & off
foe Brachial index .TECHNTQUES:

DrrPl^D( - Direct femoral arleriographg

- Trans-lurnbar arteriographg
(if bofh femoral pulses aren't pulsable)
- frans-axillarg arleriographg
(if fhe whole dislat aoria is occluded)
. COMPLICATIONS:
- Neurologica! deficit
- Hernorrhage
- Pulsalile rnass
- lnfeclion al punclure sile
- Allergic reaction to lhe conlrast
rnedia
- Thrornbosis
 1JP,440qr5 AWOC*hIE 1,,RqW ?k e I w

BES;rMDIGATTIT PFEffiAT.IGIW
tr RISK FACTORS MODIFICATION +\,E DISTALFTJNoFF - \rEDlsrALlg6laryp
. Cessation of srnoking
. Proper conlrol of DM *:Htfl#.DtS
. Conlrol BP S${oncrSrcfiertr roD.Gsrciltatr
AN
. Lipid lowering g Endartereclorng
PG
UI SYMPATHECIOMY
tr ANTI.PIATELETS V Balloon Angioplastg
ARTERIAL BYPASS
EI Arnputalion
. Aspirin 75 mgldag Wth or wilhoul Stenl
(lf patient is inloleranl) Plavix) AFO/E EE.olr,
' Clopidogrel
${qor.lAL h.lclorl.ht
tr VASO ACIIVE DRUGS
uqAirrtr TEAFJtT
tr CARE OF FOOT
tr DGRCI$E (to Oclaudicalion distance) Sgnthefic graft Saphenous Graft

rMffir{o{+Mffi (,i[r.ArmAu D{sm, FartsnsED

. lF Hf) Aorto- Femoro- Femoro-
a Aorto- Bifernoral Bgpass fernoral bgpass distal Popliteal
V lF UNFIT (e.g. cardiac . IF UNFI'
patient)) Axillo- Fernoro-Fernoral
bgpass bgpass
Bifemoral Bgpass Bgpass

SYNTHETIC fuJl a#hi

KNITTED fuJl g +.r-tll
DACR.ON
+i.lall
 5E44wr5 ENDOCXI{E IJRqW ?Aqv t wo

DEFINITION: a cornplex pathologg in a diabetic patient's fool which

is relaled to duralion & Control of the disease

tr Painless
tr Lirnb is: Swollen

tr Deep
Red, hol, lender
tvlrchor Mrcho. trler
(lnflammalorg reaclion is
tr Al pressure siles
tr Fool is :
weak as Pt. is lrnmuno- aNGretuy aN6ontn+r t
!
compromized) I On top of
/ Wann
tr Mag spread ) tr Pulse is fell INFECTION
/ Bounding pulse NO PULSE tr No bleeding
Osleorngelitis, Septic
/ Dlslended veins
shock I I I
tr Duplex :
Norrnal or high Flow
TREATMENT: DOPPLER & tr DEBRIDMENI Arnpulalion
tr : conlrol DM,
-Debridernenl tr Antibiolics
TTT
-Antibiotics
ANGIOGRAPHY tr Dailg dressing
fool care. Vilamins
-Dailg dressing till the wound
-lf gangrenous Run off Run off is TIDY) FLAP
) Amputaiion
+ SHORI +LONG
segrnent segmenl

I t
Ulcer PTA BYPASg
 lJpq-Taqr5 A{DOoFINE *PqW ? AqV IW
vAso€PAsrl DEFINITION: Recurrenl ischernic
al-lacks precipilated bg exposure
to coldness or emolional slress

DtS=.(Sri ,/ ETIOLOGY:
// ETIOLOGY:
- 'lt sgmpathelic lone - CollaAen: 9LE, Scleroderma
- Psgchologicalinslabilitg Arlerial obslruclion: Burger's disease
- Abnorma! sensilivilg of hand to coldness Nerve injurg: fhoracic oullel $, Carpa! tunnel $

CLINICAT HCTURE: Druss: Beta Blockers

- Youn! fernale "ii'lUrilrr Jsgl{JI r-".s ldf 11| iiJ:ro fi 16rJl lJ, tli{ // CLINICAL HCIURE:
- MAYAFFECT@
.
- [[ tuophic changes
- Peri-pheral Pulsatiohs are trE
- @ Trophic chanles
- [EP"ripheralPutsalions

Care of Care of Drugs Surterg TTf of Vasodilalors Sgmpathectorng

Patienl Hand I
(Avoid Bela
. Sgmpatheclomg CAUgE
. Slop smoking . Drgness
Vasodilalors
(Cervico-dorsall NO BENEFIT D(CEPT:
. Avoid cold . Babg aspirin
Blockers) . lf vasculilis occur
. Woolen gloves
weaiher . . CCB . Crgo-anlibodies
Exercise
. TTT. of anernia (Makes sgrnpalheclorng
if preseni . &&()YAW, Sgmpalhectomg is EFFECfNE ineffecfive)
. EpI$I-EIIE Emerlencg m) lmrnersion of affecied parl in Warrn waler l40-44o)
 lJPr+-Twr5 r^Jiw*Nr.eruW ?Aqv I w3

M
Biopsg jl 69iao g Angio g .-otluiS
Cr-lpNlc Other Narnes:
yoot{GpffiED{r oLD PArlED{r @ Chernodecloma
I I @ Polato Turnor

@
Affects Big
@ Angiographg:
@ Widening of the Carotid Arterg
bifurcation
vessels
e.g. aorta

Excision or ligation, wilh presen ation of ICA

Surgica! iniervention
* lndication: >7O7o slenosis if Sgmptomatic or
>8O% if Asgmplomatic
* Method : @ Hgpertension
t) Carotid Angioplasig & Stenting NOT responding
2l Endartereclomg lo medication
@ freatrnenl:
Balloon dilatation
dlte
& Stent blggcr,
efnraya been a hlgh addever, alwayc crrlvlng 6oc
hcH, grrcaer.-.rrd now audden[r lrrr cqioliled
to c.ltle for &hycri blood prrer{}unc and lers cholcstcroI?t,
 1,,Rq-IC[/,f5 a{DocPtE apaw ? Ah[, I W1
BOUNDARIES OF IHE
COMPREggINO
IRIANGLE:
1r{oRA(,lC, E
Etiologg
Cervical rib
-Scalenus anlerior
-ecalenus rnedius
E Scalene $ o+lvrr#slJl
-Firsl rib
SylbnoMe
DEFINITION: Cornpression of N. (Brachial plexus)
tr
tr
Hgperabduciion $ Uirl6ill
Mal-union of Clavicle
EI Pencosl lurnor
& arterg (Subclavian A.) while crossing through
lhe narrow triangle ir;the base of Neck

Cornpression of Lower lrunk Cornpression of Subclavian Arlerg

Compression of Subclavian Vein
of brachial Plexus
(Rare as il's oulside lhe triangle)
GltpNtc FGTSnED{snC
lscltBtlA DlrArffioN Effort fhrornbosis
oF(L Emboli to lndex &
&DW
On Ulnar side Small Muscles middle {inger
of Hand & Of Hand ) Claudication 2rg Ragnaud (DrGrrAr GANGRENE)
Forearm Alrophg & pain with Phenornenon
Weakness exercise
SIGNS:

) Radial pulse becornes weak

Angiographg:
- Cornpression of $ubclavian arterg on Elevalion of arm
- There'sPosl-slenoiicdilatation M!LD (NEUROLOGTCAL) gEvERE (ARTER|AL)
tr Plain x-rag) Cerivcal rib
tr Nerve conduclion velocilg is prolonged tr Phgsio & Shoulder exercise tr R.eseciion of Ceruical rib
or lsl rib
tr Scalenotorng
 ilPq,-Twr5 wwIJNYxMRJ Tfi{1V IW

DEFIN!IION:
l- Sac {illed with blood comrnunicaiing with an arlerg
2- Permanent localized dilatation of an arlerg l-5 limes lhe norrnal ,{
ETIOTOGY:
Congenital, Atheroselerosis, Sgphilis, Traumalic
TYPE OF PATIENT:
- Old patienl (Atherosclerolic)
- Yount palient (Traumafic, congenital)
SYMPTOMS:
- MrU be asgmptornalic ...
- Swelling, Pressure & lschemic rnanifeslalions
SIGNS:

I Cgstic
I Along course of arlerg
I Moves the arterg
I Cornpressible or partiallg cornpressible (thrombosis)
I Auscullalion) Bruil
COMPTICATIONS:
I

I Pressure rnanifeslalions) V,A, N.

T lschemia
I Ihrombosis, Embolism,Alherosclerosis
t lnfection) Rupture, secondarg hemorrhage
INVESTIGATIONS
. Screening) @
, Diagnoslic)
. Best pre-operalive lnvestigations)
N.B. Angiographg doesn'f show lhe true diameter of aneurgsrn

r-TREATMENT-r
Surgerg if indicated
Conservative
Follow up everg 3 months bg U/S . INDICAIONS OF SURGERY
- lf sgmplomatic
- Diarneter)Scrn
- High risk palient
'SURGICAI PROCEDURES
Excision & grafl
Exclusion graft
lnlra-luminal self-
inflatable graft
 cilq.q-Tmr5 flpmxnr rtlBt w ?hqv t vl

ABDOMN{ALAOFilC
INCIDENCE:
- 95% due io alherosclerosis
- g5% below origin of Renal arleries
. 75% ASYMPTOMATIC
CLINICAL PICTURE:
- Vague abdominal pain with backache
COMPLICATIONS:
* RUPTURE:
Shock, acule abdominal pain, Pulsating epigaslric rnass
* Dista! ernbolization
l) Sponlaneous) Blue loe $
2) lalrogenic) Trash Fool
INVE$TIGATIONS:
- For aneurgsrn) U/9, CT, MRA, Anliolraphg
- For olher sgslerns) ECG, CBC, Lipid profile

r-TREATMENT_r
Conservative Surgerg if indicaled
Follow up every 3 monlhs bg U/S . INDICAIONS OF SURGERY
- lf sgrnplomalic, Diarneler>Scm,High
risk patienl
. SURGICAL PROCEDURES
- Excision & grafi
- Exclusion grafl
- lnlra-lurninal self-inflalablegraft

. INTRA-PERITONEAL:Fatal
. RETRO-PERITONEAL (IEAKING A.A.): Epigastric pain & thock

O/E: Pulsating popliteal A. in a palienl who's nol thin

COMPLICATIONS:
 il?4-Tw\5 A{DocEN? "ilK#,] ?& | t1?-

Ul,;dl rF.t r-g tir+ij pgF . ln thigh )Butcher's Thigh

. Hgperdgnamic circulation in the . ln Axilla ) ii+h r,',!r$l r:lg
growing lirnb .ofar iiirs g uUgrJl dgs lJo
(Hgpendgnarnic circulation in a growing lirnb)
. Manifesied bg
!l oJrU *j rji g rsplp
"$r

IIIITT.

. Pulsalile
. Thrill & bruit General
. Cornpressible Or
Partiallg compressible

pulse Jl rJs{ fil5otl sfr rsrl!Ir:i

Pulse rll ujf rsu! rJ+iri

. INVESTIGATIONS:

.IREATMENT:
 ilPq4wt5 nrccFNtr lRh%l ?h Iw

Mauoscopic dealh of tissues due lo loss of blood supplg and is usuallg

associaled with baclerial invasion

E[]OLOGY: l. lschemic )
thrombosis, embolisrn, vasospaslic disease.
2. Neuropathic ) sgrinlomgelia, leprosg.
3. Venous Ganglrene (see below)
4. )
fraumalic direct (bed sores),or indirecl (aderial injuries)
5. lnfective ) Epecific infeclion or Non-specilic infeclion
6. Phgsiochemical ) burns, caustics, froslbile,...

TYPE$ OF GANGRENE:

Causes Chronic ischemia - Acule ischemia - PRIMARY: lnfection of lissues

- Chronic ischemia wilh with virulenl organisms leading to
pre-existing ederna gahgrene
(cardiac, DW). - $ECONDARY: lnfection of slerile
Qan{rene
Palhologg
Putrefaclion Minimal Manked
Odor liftle or no odor Veru offensive
Gross picfure - DrU,Wrinkled, - Ihe part remains of
Murnmified. lhe same size and
- Hard, Dark consislencg.
- Color: dead white
)purple or greenish
black.
Line of well de{ined ill delined (no lime for
demarcalion evaDoralionl
Fale Separalion ) Leaving Spread )
a conical slump SKIPPED LESIONS
clP l. of local death
The five cardinal s'rgns : - fhe affected limb beeomes
Lost (pulsation, Sensalion, Heaf, Funclion of swollen, edemalous and markedlg
affecled part, fxed color changes) inflamed.
- Ihe skin )moisl wilh bullae
..... Press & see How Color fades ..... - offensive odour & mag crcpilale
2. Minimalloxernia ) 3. Severe loxemia )
betler general poor genera! condition.
condition.
Trealmenl - Limb salvage - Ampulalion tillihe
(conservalive level of pulsalion
amputalion). - Ttt of lhe cause if
- Non-conservalive possible.
ampulalion.
 ilPq-Tou\5 ,ND0CRN? ileqW1 ?hqv t w

OF
- $ite> over, bong prominence
(sacrum, ischial luberositg or heels)
Etiologg
- Prolonged pressure.
- After irnrnobilizalion of paraplegic palienls,
elderlg & diabetics.
..Bong prominence culs the blood supplg of
Trealrnenl
PROPHYLACTIC TREATM ENT ACTIVE TREATMENT
- Air rnallress - Debridemenl
- Skin should be kept drg & clean. - Leave lhe wound open unlil healing
- Frequenl change of posilion everg 2 - Repeated dressing with llgcerin rnagnesia
hours. - Anlibiotics

. Sudden onsel of scrolal inflarnrnalion . Caused bg exlensive lhrombosis of lhe

. sudden onsel ofgangrene rnajor peripheral veins (phlegrnasia cerulea
. Mag be associated wilh necroiizing dolens)

fasciilis
. flealmenl:
Trealrnenl.
l) Elevate limb
2) Anticoagulanl lherapg is started.
l) Antibiolics & wide surlical excision. 3) Thrombeclorng or fibrinolglic lrealrnenl
2) Laler) skin graft lo cover lhe leslis. should be considered.
5UP.4-Tffi\5 ENmflf.lV5WR1 ?h lW
 5R4:lwr5 lRqW ?hqY t ttu
^',,*NY
TI{FOMBO$S
N.B. VTRCHOW IRIAD: VELOCITY, VlgCOglTY, VEggEL WAIL

lJlI;el uri !
TIRoMBoP+lr-EErilS TGRAD,IS VeinsJI
DEFINITION:
A tgpe of superlicial thrombophlebitis lhal resolves
sponlaneouslg in few weeks then appear in anolhet a?ea
OCCURS WIIH:
- Visceral cancer "The Earliest sign"
- Burger's disease
- Polgcgthemia, PAN
- Ulcerative colilis, SLE

DEEP
CLINICAL PICIURE:
T]IROMBO$S
. ASYMPTOMATIC: Mosl cases are silenl bul are suspected bg unerylained
Posl-operalive fever,
. gYMPIOMAIIC:
- GENEML C/P: Fever, T,
. LOCAT C/P:
COMPLICATIONS:
* GENEML: Pulmonarg Embolism
* LOCAL:
- EARTY: Phlegmasia ALBA dolens, Phlegmasia CERULA dolens
- LATE: Post-phlebitic limb leading lo 2rg Varciose veins, Venous gangrene
INVESTIGATIONS:
. FOR DIAGNOBIS:
- Colored Duplex
- Recenllg: SPIML CI, Radioactive Fibrinolen
. FOR PULMONARY EMBOLI$M:
- SPIRAL CT, V/Q LUNG SCAN, Angiographg, Chesl X-rag
. INVESTIOATIONS OF DW IN YOUNG PATIENI OR RECURRENT CASES:
. PROIEIN C&S, ANTI.IHROMBIN-3 , LUPUS ANIICOAGULANI
 ? AEV t t1l

FOR ALL FOR HIGH FOR COMPTICAIIONS

DW
PAIIENT RISK GR,OUPS
tr Earlg ambulalion E lnlra-Op Inlermitlenl
tr Active exercise Pneurnalic Cornpression
tr Post-op. Hgdration tr Prophglactic LMW heparin

GENERAL DRUG gURGICAL

Bed rcst for 7-lO
dags, Vilamin E,
Elaslic slockings Ind'rcalions:
. Confra-indicationto
Anlicoagulanls e.g. :
- Hgpertension
ANII.COAGULANTS FIBRINOTYTICg - Past Historg of
Migraine, On
. Heparin for lO dags . ln lhe lirsl 3 dags NAglDs) PU
. lnfroduce Oral anli-coagulanls 9treplokinase, urokinase . RECURRENCE OF P.E.
at the 7* drg Rece inspite of ful!
' Elop heparin at lhe lOrh and
.
heparinizalion
conlinue oral anlicoagulanls lNDlCATlOItlS:
{or 3-6 ms (tf l't DW), I gear - lsolaled llio-femoral DW
(if 2"d), or For life (if 3d) - lmpending venous gang€ne
"Phlegmasia cerula dolens"
. CONIRAINDICAIIONS:
- Wthin lO dags of rnajor
operalion
- Wrthin 2 monlhs frorn sfioke

l0 mg Loading then 5 mg/dag

PTI P[, INR (2.5-3.5 times)

lwice normal :25-36 sec N :ll-14 sec

TTI OF COMPLICAIIONS:
- PUTMONARY EMBOLISM: Morphine, O2, Thrombolglics,
Anticoagulants, Emboleclorng
- POBI PtltEBlIlC LIMB: Compression Bandage
 StilAr
erylpur
Etr lmpacled in the
eripheral arlerioles I nches of

E Recurrence)
Pulrnonarg hgpertension ClP:
- Severe pleurilic pain
- Dgspnea
- Hemoplgsis

ETIOLOGY:
. lo DW, lnfeclive endocardilis, Other emboli
Secondarg
INVESTIGATION$:
. SPIML CT: ... Clot appears as lilling defecl ...
Pulrnonarv anoio(raphu: "Mosl accurale bul "
D.DIMER: (if +ve) Conlinue invesfigalions, -ve) Sfop)

Blood lesls:
- 4LDH, Serum Alkaline phosphatase
- Norrnal Bilirubin .... (,1.1t HF occurs)
- ABG) Hgpoxia, Norrnal PCO2
Radioloou:
- ECG) P-Pulmonale, Axis devialion to lhe R''ghl
- CXR) Normal inSO% of cases, Wedge shaped peripheral capacilg
TREAIMENT:
'. Prophglaxis & TTT. of DW
frealment of pulmonarg embolism:
CURATIVE

$MALL & MEDIUM SIZED EMBOLI) Anticoagulants

MASSIVE PULMONARY EMBOTISM
l-
Cardiac cathelerizalion
2- Thrombolgtics) $lrepfokinase
3- Assess Cardiac function/G hours
lf NO irnprovernenl )
urgenl pulmonarg emboleclorng after 6 hours
R,ECURRENCE
- Prophglaxis bg IVC Filter
 cJ'R4-TWr5 1allw*UVfl,Rqw ?h 0lln

DEFINITION: Dilaled, elongafed, lorluous superficial veins of L.L.

Etiologg tr
)a
[iffi Lq {II llri FI YIrr-[E
::
rt I t
I g Vacular gl ! r,rl{;3
E Congenilal rnesenchgrnal Weakness: tr M (Most common cause)
(Marphan $, Ehler danlos $, Askar $) tr AV Fistula:
tr Congenital valvular incornpetence - CONGENIIAL: Klipple lrenaurg $
- ACQUIRED: Butcher's Thigh
E AElrevatin( faclors: E Aneurgsrn
Fernale. High paritg, marked E Burger disease
obesilg, prolonged standing E Pelvic lumors, PreAnancu
Pathologg I ncornpelent Perforators Incornpeleni Perforafors, Dilaled supeilicial
Dilated superficial veins veins*ffi
Clinical piclure:
Sgtnplorns: tr Cosmelic dis{igurernenl, Sgmplorns of complicalions (pigmentafion, ltching, Ulcer)
tr Dull aching, sensalion of heaviness with sense of holness al ihe end of ihe dag or on
prolonged slandin[
tr PATIENI: Around 3O gears E PAIN: r
tr PAtN,:[@ tr PAIN Ig RETIEVED BY:
tr PAIN IS RETIEVED BY: }1 SWE[[!NG:
(deeo veins are inlacll
S'rgns: tr GElrlERAt: tr GEIIIEMI:
- Signs of mesenchgmal weakness - Pulse, BP changes) AV fistula
tr IN$PECTIOIII: - Hearl examinalion) AV lislula
- Multiple dilated tortous vein along long, tr lilSPECIrOtrl:
short saphenous veins
Blow oul al sile of perfioralor
;
- SKIN COMPLICAIIONS: tess P'lgmenlation, Derrnalilis, eczema,
tr PATPATIOIII: resielanl ulcer, Lipodermalosclercsis
- Ihrillon cough al incornpelent sapheno- tr PATPAIIOIII:
fernoral junclion Sarne as lrg V.V. + ....
- Dilaled, Elongaled, fodous, Soft, tr AUSCUTIAIION:
Compressible lubules - Machinerg murmur) AV ftstula
- EiliflftIs) Defect if felt in deep tr gPECrAr SrGil8:
fascia opposile lo BLOW OUI. Sarne as lry V.V. + ....
tr PERCUSSIOII|:
dgs Ujlori,
i',ri [o UrrUJs
tr gPECtAt StGrrtS:
- Localizaiion of incompelenl perforalor)
EARLIEST SIGN OF CVI
TRENDTEilBERG IE8I, Multiple tourniqut
- Ankle/Maleolar flare) Dilated sub-
DEEP 8YSTEM) Perthe's Tesl, Modi{ied
Perlhe's fesl dermal veins at the medial malleolus
wilh thin fra$le skin) BIUE BLEB
 x,Rq-Tw.6 1aJlw*NvrRflw ? v tw0

lnvesligalions E DOPPLER, DUPLD(

of Blood llow wilh Vlasalva
- R.eversa! I1 ARTERIOOMPHY (A-V Fistula)
maneuy$ ol Muscle squeeze
-Thrornbosis
- Dilated Tortuous veins, lncompetenl
valves
tr INVESTIOATIONS FOR COMPTCIATIOIIIS:
-Plain X-mg) Varicose ulcer i
Perioslills

PH}iAFY
UNCOMPTICATED UNCOMPTICAIED COMPTICATED
rTT. OF THE CAUSE
& ASYMPIOMAIIC & DISFIGUREMENI OR PAINFUT

CONgERVAIIVE INJECTION SURGICAL

. Earlg,uncomplicated . Moderale cese r larte prirnarg W

. un{il for operalion . C/O: Disligurcrnenl . Complicaled cases
. RedisualV.V. a#ter

R.e-assurance
m. Of PPI faclors
Elasiic stocking
LL elevation
Warnins, lf Al! Perforators)
vEilolotrllcS
tr Bruisee, discomfort , Pain
E Nerve injurg (sensory, molor)
tr Venous lhrornbosis

ON,EFS

tr IAUPUS EQUTNUS
E [L edema tr Pigmentalion,
Etr Posl-lraurnatic derrnaliiis, eczerna
Hemorrhage E Varicose ulcer Cleanlinees, Rest, Limb elevalion
tr Euperlicial tr Lipodermaiosclercsis Cotisone, Znc 0xide
Thrombophlebitis

Earlg) Consenvalive ITT.

Recunenl) Cockel& Dodd Operation
If failed)Excision& flap
 *+:f30{f, 6.m,FM XP#l ?AqY IH

DEFINITION: Disconlinuitg of epithelium resuliing in a 3D conical

defecl in relalion fo high venous pressure on L.L.

ETIOLOGY
Aclivalion of the enlrapped WBCs in the
fortuous capillailes
Ftogrir ffldri

tr SITE: Gailer area fusl above the medial rnalleolus)

tr 9lZE: Variable
tr NUMBER: Solitarg
tr EDGE: lrregular)Sloping, serraled) Punched oul
tr FLOOR: Granulation iissue
tr BABE: lnduraled
tr MARGIN: Plgmenlalion & dermalitis
tr LNS: Enlarged if there's secondarg infeclion

COMPLICATIONS:
E lnfecfion, Hemorrhage, Osleomuelllis,
Perostitis, Marjolin ulcer
INVE$TIGAIION$:
E For lhe cause: Doppler, Duplex

VAtr'CGE\EINS
E Trendlenberg's Operation

ffi sGgraAr tr SC Slripping

FOR, PREVENTION OF RECURRENCE:

E Resl, elevation of limb
E Compression slockings tr lF FAILED: Excision & E Conlinous usage of elaslic
tr Dressing with saline, anli- Covering bg Cross leg slockings
septics skin Flap tr Leg elevalion

tr Debridemenl
 ?AEV I W)

tr GEI\IERALIZED AFFECTION: tr IOCAIZED AFFECTION:

- Miliarg TB
- Pulmonary, rcnalIB Mediaetinal [Ne
Mesenteric Utle
Pathologg tr Organism reaches LNs fhrcugh

tr Affects ASecls
tr NO ...
Affectbn of capsule, Matfin!, Affection of bapsule, Maftin!,
Caseation, Cold abecess Casealion, Cold abecess
tr ... perforates deep fascia

Clinical pic{ure
tr Manifeslalions of Pulmonarg IB.. tr IB foxemia, manifeslations of Pulmonarg TB
Dgspnea, Gcough, Epecforalion, tr Affected Lltls:
hemoplgeis -
tr Affected Lftls: .MtrI
Enlarged

- Nol fender
tr Cold abscess) Flucluanl
Nol lender
tr Egslemic spread
tr Cold abscess, 8inus, l{OT COLD abscess (2rg infeclion)
E hessu?e manifestaiions
E Caloilicalion
lnvesfigalions tr TABOMTORY:
- Leuoopenia with relalive Lgmphocgtosis
- f EgR>100
tr FOR tNS) Aspiralion, 8mear, Biopsg under O.A.
tr FOR PULMOITIARY IB) X-rag, fuberculin fesl, Sputum analgsis

s:
(sun, air, nuifuifion) * Failure of medical TT
Anli-TB drugs * Biopsg
* Single accessible group of LNe Banalorial & *Banalorial &
(lNH + Rifampicin * ldrNlegfions: MedicalTTT MedicalTTI
Streptomgcin ) * Multiple grcups (BLOOD BORNE) Aspiralion bg tRepeated
* Bad general condilion Z-lechnique dressing wtth
Streplorngcin
*lnjection of
Blreptomgcin Powder
OR *Excision
lncision wilh
No application
of drains
 1*+4W'{r, A{W*IV7'.E#I ? hEY I vf1

DEFINITION: Accumulalion of lgmph in lhe interstial space due lo Lgmphatic

obslruclion with edema of +he overlging skin which becomes
INCIDENCE:
- More in
- !f Familial)
ORGANISM:
.
W. BANCROFTI
(

*
ffirrrrL
Lgmphedema Congenilal, Precox, Tarda * Filariasis
t Varicose Lgmphatics * lrradialion
*
.f Malignant Obslruclion (Brawng edema)
* Cellulitis
C TNCAtPICf,UFE
* Discomforl
* Swelling & Heaviness..
* Disturbance of function :
- Thickening of skin, Reslricled mobililg, Recurrent lnfeclions

Pffi soFqrcAr
Etr Exercise
E lnlermiftenl pneumalic Compression
Etr Knodoleon's Op
E lntermitlenl Compression Pump
Etr $wiss Roll cake' Op
A 4lagers- Band tr Ampulalion if hugelg
tr Anlibiolics
swollen, ulceraled, lnfecled
tr TTT of Cause
N.B. Results of surgeru
aren't promising
 ,rco.6 a.|m,Phvilgw ? hEv I v15

Paihologg tr TYMPH NODEB: tr LYMPH NODES:

- $lTE$: @[! llower deep ceMcal) Axillarg - 9ITEB: More ihan I group
) Mediastinal LNs) (MULTTCENTRTc)
tr MACRO$COPIC PICIURE: tr MACROSCOPIC PICTUR,E:
- Enlarged, discrete earlg) mafted laler - Earlg discrele) Amalgamated
- Rubberg
- CUT SECTION: Pink homogenous with loss
of archileclure, lnlacl capsule
gPtEEItl) Tofree Alrnond appearance
tr MICRO8COPIC PICIURE:
. REED.SIERNBERG CETLB
. PLEOMORPHISM
- loss of archilecfi.re
Clinical ACE& BD(: Adolescenl & middle age male ACE& 8EX: Exlremes of age, Male
picture CONSIITUTIONAT SYMPIOMS: tr SWEILING:
- Fever, llching, loss of weighf - Rapidlg progressive,
- Anernic rnanifeslalions. Hard) Amalgarnalion lafer
SWEILING: tr PAIN:
- 9lowlg progressive, rubbetg) matted - Pain & itching (After alcohol
tr PAIN: "Gordon'g tesl" or lale after
- Pain & itching (Affet alcohol inlake in{ihralion)
"Gordon's leslo or lale afrer in{iliration) tr ABDOMINAL SWETLING:
tr PRES8URE MANIFEEIAIIONS: - As Hodgkin's bul more common
- Mediastinal L.Ns ) dgspnea, dgspha$a,
hoarseness & Horner's.
tr ABDOMINAT 8WELLINO:
- Splenornegalg, Para-aorlic 1.N., inleslina!
Obslruclion & obslruclive
lnvestigalion o For diagnosis ) excision biopsg if t.N. is involved.
o For D.D. & staging:
a. CBC ( pancgrlopenia, & ESR > 100)
b. LFt (Obilirubin due lo obelruclive, HC or hemolgrtic)
c. KFf (t uric acid due lo lumor lgsis $)
d. CXR, Abdominal U/B & C.f., BM puncture.
e. Staging laparolorng is rarelg used (replaced bg SPIRAI CI Scan).
frealmenl I. GENERAL IREATMENT: CHEMOTHERAPY
Vrtamins, Blood lransfusion, lron lherapg ...(Multi-centric)...
2. DEFINIIIVE IREAIMENI As Hodgkin's lgmphorna *...
... according to siage... tN NODUTAR [YPE) Chlorambucil
- la, lb, lla) Radiother.apg IN DIFFUSE TYPE )
- Ilb) Radiotherapg + Chemotherapg Cgclophosphamide,
- ll!, lV) Chemotherapg Vincilsline & hednisone.

tr gtage l) Enlarged I group of Lil. above or below diaphragm tr Highlg rnalignanl B-celllumor
tr Stage tl) Enlarged more > I group of LN. above or below tr Eliologg : EBV, Malaria
diaphragm Easlern Afiica
tr Btage lll) Enlarged L[tl. above & below diaphragm tr Sile: t
tr Sfage lV) Extra-nodal afleclion (liver & bone marrow) E MicroscoDic Diclure:
 ilE+:IW'{r, htm*tfiilP#l ?hq7 I W

oF HoDqKll.l Ln lH{otr/h
( ACCoRDINq ro s:Ac,lhlc, )
la,lb,lla IIb III, M
RADIOTHERAPY RADIOTHERAPY
gUPRA. INFRA.
DIAPHRAGMATIC DIAPHRAGMATIC
LNs LNs

t I
MANTLE INVERTED "Y"
r) Musline
2) Vincrisline "Oncovin"
THERAPY THERAPY 3) Pro-carbazine
4l Prednisolone in ld, 4ft

l) Cgclophosphamide
(2-5) ... Vinuisfine, Pro-
catbazine, Prednisolone ...

@ Lowers Hgpercalcemia in late slages

V Relieve itching
g Raises lhe mood
g lmproves CBC, appetite

EI Biopsg
EI Laparolomg
g lnleslinal Obslruction
M Jaundice

M SUPRA.DIAPHRAGMATIC M INFRA.DIAPHRAGMATIC
- Cervical - Para-aoriic
- Mediasiinal - Pelvic
- Axillarg - lnguinal
- Bplenic axis
 X.E+:IW{r, A'.W;fN,VXf.#I

ARTERIAL SYSTEM
. lnlermittent claudication Mag be an indication for bgpass surgerg if it
interfere which the palient normal life.
. Sensorg loss mag be reversible after revascularization.
. ln diabetic fool infeclion drainage through a small incision over lhe
pointing area is enough in most patient and debridement should be
avoided especiallg in presence of good vascularizafion lo avoid excessive
bleeding.
. The presence of osteomgelitis of small bones of the foot might be an
indicalion for ampulalion in Septic fool infection in diabeiics.
. Allen lesl is done lo detecl Dominant blood supplg of the hand.

VENOUS SYSTEM
. Acule severe deep venous lhrombosis can present bg the limb
. A-Warm, swollen with tur$d calf muscles.
r B- Cold, swollen wilh sever cganosis.
. fhe main line of lreatmeni of lipodermatosclerosis is Cornpression elaslic
slockings.

LYMPHATIC SYSTEM
. Hodgkin's disease can presenl wilh 2rg lgmphedema if the inguinal LNs
are involved.
. Purilies is nol a marker of poor prognosis in Hodgkin's lgmphoma.
. Werghl loss more than lO%in the Iasf six monlhs, Night sweals, and
Reed-gternberg cells in the bone marrow are markers of poor prognosis
in Hodgkin's lgmphoma
 ilP+Imfi A.mcrhEwwl ? hqv t v+8

l. Palient wilh historg of mifra! slenosis

&AF presenfs with sudden onset of severe
pain in his lower limb, toes cannol be
moved, complele loss of sensalion, pallor
and pnogressive coldness of the limb.
O/E absent peripheral pulsation. No pasl historg lo claudication pain.
,4cntc isctlaflh
2. Old aged paiient wifh positive hisiorg to D.M , smoking, or hgpertension,
dgslipidemia & alherosclerosis presenls wilh cramping pain cornes on walking
&exercise ai {irsl with cerlain distance , relived bg stopping now lhe pain get
worse and forces him to stop associated with cramping pain in abdomen in
relation to meals.
6ltmb llrbclteuia dssutilttd lfffi pst +ba/ ailgrla,
3. Old aged patient with positive historg lo D.M, smoking, or hgperlension,
dgslipidemia & alherosclerosis presenls with persistent resl pain, presence of
ischemic ulcer or small gangrenous pafches.
Grfiical lmb bclwtrk
4. Young female presenls with bilateral pain and cganosis in tip of her fingers
precipitated bg exposure to cold or emolional slress. No irophic changes with
inlacl peripheral pulsation.
Rqruns dbasa/ n7
Youn! male heavg smoker complaining of chronic ischemia in a Iimb
Brgr s dbwa
6. 7- Uoung female complaining of tingling and numbness along the ulnar side of
lhe hand and forearm with weakness of small muscles of the hand also
claudicalion pain in upper limb with exercise.
Tltwanb atlet sytdrulla
7. Middle aged male or female presenls wiih slowlg growing swelling adjacenl lo
the hgoid bone, anterior lo slernomasloid, compressible, pulsalile, moves from
side to side not verlical.
GarotilMl fuma ( clte,nfutwttd.
8. Old age palienl with posilive hislorgto afherosclerosis or sgphilis presents with
cgslic compressible swelling a cross of arlerg, gives expansile pulsafion.
*fer,,U ailqolstt/
 1e,q*Twt5 ww/J.t71Rqw ?hqvtw

ioN
aa
,

DW " PDFs , C/P, lnvesligations, Fale & cornplicaiions"

(Kasn 2@Z 2W- Au shams, 2@5,2d/-
Azlur f,2@Z 2@4,2M-
Azhar rl/, 2ob, 2M, 2mL/)
Acute ischernia
(Kasn 2M. 2d/- Au sl/afils, 2@2, 2M, 2M -
Ay'rar f,2@6,2M- ,4y'tar ril, Zd, ZWS
Manifeslalions, Cornplicalions and TTT. of varicose veins
6i/ siafils,2W - Ay'rar f,2@5,2@4 -
,42/rar ril, 2oh, 2@Z 2@/)
r Diagnosis & fTT. chronic ischernia
Uh sfiart/s, 2@5,2fu)
r Chronic Venous insufficiencg
( Ailar f,2@7)
r Eiio-pathologg of lgrnphederna
( Kasn 2d/ )
5JP4-T0UI5 ww,Btrtv 5ll?q%l I t60

il
ao