Revision

Revision
of Surgery I

Index
Section 1: Cases 1
Section 2: Written Questions 12
Vascular surgery 13
Thyroid 15
Breast 18
Hernia, Skin and Subcutaneous Tissues, Head and neck 21
Jaundice, Liver, Gall Bladder 24
Gastrointestinal Emergencies 28
Gastrointestinal Miscellaneouses 29
Urology 32
Testis 33
Orthopedics 34
Chest surgery 36
Neurosurgery 37
Section 3: Explain 39
Special Thanks to Prof Amr El-Shayeb

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Revision of Surgery 1

Section 1: Cases
Case
number Diagnosis
Case 1 Open arterial injury of incomplete type
Case 2 Open arterial injury of complete type
Case 3 Arterial embolism
Case 4 Leaking aortic aneurism
Case 5 Diabetic foot infection with superimposed septicemia
Case 6 Iliofemoral deep venous thrombosis
Case 7 Thyrotoxicosis (mostly primary)
Case 8 Cancer thyroid
Case 9 Breast lump
Case 10 Malignant obstructive jaundice
Case 11 Hematemesis
Case 12 Rupture spleen
Case 13 Bleeding peptic ulcer
Case 14 Acute appendicitis complicated with appendicular mass
Case 15 Perforated peptic ulcer
Case 16 Pyloric stenosis
Case 17 Acute osteomyelitis
Case 18 Chest injury
Case 19 Tension pneumothorax
Case 20 Head trauma

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2 Summary of Special Surgery

Case 1 2.For arterial injury: INcomplete
a. if transverse tear : measure the tear
72 years old male come to ER 24hours after i. If < 1/2 circumferential : direct suture or patch graft
transfemoral coronary angioplasty with a ii. If > 1/2 circumferential : turn into and treat as
progressive pulsatile swelling in right femoral complete , do end to end anastomosis or vein graft
triangle, pulse 120/min, blood pressure 70/60 b. If longitudinal tear: vein patch graft
Analysis of the case: 3.Postoperative:
- After 24 hours: indicate hypovolemia especially with You should look for pedal (peripheral) pulsations for
tachycardia and hypovolemia 48 hours to ensure patency.
- Transfemoral angiography: mostly the arterial injury is -you should predict acute tubular necrosis and renal
incomplete shut down.
-you should predict possibility of myocardial
A. What is your diagnosis? infarction
Answer: Arterial injury (incomplete (open)
Case 2
B. What investigations would you order?
33 years old males presented to ER after he
Answer:
sustained a stab wound in the region below
• Investigations for the arterial injury:
left inguinal ligament. The wound was oozing
1. Angiography
red blood , pulse , 110/min , blood pressure:
2. Doppler ultrasound
80/60
3. Colored duplex
- Searching for the following findings:
Analysis:
· Site of injury
· Type of injury whether complete or incomplete -Stab wound: if arterial injury, it should be complete.
· Extent of injury -Below inguinal ligament: in femoral triangle.
· Presence of false aneurysm -Tachycardia and hypotension: indicating hypovolemia
· DISTAL RUN OFF -Bright red blood: excluding venous injury
• Investigations for cardiac condition: A. What is your diagnosis and differential
· ECG · Echocardiography diagnosis?
• Investigations to assess fitness for surgery: Answer:
- Kidney function tests - Diagnosis: open arterial injury of complete type.
· Serum urea, creatinine and creatinine clearance - Differential diagnosis:
· To exclude renal tubular necrosis 1. Incomplete arterial injury
- Blood sugar: for diabetes 2. Artero venous injury with later communication
- Cooagulation profile: especially prothrombin time 3. Muscular injury
and concentration B. What investigations would you order?
- Arterial blood gases and serum electrolyte Answer:
C. What is the treatment of the case? • Investigations for arterial injury:
Answer: 1. Angiography
• Correction of hypovolemia 2. Doppler ultrasound
1.For volume resuscitation: 3. Colored duplex
a. IV fluids ( Ringer's lactate or saline ) - Searching for the following findings:
b. fresh blood transfusion · Site of injury
c. volume expanders (dextran or gel fusion ) · Type of injury whether complete or incomplete
2.Proper oxygenation · Extent of injury
3.General care: discuss general care of patient from · Presence of false aneurysm
· DISTAL RUN OFF
management of class III / IV hemorrhage, page 13
· Absolute bed rest in trendelenburg position and warmth • Investigations to assess fitness for surgery:
· Analgesia (pethidine) - CBC: for hemoglobin and hematocrite
· IV Na bicarbonate to correct - Kidney functions tests: serum urea, creatinine and
· Inotropics and vasopressors
· Proper monitoring of vital signs creatinine clearance
- Coagualtion profile
• Treatment of arterial injury:
- Arterial blood gases and serum electrolytes
1.Exploration with evacuation of hematoma.

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C. Discuss clinical evaluation and preparation B. What investigations would you order?
for treatment. Answer:
Answer: • Investigations for cardiac condition:
Clinical evaluation: · ECG · Echocardiography
• Evaluation of hypovolemia: • Investigations for arterial embolism:
Discuss signs of hypovolemic shock, page 17 1.angiography
- CNS: anxious to drowsy 2.Doppler ultrasound
- Pulse: tachycardia (rapid, weak) thready 3.Colored duplex
- Blood pressure: hypotension - Searching for the following findings:
- Respiratory rate: tachycardia and air huger · Site of impaction of embolus
- Temperature: hypothermia · Extent of secondary arterial embolism
· Distal run off (collateral circulation)
- Skin: pale, cold, sweaty with collapsed vein
- Urine output: oliguria • Investigation to assess fitness for surgery
1.CBC: for hemoglobin & hematocrite.
• Evaluation of limb condition (viable or not
2. Kidney function tests.
viable): discuss 3. Liver function tests.
The 5 cardinal signs of acute ischemia, page 90 + C. What is the treatment of the case?
th
capillary circulation as 6 item.
Answer:
i- Pain: discuss
ii- Pallor: discuss 1. Surgery: Urgent embolectomy :
• Under Local Anaesthesia.
iii- Pulse: if peripheral pulse is :
• Immediate heparinization: to prevent propagation of
· FELT but weak: incomplete injury
arterial thrombosis.
· NOT felt: complete injury • Urgent embolectomy: Discuss.
iv- Parasthesia: discuss • Delayed embolectomy: Discuss.
v- Paraplegia: discuss • Complication of embolectomy & their treatment: Discuss
vi- CAPILLARY CIRCULATION : THE MOST 2. Fibrinolysins (Thrombolytic Therapy): Discuss.
IMPORTANAT ITEM: 3. Amputation: in late cases with limb gangrene.
· If present, so VIABLE limb
· If FIXED color changes, so NON viable limb. After correction of embolism, the patient should be
Preparation for treatment: transferred to cardiology department for proper cardiac
assessment & management.
• Investigations: as above
Case 4
• 4As:
· Analgesia · Antitetanic · Antibiotic A 75 years old patient came to ER with
· Anti shock measures: discuss correction of hypovolemia sudden severe epigastric pain referred to
• Predict and treat possible complications: back. On examination, there was pulsatile
A. Acute tubular necrosis and renal shut down: epigastric swelling. Pulse: 110/min, Blood
· From hypovolemia or from myoglobin from injured or pressure: 70/50, Respiratory Rate: 35/min.
ischemic muscle A. What is the Diagnosis & Differential
· Treatment: by forced diuresis by mannitol OR By dialysis
Diagnosis?
B. DVT and pulmonary embolism:
- Diagnosis: Leaking Aortic aneurism.
· Treatment: thrombolytic therapy.
C. Reperfusion injury: especially hyperkalemia - Differential Diagnosis: Pseudopancreatic cyst is the
· Treatment: IV glucose + insulin commonest Differential diagnosis:
D. Compartmental syndrome: • Disappear on sitting on knee-elbow position.
· Treatment: fasciotomy • By Barium Meal: Shows forward displacement of the
stomach in lateral view.
Case 3
B. What investigation would you order?
A 28 years old female with a history of mitral Answer:
stenosis presented to ER with sudden severe
• Investigation to reach diagnosis:
pain in Right lower limb, by examination, the
1.Abdominal scan
limb was pale and cold. 2.CT scan with IV contrast
A. What is your diagnosis? - Searching for the following findings:
Answer: arterial embolism

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· Site of the aneurism: supra- or infra- renal (above or · Serum electrolytes. · ECG.
below L2) C. What is the treatment of the case?
· Size of aneurism: if > or < 5 cm
· If there is a dissecting element or not.
Answer:
3.Angiography: after resuscitation & stabilization of • Treatment of Diabetic foot: Discuss ttt of Diabetic
general condition of the patient. foot
N.B.: Do NOT Order Doppler or Duplex; of NO
importance an a such a case • Treatment of Septicemia: Discuss ttt of Septic shock
• Investigation to detect possible complications: p.20. Note that some items are repeated the same as in
diabetic foot, Do NOT Repeat.
1. CBC, Hemoglobin & Hematocrite: for hemorrhage.
2. Kidney function test: -In ICU.
· Serum urea, creatinine, creatinine clearance. -Antioxidants: for oxygen free radicals.
· For possibility of acute tubular necrosis & Renal Shut- -Indomethacin: anti-inflammatory medications.
down by hypovolemia or involvement of renal A.
in Dissection. -Circulatory support by vasopressin & inotropes.
3. Investigation for lower limb ischemia: Doppler & -IV Na Bicarbonate for acidosis.
Duplex on lower limb vessels. - Proper monitoring: by CVP, ECG, PAWP, Pulse, Blood -
4. ECG & Electrocardiography: for Myocardial Pressure, Temperature, urine output, ABG
infarction. Case 6
5. Fasting Blood Sugar.
6. Coagulation profile: esp. Prothrombin Time & 31 years old female after labor developed
Concentration. severe pain & swelling of her right lower limb.
7. Arterial Blood Gases & Serum electrolytes. On examination, the peripheral pulses were
C. What is the treatment of the case? felt, vital signs are normal, No fever.
Answer: Analysis:
1. Correction of hypovolemia: Discuss · Felt peripheral pulses exclude ischemia.
2. Repair of aneurism: open surgery by opening the · No fever excludes cellulitis.
aneurism sac & implanting synthetic graft inside it. A. What is your diagnosis & Differential
3. Post operative ICU care: for proper maintaining & Diagnosis?
management of possible complications mentioned Answer:
above, Renal shut down, MI.
- Diagnosis: Iliofemoral Deep Venous Thrombosis.
Case 5 - Differential Diagnosis:
· Pblgmania Alba Dolens: Painful white swelling
A 68 years old male came to ER drowsy, - Pallor, coldness, diminished pulsations.
flushed with swollen warm left foot. The · Pblgmania Cerulae Dolens: Painful Blue swelling
- Cyanosis, severe pain, marked LL edema, venous gangrene.
patient is diabetics. On examination, Pulse:
120/min, Blood Pressure: 70/50, Temperature
Answer:
39, the foot was hot & tender. Analysis:
1.Doppler ultrasound
Hypotension, Drowsy & flushed indicate 2.Colored duplex
septicemia. 3.Venagraphy
A. What is your Diagnosis? 4.Helical 3D CT scan
Answer: Diabetic foot infection with superimposed - Searching for the following findings:
i. Level of thrombosis
septicemia. ii. If there are incompetent perforations
B. What investigations would you order? iii. State of superficial system
Answer: iv. Starting recanalization or not
C. What is the treatment of the case?
• Investigation for diabetic foot:
Answer: Discuss curative treatment of DVT,
1. Fasting blood sugar.
2.Culture & Sensitivity for pus from infected foot. prophylaxis treatment is NOT required.
3.Plain X-ray on foot: to exclude osteomyelitis. • Aims of treatment: enumerate
4.Doppler & Duplex scan on ankle vessels. • Lines of treatment:
• Investigation for septicemia & septic shock: 1.Bed rest & bandage: discuss
· Blood Culture. · Arterial blood gases. 2.Anticoagulants:
· Serum lactate. · Kidney function tests
· Liver function tests (Coagulation Profile)

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- Heparin: discuss mechanism of action, methods, *Postoperative L thyroxine replacement should be
duration & control of Administration, antidote & postponed till time of delivery to avoid fetal
complications of heparin.
hypothyroidism.
- Overlap: discuss
- Oral anticoagulants: discuss mechanism of action, Case 8
methods & control of Administration, antidote & A58 years old male presenting by recent hard
complications of oral anticoagulant.
3.Thrombolytic therapy: plasminogen activation swelling in the lower part of the neck with
4.Surgery: pain referred to ear, examination revealed
IVC interruption by filter insertion through jugular vein palpable firm neck node.
to prevent recurrent pulmonary embolism
A. What is your diagnosis and differential
Case 7 diagnosis?
34years old pregnant female (14week) Answer:
presenting with recent insomnia, loss of - Diagnosis: - cancer thyroid
weight, palpitation .on examination, she was - Differential diagnosis: - from other hard swelling in
found to have tachycardia and big pulse thyroid
volume. · Riedle’s thyroiditis · Calcified simple nodular goiter
A. What is your diagnosis? B. What investigation would you order?
Answer: thyrotoxicosis (most probably primary toxic Answer:
goiter, Graves’s disease) Discuss all investigations of cancer thyroid including those of
B. What investigations would you order? different pathologies (follicular, papillary, anaplastic,
medullary)
Answer:
1. T3, T4: obligatory free (more accurate), not total which is
C. What is the ttt of that case?
affected by proteinuria in pregnancy. Answer: discuss ttt of cancer thyroid
2. TSH: decreased • Operable case: discuss
3. ECG, Echocardiography, very important because • Inoperable case: discuss
hyperdynamic state of both pregnancy and • Histological surprise & prognosis: not required
thyrotoxicosis.
4. CBC, Hemoglobin and hematocrite: Case 9
- Because of: 43 years old female presenting with a lump in
· Physiological anemia during pregnancy the upper quadrant of her right breast
· Catabolic state of thyrotoxicosis A. Discuss differential diagnosis of this case
5. Neck ultrasound & colored duplex scan on Answer:
neck: Showing diffuse swelling & hypervascularity Enumerate all causes of chronic breast lumps
(Hallo sign) including hard & cystic masses
6. Serum Ca and alkaline phosphatase • Hard masses:
NB: thyroid scan must NOT be done because radioactive · Cancer breast · Hard fibroadenoma
iodine is teratogenic. · Chronic breast abscess · Duct ectasia
· Calcified hematoma · Traumatic fat necrosis
C. Discuss treatment of this case
Answer: • Cystic masses:
· Cyst of fibroadenosis
This pregnant female is at the start of second trimester · Retention cyst due to duct papilloma
*During this period, minimal dose of B blocker · Galactocele · Cold abscess
(propranolol,inderal) should be given till 3rd trimester · Hydatid cyst · Traumatic fat necrosis
- Mechanism of action, dose, side effects of inderal: discuss · Degenerated carcinoma
*Antithyroid drugs are TOTALLY CONTRAINDICATED,
to avoid fetal hypothyroidism.
*If developed severe manifestations of thyrotoxicosis
during 3rd trimester, go ahead for surgery; subtotal
thyroidectomy

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Table Differential diagnosis of most important causes of chronic breast lump
History General Local examination
examination
Breast mass Axillary nodes
Cancer breast · Accidental discovery Metastasis · Firm to hard. Enlarged, painless, hard,
of painless lump. · Early mobile, later fixed. early mobile, later
· ± Nipple discharge. · With FLAT UNDERSURFACE. fixed.
· ± Skin manifestations
Fibroadenoma Free Free · Extremely firm. No palpable Axillary
· Freely mobile (Breast mouse). nodes.
· Well defined, rounded.
Fibrocystic History of Free · Bilateral · Cystic · Tender No palpable Axillary
premenstrual tension · Mobile · Well defined nodes.
disease
syndrome (± discuss) · Felt ONLY by Tips not flat of hand
Duct papilloma Free Free · Firm · Mobile · Painless. No palpable Axillary
· Well defined. nodes.
· RETROAREOLAR
· With BLEEDING PER NIPPLE.
Duct ectasia Free Free · Firm · Mobile · Painless. No palpable Axillary
· Well defined. nodes.
· RETROAREOLAR
· With CREAMY NIPPLE
DISCHARGE.
Chronic breast History of lactational Constitutional · Well defined. · Cystic. With palpable TENDER
mastitis manifestations · TENDER. Axillary LNs.
abscess
· ROUNDES with LIMITED MOBILITY
Traumatic fat History of trauma Free · Firm to hard. No palpable Axillary
· Fixed. · Painless. nodes.
necrosis
B. What investigations are required to reach A. What is your diagnosis?

definitive diagnosis? Answer: Malignant obstructive jaundice (most
Answer: probably due to cancer Head of pancreas).
Table Investigations to reach definitive diagnosis B. What investigation would you order?
Step I Breast ultrasonography Answer:
Cystic Solid A. Laboratory investigations: Discuss laboratory
Aspiration Step II Mammography investigations of obstructive jaundice as before.
Searching for Searching for criteria of malignancy in 1.Urine analysis: absent urobillirogen, positive
criteria of mammography: enumerate (if billirubin & bile salts
malignant aspirate: suspicious of being malignant, do PET 2.Stool analysis: absent stercobillirogen & bile salts,
enumerate scan) increased fat may be occult blood.
Step III Biopsy 3.Liver function test:
1. Needle biopsy: - Increased total & direct billirubin, alkaline
a. FNAC b. True cut needle phosphatase enzyme
2. Surgical biopsy - Normal liver enzymes except if prolonged obstruction
a. Incisional b. Excisional - Gamma glutamyl transpeptidase
Tumor markers
Step IV - Prolonged Prothrombin time & lowered Prothrombin
concentration (Should be above 60% before
If proved to be malignant, so do: surgery, PTC, sphincterotomy)
· Estrogen receptor status · Metastatic work up
4.Kidney function test: to exclude renal impairment
GIT Surgery B. Radiological investigations: Discuss laboratory

investigations of malignant obstructive jaundice as
Case 10 before.
62 years old male patient, presented to 1.CT scan with IV contrast, investigation of choice
outpatient clinic with progressive jaundice, showing pancreatic tumors.
2. ERCP: diagnostic & therapeutic.
dark urine. On examination, a mass was felt • Inserting stent in.
in upper abdomen with pain referred to back. • Detect level of obstruction & causes.

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3. PTC: Especially in patients with cholongiocarcinoma: - Jaundice, manifestations of Liver cell failure in
show level & cause of obstruction. varices as:
4. Hypotonic dudenography: shows: · Ascitis. · Bleeding Tendency.
• 'Inverted 3' in periempullory carcinoma. · Palmar erythema, Spider nevi, Gynecomastia.
• 'C' in cancer head of pancreas. · Hepatic coma.
C. Treatment of the case • Local Examination:
Answer: i. Evidence of liver cell failure, Splenomegally & Ascitis in
bleeding varices.
Preoperative preparation of jaundiced ii. Pointing sign in bleeding peptic ulcer.
patient: Discuss. iii. Epigastric Tenderness in Gastric erosions.
B. Investigations:
Treatment: 1) Laboratory: Discuss Laboratory
• Operable cases: tests in investigations of
- For cancer head of pancreas: radical resection by hematemesis p.193.
Whipple's Pancreatoduodenectomy: Enumerate 2) Radiological: Discuss abdominal scan & CT in
- Structures to be removed in Whipple's operation, p. investigations of hematemesis p.194.
105. 3) Endoscopy: Discuss endoscopy in investigations of
¾ Structures to be removed in Whipple's operation: hematemesis p.193.
i.Head & neck of pancrease. · Investigation of choice, also therapeutic.
ii.While duodenum. C. Treatment:
iii.Gastric antrum. 1. Correction of hypovolemic shock: Discuss in brief.
iv.Gall bladder & CBD. 2. Specific management: if:
• Inoperable cases: • Bleeding varices:
- To prevent Encephalopathy: Discuss how to prevent
- Biliary stent: encephalopathy in active bleeding from varices, p.62.
· Internal by ERCP. · External by PTD. - To stop Bleeding: Discuss how to stop bleeding in active
- Surgical drainage by Cholecystojejunostomy. bleeding from varices, p.62 & 63.
Case 11 • Bleeding peptic ulcer:
A 45 years old female presented to ER with Choice of management depends on amount of
blood loss.
attack of hematemesis, - Surgical Treatment: if blood loss > 1L.
Discuss management of this case? i. Gastrotomy or Duodenotomy to visualize the ulcer;
Answer: the bleeding vessels are ligated under vision.
ii. Definitive ulcer treatment if good general condition:
Possibilities: · Truncal Vagotomy & Gastrojejonostomy. OR
1. Bleeding varices. · Billroth I partial Gastrectomy.
2. Bleeding peptic ulcer. - Conservative Treatment: if blood loss < 1L.
3. Gastric erosions. Discuss Conservative treatment of bleeding peptic
Management: ulcer, p.33.
• Gastric erosion: Discuss treatment of gastric erosion,
A. Clinical: p.21 & 22.
• History: Case 12
i.History of Bilharziasis, Jaundice, Ascitis, Previous
Sclerotherapy in bleeding varices. 8 years old boy presented to ER with in left
ii.History of ulcer dyspepsia & hunger pain in bleeding upper abdomen following abdominal
peptic ulcer. trauma.Pulse:120/min, BP: 90/60, with tender
iii.History ulcerogenic during intake as Aspirin & NSAIDs in
bleeding peptic ulcer. left hypochondrium.
• General Examination: A. What is your Diagnosis?
- Signs of Hypovolemia: Answer: Rupture Spleen.
· CNS: anxious to drowsy B. What investigation would you order?
· Pulse: tachycardia (rapid, weak) thready Answer:
· Blood pressure: hypotension
· Respiratory rate: tachycardia and air huger
Laboratory:
· Temperature: hypothermia i.CBC: Hemoglobin & Hematocrite.
· Skin: pale, cold, sweaty with collapsed vein ii.Coagulation profile.
· Urine output: oliguria iii.Arterial blood gases & electrolyte.
N.B.: if old patient, add investigations to assess fitness for
surgery.

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Radiological: - Irregular filling defect, ulcer niche outside ulcer
burning area, linitis plastica for cancer stomach.
Abdominal Ultrasonography & CT scan with contrast:
for the following: C. Treatment of the case
· Type & Degree of rupture spleen. Answer:
· Perisplenic hematoma. 1) Anti shock measures: Discuss in brief.
· Free fluid in peritoneal cavity.
· Other associated abdominal injuries. 2) Surgical treatment: conservative treatment is NOT
suitable in this case.
Others:
• Methods:
• Abdominal paracentesis: reveals blood. i. Gastrotomy or Duodenotomy to visualize the ulcer;
• Diagnostic peritoneal Lavage (DPL) : the bleeding vessels are ligated under vision.
- Criteria of positive DPL: Enumerate. ii. Definitive ulcer treatment if good general condition:
N.B.: Selective Splenic angiography should NOT be done · Truncal Vagotomy & Gastrojejonostomy. OR
because patient is in shock. · Billroth I partial Gastrectomy.
C. Treatment of the case
Answer: Case 14
A. Anti shock measures: Discuss in Brief. 28 years old female presented with history of
B. Urgent Splenectomy (Open or vague umbilical pain 3 days ago, now the
Laparoscopic): is the classic. pain is well localized to right iliac fossa. On
C. Splenic preservation: is considered as the patient examination, pulse 90/min, BP 120/80, temp
is CHILD: 38°c with a palpable tender mass in right iliac
i. Splenorrhaphy: suture of small lacerations or tears. fossa.
ii. Partial Splenectomy: if only avulsed one pole.
A. What is your diagnosis?
iii. Autosplenectomy: Discuss.
N.B.: Conservative non-operative management is totally Answer: Acute appendicitis complicated with
contraindicated because patient is in shock. Also, appendicular mass.
Therapeutic Embolization is NOT favorable line of
treatment.
Answer:
Case 13
60 years old male present with recent attack • Laboratory: CBC for Leucocytosis & ESR.
of vomiting of fresh blood, pulse 110/min, BP • Abdominal sonar: Discuss.
90/70. On examination there was epigastric • Laparoscope: Discuss.
tenderness, the patient mentioned he was C. Treatment of the case?
Answer:
receiving medications for dyspepsia.
A. What is your diagnosis & differential • Treatment of appendicular mass: Discuss.
• If complicated by appendicular abscess: Discuss
diagnosis? treatment of appendicular abscess.
Answer:
Case 15
• Diagnosis: bleeding peptic ulcer.
• Differential diagnosis: Cancer stomach.
32 year-old-male presented to ER with severe
B. What investigations would you order? epigastric pain with nausea & vomiting, pulse
Answer: 120/min, BP 100/70. On examination, ther
was tenderness & rebound tenderness in the
Laboratory:
epigasterium with shifting dullness. The
· CBC · Coagulation profile.
· ABG & electrolytes. · Liver function tests. patient gave history of recent intake of
· ECG & kidney function tests. NSAID.
Endoscopy: A. What is your diagnosis?
· Investigation of choice. Answer: Perforated peptic ulcer.
· Diagnostic for bleeding peptic ulcer.
· Therapeutic by injection sclerotherapy or laser B. What investigations would you order?
electrocautary. Answer:
Other investigations: should be done after initial The most important are laboratory & plain x-ray:
resuscitation. 1. Laboratory:
• Barium meal: i.CBC, leucocytosin, hemoglobin & hematocrite.
- Ulcer niche for peptic ulcer. ii.ABG, serum electrolytes & renal function tests.

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2. Plain x-ray abdomen erect reveals: - CBC, hemoglobin, hematocrite.
- Air under right copula of diaphragm. - Serum, electrolytes, PH.
- Multiple air fluid level. - Liver function test: most important is serum albumin.
3. Gastrografin swallow reveals: 2. Barium meal: soup dish appearance
- Escape of dye. - Discuss findings.
4. Sonar reveals: 3. Endoscopy: reveals:
- Intra-abdominal fluid. - Stenosed pyloric ring. - Retention gastritis.
- Excludes other causes. C. Treatment of the case?
5. Peritoneal tapping. Answer:
6. Endoscopy.
Preoperative preparation: all initial effort is
C. Treatment of the case
directed at building up nutritional status of the patient
Answer:
in order to decrease complications of surgery.
• Preoperative urgent resuscitation: Discuss, similar i. Nasodigastric tube suction.
to IO) ii. High protein diet.
• Operative: iii. Correction of fluid, electrolyte disturbance.
iv. Chest physiotherapy & antibiotics.
1.Simplest, most popular: is omental patch: Discuss.
2.Definitive ulcer treatment:
Surgery:
- Provided that: 1. Truncal vagotomy & posterior gastrojejonostomy
· The patient is generally fit. for drainage of obstructed stomach.
· The surgeon is competent. 2. If stomach is hugely dilated, so do partial
· The hospital is well equiped. Gastrectomy.
- So defenitive ulcer surgery should be done: Case 17
· For duodenal ulcer, do vagotomy &
gastrojejunostomy. 7 years old boy brought to ER, complaining of
· For gastric ulcer, do partial gastrectomy & inability to walk with severe pain over his
gastroduodenostomy.
lower right thigh. There was history of mild
• Postoperative care:
trauma 1 month ago. On examination, severe
· Continue preoperative care, then:
· The patient should continue on medical conservative tenderness & hotness over lower right thigh
treatment of peptic ulcer (antacids) provided with diffuse swelling. P 110/min.
the simplest procedure was done. temperature 39°.
Case 16 A. What is your diagnosis & differential
32 years old male presented with upper diagnosis?
abdominal distension,vomiting after meals Answer:
wih old history of dyspepsia which was • Diagnosis: Acute osteomyelitis.
medically treated on examination rital signs
• Differential diagnosis:
are normal with hyper resonance,distended
- 2 Tumors:
upper left abdomen. i. Osteosarcoma.
A. What are the possible causes? ii. Ewing’s sarcoma.
Answer: - 2 Arthritis
iii. Septic arthritis.
• Possible diagnosis: pyloric stenosis due to iv. Rheumatic arthritis.
scarred(fibrosed) duodenal ulcer. v. Cellulitis.
• Diffrential diagnosis: from other causes of pyloric B. What investigations would you order?
stenosis except congenital. Answer:
- Traumatic: impact foreign body or corrosive stricture. • Laboratory:
- Inflammatory: crohn’s disease. - Blood picture: Leucocytosis & ESR.
- Neoplastic: cancer pylorus, less commonly liomyoma. - Blood culture.
- Pressure from out side: lymph nodes, Cancer head of • Radiological:
pancreas, pseudo pancreatic cyst.
- Radio isotopic bone scanning:
B. What investigations would you order? · Increased activity in early stages of inflammation.
Answer: - Pain X- Ray:
1. Laboratory: · No bony changes before 3 weeks. Changes
indicate chronicity.

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C. Discuss clinical picture & X-ray finding Answer: Discuss urgent investigations in cases of chest
Answer: injuries.
• Clinical picture: Discuss clinical picture of acute • Laboratory: Discuss.
osteomyelitis. • Radiological: Discuss.
• Plain X- ray finding: • Instrumental:
· ECG, Echocardiography. · CVP.
- No bony changes before 3 weeks. · Thoracocentesis: Discuss.
- Changes appear in chronic condition in form of: · Bronchoscopy. · Esophagescopy.
· Involucrum: New bone formation. C. What are the possible diagnosis & its
· Sequestrum: Separated dead pieces of bone.
· Abscess. · Sinuses. management?
· Cloaca: Openings. Answer:
D. Treatment of the case Possible Diagnosis:
Answer: Discuss treatment of acute osteomyelitis. 1. Fracture ribs & flail chest:
Case 18 • Management:
30 years old male brought to ER after road i. If small: cotton bad & adhesive plaster.
ii. If severe in old: Intermittent Positive Pressure
traffic accident, alert but Dyspnic, Pulse Ventilation.
140/min, Bp 90/60. Temperature 37°. There 2. Hemothorax:
were abrasions & contusions on his left chest • Management:
wall. Abdominal examination is free. Intercostal tube inserted at 5th space midaxillary line,
connected to underwater seal drainage or
Analysis: Thoracotomy.
· Alert: No head injury. 3. Tension Pneumothorax (provided the patient has
· Dyspnic: indicating chest injury.
· Severe tachycardia, hypotension: shock. Tracheobronchial tear).
· Free abdominal examination with left chest injury: No • Management:
nd
rupture spleen. - Wide bare needle in 2 intercostals space,
th
A. How to proceed to proper clinical midclavicular then intercostals tube in 5
Intercostal space midaxillary.
examination? - Surgery if bronchopleural fistula (continuous
Answer: bubbling of air in Intercostal tube).
Main causes of death in cases of chest
trauma: Case 19
i. Circulatory failure.
ii. Respiratory failure.
25 years old male injured in a car accident. He
First aid measures: was alert but very Dyspnic. Examination
1. Support circulation by anti shock measures:
reveals Hyperresonsnce & diminished air
Discuss in brief. entry on right side.
2. Support respiration: Discuss management of the case
• General: Analysis:
i. Maintain patient upper airway. · Alert: No head injury.
ii. Analgesics. · Severe Dyspnic: serious chest injury.
iii. Aspirate secretions. Answer:
iv. Proper oxygenation:
By: Diagnosis: Pneumothorax, most probably tension
· O2 mask. · Tracheastomy. Pneumothorax.
· Endotracheal tube & mechanical ventilation.
If: Management:
· RR > 40/min. · PO2 < 60 mmHg. • Main causes of death in cases of chest injuries:
· PCO2 > 45mmHg. · Flail chest.
• Circulatory failure.
· N.B.: No head trauma in this case.
• Respiratory failure.
• Specific: For flail chest:
Support of flail segment by external Strapping or • First aid measures:
positive pressure ventilation. 1.Support circulation by anti-shock measures:
B. What investigations would you order? Discuss in brief.
2.Support respiration:

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• General: Answer: From management of head injuries.
i. Maintain patient upper airway.
ii. Analgesics.
Initial care at hospital (emergency room):
iii. Aspirate secretions. Discuss from page 190.
iv. Proper oxygenation: Initial examination: Discuss from page 190,191.
By: · Glasgow coma scale: Discuss (already discussed).
· O2 mask. · Tracheastomy.
· Endotracheal tube & mechanical ventilation. Urgent investigations: Discuss from page 191,192.
If: Nursing care & observation & repeated
· RR > 40/min. · PO2 < 60 mmHg.
· PCO2 > 45mmHg. · Flail chest. observation: Discuss from page 192.
· N.B.: No head trauma in this case. · Causes of deterioration of patient under observation
• Specific: For tension Pneumothorax. after head trauma: Enumerate.
- Wide-bare needle (14-16) inserted in 2nd Management of injuries: Discuss from page 193.
intercostals space, Midclavicular.
• Urgent investigations:
• Laboratory: Discuss.
• Radiological: Discuss.
• Instrumental:
· ECG, Echocardiography. · CVP.
· Thoracocentesis: Discuss.
· Bronchoscopy. · Esophagescopy.
• Specific treatment: Tension Pneumothorax
Management:
nd
- Wide bare needle in 2 intercostals space,
th
midclavicular then intercostals tube in 5
Intercostal space midaxillary.
- Surgery if bronchopleural fistula (continuous
bubbling of air in Intercostal tube).
Case 20
30 year patient admitted to ER after head
trauma. The patient was drowsy. After few
hours, the level consciousness started to
deteriorate.
A. Mention two causes for deterioration of
level of consciousness?
Answer:
i. Massive brain edema.
ii. Intracranial hematoma.
iii. Airway obstruction & hypoventilation.
B. What investigation would you order?
Answer:
Glasgow coma scale to assess condition:
Discuss from page 191.
Laboratory investigations: very important:
· ABG: PO2, PCO2. · Serum electrolytes.
· Blood gases. · Renal function tests.
· Blood picture.
Radiological investigations:
· Plain X-ray.
· CT brain with IV contrast, MRI: for intracranial
hematomas.
N.B: DO NOT mention lumbar puncture; it is
contraindicated.
C. Discuss treatment of condition

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Section 2: Written Questions

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· Complete venous obstruction
Vascular Surgery · Cyanosis, severe marked U edema (Compartemental

Syndrome) causing Venous gangrene
• Late complications:
1. Secondary varicose veins & their complications:
1. Enumerate causes and discuss complications Discuss skin & vein complications of varicose veins,
page 131
of acute ischemia. 2. Chronic venous insufficiency (post-phlebitis
Answer: limb): discuss
• Causes of acute ischemia: enumerate the 5 causes of 5. Discuss clinical picture and investigations of
acute ischemia DVT.
1. Embolism 2. Acute thrombosis Answer:
3. Arterial injuries 4. Phlegmasia alba dolens
5. Dissecting aneurysm • Risk factors: enumerate risk factors for DVT
• Complications of acute ischemia: - Post-operative: THE COMMONEST
- Complications of acute ischemia: - Females during pregnancy and perpurium
- Old age, malignancy, obesity and delivery
1. Secondary distal thrombosis: discuss - Contraceptive pills
2. Nerve ischemia: discuss • How to suspect DVT after operation: if fever,
3. Peripheral Edema: discuss
tachycardia, increased ESR in early post operative
4. Incomplete recovery: discuss
period, unexplained from operation
5. Moist non septic gangrene: describe
· Black swollen edematous limb with skin blebs and • Symptoms and signs: discuss
offensive odor. • Differential diagnosis:
6. Volkman ischemic contracture: define - From other causes of leg swellings: enumerate causes of
· Massive infarction of forearm flexors, followed by leg swellings.
fibrosis contracture and deformity, when brachial A. is - From other causes of leg pain: enumerate causes of leg
injured due to supracondylar fracture of humerus. pain
- Complications of treatment: • Investigations:
1. Sudden death due to pulmonary embolism 1. Doppler ultrasound
2. Compartmental syndrome: discuss 2. Colored duplex
3. Reperfusion injury: discuss 3. Venagraphy
2. Discuss management of arterial embolism 4. Helical 3D CT scan
Answer: Discuss management of arterial embolism 5. Radio-iodine labeled fibrinogen.
-Searching for the following findings:
including differential diagnosis with Acute i. Level of thrombosis
thrombosis ‘Table p.95’ ii. If there are incompetent perforations
3. Discuss predisposing factors for DVT. iii. State of superficial system
iv. Starting recanalization or not
Answer: • Complications: discuss, enumerate or ignore according
• Virchow's triad: discuss to marks and time of question.
• Abnormalities of thrombosis & fibrinolysis: 6. Give an account on capillary hemangioma
enumerate Answer:
4. Discuss fate & complications of DVT. • Definition: define capillary hemangioma
Answer: • Differences between hamartoma and true
Fate of DVT: discuss fate of venous thrombosis. benign tumors: discuss
Complications of DVT: • Types:
• Early complications - Strawberry angioma: discuss
1. Pulmonary embolism: - Port wine stain: discuss
· Fatal type: discuss - Spider naevi: discuss
· Massive type: discuss - Hereditary hemorrhagic telangectasia: discuss
· Moderate type: discuss 7. Discuss pathology of TB lymphadenitis.
· Recurrent showers: discuss
2. Venous gangrene: phlegmasia cerulae dolens: Answer:
discuss • Organism: human or bovine bacilli
· Painful blue swelling

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• Types: · Evident well-defined primary malignancy of head
&neck e.g. (Cancer thyroid, cancer tongue, cancer
1. Blood borne TB: military TB in immunocompromised anal cavity)
adult patient, rare condition · Hidden malignancy e.g. (Cancer pharynx and larynx)
2. Lymph borne TB: localized to upper deep cervical · Metastasis first presentations with occult primary e.g.
LNs in children (In cancer thyroid with lateral aberrant LNs)
• Fate of lymph borne TB: - LNs: hard, painless, early mobile later on fixed to
Fate depends on body resistance and virulence of surroundings.
organism: Investigations:
· Body resistance = virulence of organism: discuss
• Laborotomy:
· Body resistance › virulence of organism: discuss
· Body resistance < virulence of organism: discuss 1. Blood picture:
· To exclude leukemia
• Complications: enumerate · Leucocytosis in acute inflammation
• Gross description: · Lymphocytosis in chronic inflammation
- Matted LNs due to peri-adenitis 2. ESR
- Rosary beads 3. Serum LDH: characteristically increased with lymphoma
4. Tuberculin test & PCR
• Pathology of blood borne TB: discuss 5. Bone marrow aspirate: for leukemia & lymphomas
8. Discuss pathology and complications of • Radiological:
Lymphedema 1. Chest x-ray: for TB
2. Abdominal Ultrasonography & CT: for assessment of:
Answer:
· Paraortic LNs
• Definition: define Lymphedema · Liver & spleen involvement
· Other visceral involvement esp. in lymphoma
• Causes: Enumerate causes of Lymphedema
3. Lymphocentography
- Filariasis: discuss N.B. P.137
• LNs BIOPSY: THE MOST IMPORTANT INVESTIGATION
• Pathology: discuss 4 stages of Lymphedema
10. Discuss Differential diagnosis of leg ulcers
• Complications: enumerate.
Answer:
9. Discuss differential diagnosis of enlarged
1. Vascular ulcers:
upper deep cervical LNs. What investigations · Venous ulcers: describe
you need to reach diagnosis? · Ischemic ulcer: describe
Answer: · Lymphedema ulcer: describe
2. Traumatic ulcers (neuropathic):
Differential Diagnosis: Enumerate causes of diseases · Diabetic ulcer
of LNs p.140 · Spinal cord lesion (esp. syringomyelia)
-Among the above mentioned causes, the most 3. Inflammatory:
important are: Chronic inflammatory: TB, chronic osteomyelitis
• Tuberculosis: Discuss clinical picture &complications of 4. Neoplastic:
TB lymphadenitis · Squamous cell carcinoma: describe
-Children with poor general condition · Ulcerating malignant melanoma: describe
-LNs: matted due to periadenitis, with rosary beads 5. Blood: sickle cell anemia (vaso-occlusive)
-Complications: enumerate. 6. Others:
• Lymphomas: · Autoimmune diseases (SLE, SS)
*Non Hodgkin’s lymphoma: · Rheumatoid diseases.
· Affected LNs are amalgamated with heterogenous
consistency, early mobile later on fixed
*Hodgkin’s lymphoma:
- LNs: firm, mobile, rosette shaped
- Systemic manifestations:
· Pel – Ebstein fever: 2 weeks of fever alternating with
2 Weeks of freedom
· Pain at the site of disease induced by alcoholics.
• Metastasis:
- Presented either:

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2.Superior mediastinal syndrome: discuss symptoms of
Thyroid superior mediastinal syndrome
• Signs: discuss signs of superior meditational syndrome
Inspection, palpation, percussion: discuss
1. Give an account on thyroglossal duct
Differential diagnosis: from other causes of
Answer: superior mediastinal syndrome: enumerate.
Anatomical consideration: discuss embryology of · Thymoma · Aneurysm of aortic arch
thyroid gland page 148 · Enlarged superior mediastinal syndrome
rd
Thyroid gland appears at the 3 week IU as a median Investigations: in order of importance
epithelial growth at the floor of primitive pharynx 1. CT SCAN CHEST: discuss: MOST IMPORTANT
(foramen cecum) .It descends to lower part of front of 2. Tc 99 thyroid scan: thyroid traced in chest not in neck
the neck connected to foramen cecum of tongue by
3. Chest x ray
THYROGLOSSAL DUCT which disappears before birth.
Treatment: only treatment is surgery
Definition: unobliteration remnant of thyroglossal duct, - Discuss treatment of retrosternal goiter
considered as tubulodermoid cyst.
- Preoperative preparation of thyrotoxic retrosternal
Pathology: discuss including site goiter patient: discuss (NB)
Complications: COMMENST is abscess and fistula 3. Discuss complications and treatment of
(ALWAYS ACQUIRED) then discuss thyroglossal fistula.
simple nodular goiter.
Clinical picture: Answer:
- Discuss clinical picture of thyroglossal cyst
- OR by fistula
Complications:
1. Tracheal obstruction by compression: discuss
Differential diagnosis: from other causes of cystic
2. Secondary thyrotoxicosis: discuss pathophysiology of
swelling in the midline of the neck
secondary toxic goiter page 160
Enumerate cystic swelling of midline of neck page 294
· Cold abscess · Dermoid cyst - Long standing simple nodular goiter before toxicity
· Sub hyoid bursitis · Laryngocele due to stimulation of internodular tissues
· Cystadenoma of thyroid isthmus by thyroid antibodies.
Treatment: discuss Sistrunk operation (this NOT - Nodules are inactive, while the internodular thyroid
considered operative details) tissues are overactive.
2. Give an account on RETROSTERNAL goiter. 3. Malignant transformation into follicular
Answer carcinoma in 3%
Discuss behavior of follicular carcinoma of thyroid
Definition: it is an anatomical entity NOT a pathological
page 171
one
- Incidence: 17% - Females
Anatomical consideration: discuss attachment of - Little TSH dependent - Radioactive iodine uptake
pretracheal fascia page 148 - Bad response to radiotherapy - Mortality rate: 24%
Thyroid gland moves up and down with deglutition, being 4. Cyst formation: discuss
enclosed within pretracheal fascia which is attached to: 5. Hemorrhage into cyst
· Above: to hyoid bone and oblique line of thyroid cartilage 6. Calcification: discuss
· Below: to adventitia of aortic arch 7. Retrosternal goiter
· Laterally: to carotid sheath - Retrosternal extension: discuss its pathology from P 176
· At the isthmus: fuses to tracheal rings 2, 3, and 4
- Plunging goiter: discuss its pathology from P 176
So it is retromanubrial extension
- Do NOT discuss intrathoracic goiter.
Types:
Treatment:
1.Retrosternal extension of large goiter: discuss: will
eventually pass into plunging goiter. • Prophylactic:
2.Plunging goiter: discuss By correction and avoidance of predisposing factors for
3.Intrathoracic goiter: discuss physiological and colloidal goiter: (enumerate causes of
Clinical picture: simple goiter page 156)
- Iodine deficiency: relative or obsolete
• Symptoms: 2 main presentations: - Enzymatic deficiency: Pendred's syndrome by screening
1.Thyroid disease: either (just enumeration) - Goitrogens
· SNG · Toxic goiter OR · Malignant goiter • Curative:

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- Indications: Treatment:
· Complications: (enumerate if the question is 1. If cyst, so do aspiration:
treatment only)
- If you find criteria of malignant aspirate which are:
· Cosmetic disfigurement
· Hemorrhage · Residual mass after aspiration
- Procedure:
· Rapid accumulation of fluid
· For solitary nodule: hemithyroidectomy = one lobe + isthmus
· For multinodular: subtotal thyroidectomy, discuss
· +ve cytology for malignant
- Postoperative: · L thyroxine: discuss , So proceed to surgery
NB: NOT below 25 years: discuss 2. If benign condition, hemithyroidectomy is enough
4. How can you solve a problem of solitary 3. If malignant condition:
nodule? - If papillary: proceed to total thyroidectomy, being
multicentric
Answer: - If follicular:
Definition: either · If non invasive: hemithyroidectomy is enough
· If invasive: proceed to total thyroidectomy
- True solitary: define OR - Dominant nodule: define
Causes: enumerate the 6 causes of solitary thyroid nodule 5. Discuss postoperative complications of
Differentiation by history, general and local thyroidectomy operation.
examination Answer
Table General postoperative complications:
Differentiation between different causes of solitary thyroid nodule
History General Local examination enumerate

examination 1-Shock 2-Hemorrahge
Carcinoma -recent swelling +/- metastasis Swelling: 3-Infection 4-Pulmonary complications
rapidly · Firm to hard
progressive · Painless Local manifestations:
- pain referred to · Early mobile, later fixed
ear +/- palpable enlarged LNs in neck 1. Recurrent laryngeal N. injury
Toxic Metabolic , CNS, Metabolic , Signs of hypervascularity : · Unilateral partial: discuss · Unilateral complete: discuss
CVS, symptoms CNS, CVS, - Inspection:
nodule · Bilateral partial: discuss · Bilateral complete: discuss
of thyrotoxicosis signs of • Visible pulsation
: discuss thyrotoxicosis • Dilated veins over neck
: discuss - Palpation: warm
2. External laryngeal N injury
• Palpable thrill 3. Hypoparathyroidism
• Palpable expansile pulsations
- Auscultation: audible bruit - Cause: discuss
- Clinical picture: discuss latent and manifest tetany
Simple -ve -ve Swelling:
nodule - firm -painless -mobile 4. Hypothyroidism &myxedema: from removal of too
+/- complications
much gland
Adenoma As simple nodule , differentiated by biopsy
5. Progressive exophthalmos:
Cyst Swelling : cystic either by cross
fluctuation or Paget's test - In some toxic patients, not treated and before
Localized May find history May find Swelling : operation (for at least 6 months)
of other features of - Firm - tender - mobile
hashimoto autoimmune autoimmune +/- enlarged LNs in neck(inflamed) - Treatment: discuss
disorders disorders
6. Thyrotoxic crisis:
Investigations: - Causes, clinical picture, treatment: discuss
Table Investigations for solitary thyroid nodule 7. Injury of important structure: trachea, esophagus,
T3, T4, thyroid scan muscles, hematoma
, hot Normal, cold nodule
nodule 8. Recurrence of thyrotoxic manifestations: due to
Neck ultrasound
Toxic Cyst Solid inadequate removal of thyroid tissue.
nodule
9. Keloid and adherent scar: in low manubrium area.
Thyroid antibody titer
+ve - ve 10. Post operative dyspnea: enumerate its causes
Localized Simple nodule, 6. Causes and management of dyspnea in post
hashimoto Malignant nodule or
Adenoma thyroidectomy cases.
Differentiated by:
- Tumor markers
Answer
- Biopsies: Causes and their management:
FNA, True cut needle,
open biopsy 1. Recurrent laryngeal nerve injury:

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- Management: tracheostomy - Discuss pathology of medullary carcinoma & lymphoma of
2. Hypoparathyroidism: thyroid.
- Management: IV calcium gluconate 9. Discuss outline of treatment of Grave’s
3. Thyrotoxic crisis: disease
- Management: discuss management of thyrotoxic crisis Answer:
4. Injury of important structures: 1. Medical treatment:
• Tracheal injury:
• Indications:-
- Management: by repair
· For a period of 18 months · Children & young pts
• Hematoma compressing trachea: · Pre-operative preparations
- Management: by evacuation · Post – operative recurrence · Refusal of surgery
5. Tracheomalacia: • Contraindications
- Discuss tracheomalacia · Retro-sternal extensions · Pregnancy & lactation.
- Management: tracheostomy NB: - don’t say ‘Toxic autonomous nodule”
6. Postoperative pulmonary complications • Lines of treatment: discuss
A. Atelectasis:
• Drugs used:-
- Define: obstruction of tracheobronchial tree by thick mucus
i. B- blocker: discuss (mainly mechanism & side effect)
plug
ii. Anti –thyroid drugs: discuss (mainly mechanism & side
- Management: discuss management of atelectasis "book effects)
special surgery page 172"
• Disadvantages: discuss
· Expel obstructing plug by: turning patient, percussing
· Mucolytic · Expectorant 2. Radio active iodine:
· Antibiotics · Suction • Indications:-
B. Pulmonary embolism: · Recurrence of toxicity after operation
- Cause: Vircow's triadDVT Pulmonary embolism · Thyrocardiac pt or refusal of surgery
- Treatment: · After Age above 45 years
· Thrombolytic therapy · Heparin and oral anticoagulant NB: - DON’T mention (toxic autonomous nodule)
C. Adult respiratory distress syndrome: • Contraindication:-
- Definition: syndrome of acute respiratory failure with the · Young age · Pregnancy & lactation · Iodine allergy
formation of a non cardiogenic pulmonary edema • Mode of action, onset, dose: discuss
leading to reduced lung compliance &hypoxemia
• Complication: discuss
refractory to O2 therapy
· Diffuse pulmonary infiltration on x ray 3. Surgery:
· Pulmonary A. wedge pressure < 16 mmHg • Indication:-
· PO2/ Fi O2 ratio: of < 200 mm Hg · Severe toxicity · Retrosternal goiter · Failed medical ttt
- Treatment: discuss treatment OF ARDS “book special
• Pre operative preparation: discuss
surgery, page 175”
7. Discuss outlines of treatment of cancer • Operation: subtotal thyroidectomy
thyroid • Post-operative follow up: discuss
Answer: • Complication: enumerate
- Treatment of Operable cases: discuss 4. Special problems with toxicity:
- Treatment of Inoperable cases: discuss A. Thyrotoxicosis in pregnancy: discuss
- Treatment of complications: discuss B. Thyrotoxicosis in children: discuss
- Postoperative follow up: discuss C. Thyrocardiac pt: discuss
- Histological surprise: discuss - Prognosis: discuss D. Progressive exophthalmos: discuss management
8. Compare between different types of cancer only (cause not required)
thyroid in table form? E. Recurrent thyrotoxicosis after surgery: discuss
Answer: F. Thyro-toxic crisis: discuss management only (cause
- Discuss pathological differences between different types & clinical picture not requried)
of adenocarcinoma (follicular, papillary, and anaplastic)
in table form, including following items: Incidence, Age,
Sex, microscopic picture, multiplicity, spread &behavior.

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Table How to differentiate between causes of nipple discharge
Breast Nature of
discharge
Associat
ed mass
Unilateral
or bilateral
Single or
multiple
ducts
Cancer breast Serosangious Yes unilateral Multiple
1. Discuss management of acute breast abscess or bloody (usually)
Duct Bloody Yes Unilateral Single
Answer: papilloma
Duct ectasia Creamy , Yes Unilateral Single
Clinical picture: cheesy,
brownish (if
• Symptoms: lactating female with redness, hotness & 2ry infected )
or bloody
pain in her breast Fibrocystic Serous or Yes Bilateral Multiple
• Signs: disease serosanginous (masses)
Pills Serous No Bilateral Multiple
- General: general constitutional symptoms & sings: Galactorrhea Milky No Bilateral Multiple
enumerate Inflammation Purulent (may be Unilateral Single
- Local: abscess)
· Breast: discuss breast signs in milk engorgement, acute Severe Bloody Yes Unilateral Single
mastitis & acute abscess including the following trauma
items: pain, fever & physical signs - In addition to the above mentioned criteria,
· Axillary nodes: enlarged, firm, tender, mobile general examination may reveal:
Differential diagnosis: from mastitis carcinomatosa i. Constitutional manifestation: for inflammation
Discuss difference between lactational mastitis & mastitis ii. Signs of metastasis: for cancer
iii. Signs of endocrine disturbance: for galactorrhoea
carcinomatosa in a table form, from page 197
In other conditions, general examination may be free
Complications: • Investigations:
1.Milk fistula: pointing into skin
1. Cytological examination of discharge: looking for
2.Antibioma (chronic breast abscess): if acute abscess RBCs. Pus cells, inflammatory cells, malignant cells
heavily antibiotics without drainage of acute abscess
2. Ultrasound on breast:
3.Toxemia: due to spread into circulation If cyst, do aspiration: looking for criteria of malignancy
Investigations: aspirate (enumerate):
- ESR & total leucocytic count: leucocytosis · Hemorrhagic · Rapid re-accumulation
- Mammography: to exclude mastitis carcinomatosa · Residual mass · +ve cytology
3. Mammography: if not cyst by sonar
Treatment: Looking for criteria of malignancy: enumerate
• Prophylaxis: discuss · Micro density · Hyper dense
• Treatment: · Hyper vascular mass
4. Biopsy: if associated with a mass
- Treatment of acute mastitis: discuss
· FNAC · True cut needle
- Treatment of acute abscess: · Open surgical biopsy
· NEVER wait for fluctuationevacuation
· Under general anesthesia
Treatment: discuss treatment of nipple discharge
· Discuss treatment of acute abscess 3. Discuss differential diagnosis & management
2. Discuss differential diagnosis & management of a case of bleeding per nipple:
of a case of nipple discharge Answer:
Answer: Discuss the full differential diagnosis & management
Differential diagnosis: of the following 5 conditions:
1. Cancer breast 2. Duct papilloma
• Possible causes: 3. Fibroadenosis 4. Inflammation severe
1. Cancer breast 2. Duct papilloma 5. Breast trauma
3. Duct ectasia 4. Fibrocystic disease 4. Discuss differential diagnosis & investigations
5. Pills 6. Galactorrhoea
7. Inflammation 8. Severe trauma of a case of chronic breast lump.
• How to differentiate: Answer:
- Enumerate ALL causes of chronic breast lump including
hard & cystic swellings.
- Discuss differential diagnosis of the most important 7
causes of chronic breast lump concerning history,
general examination & local Examination, from case 9

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- Discuss Scheme for investigations required to reach 2. Puckering:
definitive diagnosis of a case of chronic breast lump, · Discuss · NOT pathognomonic
from case 9
3. Peau d’orange:
5. Give an account on pathological · Discuss · NOT pathognomonic
classification & staging of cancer breast 4. Skin nodules:
Answer: · Discuss · Pathognomonic
Pathological classification of cancer breast: 5. Cancer en cuirass: discuss
1. Lobular carcinoma: from acinar epithelium 6. Malignant ulcer:
A. Non invasive: · Discuss · Pathognomonic
-Multicentric -Never turn invasive 7. Dilated veins over skin of the breast
B. Invasive: 8. Mastitis carcinomatosa:
-Bilateral mirror image in 25% of cases.
- Discuss criteria of mastitis carcinomatosa from
2. Duct carcinoma: from duct epithelium. table P 197:
A. Non invasive (DCIS): · Extensive lesions affecting >1/3 breast, with dusky red
i. Papillary tumor: discuss color
ii. Comedo tumor: discuss · Breast is mildly tender, with non tender axillary LNs
B. Invasive: with no response to antiobiotics in one week course
i. Scirrhous carcinoma: discuss gross & microscopic 9. Paget’s disease of areola and nipple:
picture of schirrous carcinoma. - Discuss criteria of Paget’s eczema from table P
- Atrophic schirrous carcinoma: 198:
· Subtype from schirrous carcinoma · Unilateral well defined eczema with NO itching,
· Discuss atrophic schirrous carcinoma vesciles or oozing
ii. Medullary carcinoma (Encephaloid Carcinoma): · Nipple is eroded
Discuss gross & microscopic picture of medullary · Breast lump is left
carcinoma · NO response to eczema treatment
- Mucinous carcinoma: 10.Retracted nipple:
· Subtype of medullary carcinoma
· Unilateral · Recent
· Discuss gross & microscopic picture of Muanous
· Associated with breast mass
carcinoma
· Discuss its prognosis 7. Give an account on Paget’s disease of nipple
iii. Mastitis carcinomatosa and areola
· Most malignant, resembling mastitis, occurs during Answer:
pregnancy & lactation, of poor prognosis, it simulates
acute mastitis& must be differentiated from it. Definition: malignant eczema of nipple and areola
·Table for differentiation between mastitis Pathology: 2 theories, usually followed by or
carcinomatosa & acute lactational mastitis is NOT associated with breast mass:
REQUIRED. 1. Duct epithelium turning malignant, spreading
3. Paget’s disease of areola and nipple into 2 ways:
· Malignant eczema of nipple, caused by either duct A. Intraductal, implanted in nipple and areola causing
carcinoma in situ or invasive breast cancer Paget’s eczema
growing into ducts and onto nipple surface B. Invading basement membrane and breast stroma
· Table for differentiation between Paget’s eczema causing duct carcinoma (however not accepted
and ordinary eczema is NOT required nowdays)
Staging of cancer breast: 2. 2 separate primaries; predisposed to cancer
1.TNM staging: discuss Clinical picture:
2.Manchester classification: discuss · Unilateral, Non itchy, eroding eczema of areola and nipple
6. Give an account on skin manifestations of · Breast mass (firm to hard, mobile or fixed)
· With palpable enlarged painless axillary LNs
cancer breast
Answer: Staging:
1. Dimpling: • TNM staging: either:
· Tis, N0, M0 if no breast mass
· Discuss · NOT pathognomonic

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· T1, N1, M0 if developed breast mass B. Detect local recurrence, distant metastasis or
• Manchester: stage I carcinoma of the other breast (e.g. lobular
Differential diagnosis: from ordinary eczema: carcinoma)
Discuss table for differentiating Paget’s eczema from 5. Reconstruction: discuss
ordinary eczema, P 198 NB: NO pregnancy for 3 yeasr with NON hormonal
Investigations: contraceptivon
1. Biopsy from skin eczema: for the characteristic 6. Prognosis: discuss prognosis of cancer breast
Paget’s cell: 9. Enumerate 5 risk factors for cancer breast
· Large giant cells with darkly stained nucleus and
vacuolated cytoplasm
Answer: enumerate 5 risk factors for cancer breast; try to be
the most important risk factors
2. Mammography or PET scan: for detection of

associated breast mass

Treatment:
• Surgical options: either
1.Conservative breast surgery: for the case without
breast mass
Discuss conservative breast surgery
2.Modified radical mastectomy: for the cases with
breast mass
Discuss modified radical mastectomy
• Axillary node sampling: discuss
8. Give an account on outlines of treatment of
early cancer breast
Answer:
1. Surgery:
For breast: either
A. Conservative breast surgery: discuss
B. Radical mastectomy:
- If the mass is attached to pectoral muscles which
entails removal of:
· The whole breast including nipple and areola
· 2 pectroal muscles
· Evacuation of axillary nods
C. Modified radical mastectomy: discuss
For axillary nodes:
A. Sentinel node biopsy: discuss
B. Axillary node sampling: discuss
2. Radiotherapy:
Postoperative radiotherapy to breast bed, supraclavicular,
mediastinal areas and axilla is indicated after the above
mentioned operations to prevent local recurrence, NOT
to increase survival
3. Adjuvant therapy:
- If ER positive, so hormonal treatment: discuss
- If ER negative, so chemotherapy: discuss
4. Follow up for 5 years: for
A. Complications of operation:
· Postoperative arm edema: discuss
· Cosmotic and psychiatric problems

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B. Anatomical Types :
Hernia, Skin and • Subcutaneous
· Diffuse type.
Subcutaneous Tissue,
· Localized type.
• Subfascial.
• Intermuscular type.
Head and Neck •

•
Subperiosteal type.
Intra articular.
• Submucosal.
1. Enumerate Types of Dermoid cyst • Subserous.
Answer • Extraduralinside vertebral column only not
intracranial
Def: cyst lined by sq. epithelium containing sebaceous • Intraglandular.
material +/- hair. 4. Discuss D.D. Of ulcer of face?
Types: Answer
1. Sequestration Dermoid:
- Inclusion of sq. epithelium of skin in subcutaneous
Types & Clinical Picture:
tissue at the line of fusion Æ dermoid cyst. 1. Traumatic:
- Never in upper + lower limp Ægrows by Budds. · Site Æ anywhere. · Size Æ variable.
2. Inclusion Dermoid: · Shape Æ rounded or oval. · Edges Æ punched out.
- Inclusion of epidermis inside a cavity during closure of · Floor Æ unhealthy granulation tissue.
these Cavities. E.g.: · Base Æ painfully indurated.
-Mediastinal Dermoid cyst. · No palpable L.N.s in neck.
-Sublingual Dermoid cyst. 2. Inflammatory:
-Supra sternal Dermoid cyst. a. Acute herpetic ulcer:
3. Tubulo Dermoid: · Small, extremely painful.
- Due to degeneration in remnants of tubular structure. · Vesicle Æ ruptures & ulcerates.
E.g.: · Along trigeminal nerve distribution.
-Thyroglossal cyst discuss C/P. · Shallow ulcers.
-Bronchial cyst discus sC/P. · Floor Æ healthy granulation tissue.
4. Teratematous Dermoid: · Margin Æ hyperemic.
- Arises from totipotent cells. · Palpable tender L.N.s in neck.
- Contains elements from ectoderm, mesoderm and b.Chronic ulcer:
endoderm. · TB ulcerÆDiscuss from table of ulcers of tongue.
- Contains sebaceous materials. · Syphilitic ulcerÆDiscuss from table of ulcers of
- Commonly arises in testis & ovaries. tongue.
5. Implantation Dermoid (Acquired) 3. Neoplastic
- Due to puncture wound causing inclusion of epidermal a. Basal cell carcinoma:
cells into S.C. Tissue. - Site: commonly at outer + inner canthas and along
2. Discuss Complications of sebaceous cyst? nosolabial fold.
- Criteria:
Answer · Rolled in edges + beaded.
1. Infection: abscess formation. · Necrotic floor. · Indurated base.
2. Sebaceous Horne: contents become inspirated in - Types:
· Deep excavating. · Fire field.
layers over base.
- No palpable L.N.
3. Rupture: cock's peculiar tumor. If palpable:
- Forming one ulcer with raised everted edge, (mistaken · Epitheliometous transformation
with squamous cell carcinoma) so Biobsy is · Secondary infection.
needed. b.Squamous cell carcinoma: Discuss.
4. Localized allopecia. c. Ulcerating malignant melanoma:
3. Enumerate Types of lipoma · Nodular melanoma Æ Discuss.
· Superficial spreading type Æ Discuss.
Answer · Criteria of transformation of a benign naevus into
A. Pathological Types: malignant melanoma (Discuss).
• Pure lipoma fat tissue only. 4. Keratoacanthoma: Discuss.
• Fibro lipoma fat & fibrous tissue. 5. Rare conditions: brown's disease of skin, burn ulcer,
• Angiolipoma fat & vascular tissue. senile reratesi, infected ulcerating granuloma.
• Mylolipoma fat & cartilaginous tissue. Investigations:

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Biopsy from the edge - Abscess (obstruction stasis Æ infection).
- M/P of basal cell carcinoma Æ Discuss. - Salivary fistula.
- M/P of sq cell carcinoma Æ Discuss. Management:
- M/P of Malignant melanoma Æ Discuss.
- Other ulcers Æ Macrophage, lymphocytes & Plasma cells. - C/P: discuss
5. Discuss Pathology and management of - DD Æ from enlarged Submandibular L.N.s (multiple,
rolled on mandible, better felt from out side not from
basal cell carcinoma? inside the mouth).
Answer: discuss - Investigation: discuss
- TTT: discuss
- Incidence - Risk factors.
- Site. - Gross picture. - Microscopic picture. 9. Discuss pathology C/P, investigations and
- Spread.Types (excavating + fire field). treatment of cancer tongue
- Investigations. - Treatment. 10.DD of tongue ulcer? P271, P272
6. Give an account on management of parotid
11.Enumerate different types of inguinal
abscess?
hernia
Answer
Answer
Clinical Picture:
Direct :
1-Swelling at parotid region raising ear lobule with
· Medial type. · Lateral type.
general constitutional manifestations (throbbing
pain + hectic fever). Indirect type
2-Local examination : - Congenital
- Tender with +ve erc fluctuation and overlying skin is
- Infantile
hot red & edematous.
3-Enlarged tender mobile upper deep cervical - Acquired
nodes. · Pubonocele · Funicular
· Complete and scrotal
Investigations 12.Discuss pathology and management of
1.CBC Æ Leucocytosis & ESR. strangulated hernia
2.sonar & CT Æ lesion with central break down. 13.Discuss causes, complications,
Treatment: investigations, TTT of thoracic outlet
1.Don't wait for fluctuation.
2.Under general anesthesia. syndrome
3.Drained by Helton method. 14. DD of swellings in Neck triangle
- A longitudinal skin incision along hair line, Abscess
will be drained after rotating the forceps 90° to
15.Give a report on discharging openings
be parallel to facial nerve. around umbilicus
Complications: Answer
1.Facial nerve injury. Causes:
2.Grey's syndrome (auriculotemporal) artificial
synapse between Secretory fibers & sympathetic 1. Congenital:
fibers eating Causes sympathetic overactivity. • Patent umbilicus.
3.Salivary fistula if not healed. • Patent vetillo- intestinal tract: (feculent discharge).
7. Discuss pathology of paleomorphic 2. Inflammatory:
adenoma? a. Chronic infective granuloma.
b.Chronic abscess.
Answer: discuss c. Sinus following surgery.
- Pathology. - Clinical Picture. 3. Neoplastic:
- DD. - Ulcerating intestinal malignancy.
- Investigations. - TTT. - Abdominal malignancy opening on skin e.g. Cancer
8. Discuss complications and management of colon
salivary stones 4. Pilonidal sinus:
Clinical Picture:
Answer
- There is an opening
Complications: - Discharge nature:.
- Chronic Submandibular sialadenitis. · UrineÆ patent uracus.

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· FeculentÆVetillo- intestinal tract.
· Purulent Æinflammatory.
· HemorrhagicÆneoplastic.
· Purulent with hair tuftÆ Pilonidol sinus.
Investigations:
- Cytology.
- C&S.
Treatment:
1.Treatment of underlying cause.
2.Broad spectrum antibiotics.
3.Chronic abscess should be opened ,curetted ,washed
with antiseptic solution with proper daily dressing
until healing with healthy granulation tissue.
16.Discuss differential diagnosis of irreducible
inguinoscrotal swellings
Answer:
1.Irreducible hernias: Discuss clinical picture of inguinal
& femoral hernias.
2.Enlarged inguinal nodes: Discuss clinical picture &
investigations of:
- Hodjkins lymphoma. - Non Hodjkins lymphoma.
- Metastasis.
3.Iliopsoas abscess: Discuss clinical picture &
investigations of Pott’s disease.
4.Subcutaneous lipoma: Discuss clinical picture of
subcutaneous lipoma.
5.Clotted aneurysm.
6.Undescended inguinal testis:
- Empty corresponding aspect of scrotum.
- Sickening sensation on pressure.
7.Encysted hydrocele of the cord: Discuss clinical
picture of encysted hydrocele.
8.Thrombosed varicocele.
9.Chronic inflammation.
· TB: beaded.
· Filariasis: amalgamated.
· Bilharziasis: nodular.

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· Blood sugar, kidney function test, ECG.
Liver, Jaundice, Treatment:

1. Patients with silent gall stones: Discuss.
2. Patients with symptomatic gall stones:
Gall bladder Conventional open cholecystectomy or
laparoscopic cholecystectomy.
· Advantages & contraindications of laparoscopic
1. Discuss pathology & types of gall stones cholecystectomy: Enumerate.
Answer: 3. Give an account on pathology &
Pathology: management of acute cholycystitis
• Incidence: Fatty, fertile, female above 40 years. Answer:
• Mechanism of formation : Pathology:
- Metabolic: Discuss. • Type:
- Stasis: Discuss. i. Acute obstructive (95%): due to stone obstructing
- Infection: cystic duct or Hartmann's pouch.
ii. Acute non obstructive (5%).
· Causative organism: Enumerate.
· Mechanism of formation: Discuss. • Organisms: Enumerate.
Types: Discuss table of differentiation between the 3 • Fate: Discuss pathology including fate.
types of gall stones; mixed, infected, cholesterol &
Clinical picture:
pigment stones.
• Symptoms:
2. Discuss complication, investigation & - Picture of simple obstruction: Discuss.
treatment of gall stones - Picture of inflammation: Discuss.
Answer: • Signs:
Complications: - General:
• Obstructive complications: Discuss. · Fever, tachycardia, tachypnea.
• Infective complications: Enumerate. · Jaundice in 10% of cases: Explain.
- Local abdominal:
• Ulcerative complications: · Inspection: loss of movement with respiration.
- Chronic peptic ulcer: · Palpation:
Due to reflex pylorospasm which causes gastric ¾ Tenderness & rigidity in right hypochondrium.
stenosis Æ stimulation of G.cells at pyloric antrumÆ ¾ Mass: Discuss.
secretion of Gastrin Æ HCL ÆDuodenal ulcer. · Auscultation: silent abdomen if ileus.
- External & internal Biliary fistula: · Boa sign.
Due to acute cholycystitis which causes pericholycystic • Differential Diagnosis: from other causes of acute
abscess, which may open in: upper abdomen: Enumerate.
· Internal organ as stomach, duodenum or colon
causing INTERNAL Biliary fistula.
Investigations:
· Skin causing EXTERNAL Biliary fistula. • Laboratory investigations:
• Malignant complications (<1%): Enumerate. - CBC: for Leucocytosis & ESR.
Investigations: in order of importance: - Liver function tests.
1. Abdominal ultrasound: MOST ACCURATE, NON • Radiological:
INVASIVE, shows the stones & thickness of gall - ULTRASONOGRAPHY: investigation of choice 90%
bladder wall.
accuracy.
2. Oral cholycystography: Discuss findings.
- HIDA scan: Discuss finding.
3. Plain X-ray: Discuss.
4. Laboratory investigations: Treatment:
- Liver function test: Prothrombin time & • Early surgery: Cholecystectomy within 3 days.
concentration. - Advantages: Enumerate.
- For the cause: • Conservative treatment: Discuss
· Serum cholesterol. · Complete Blood Count.
· Electrophoresis.
- To assess fitness for surgery:

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4. Compare between Calcular & Malignant Answer:
obstructive jaundice in a table form
Calcular obstruction Malignant obstruction
Patient Middle aged, fatty, female. Usually old male.
Pain Onset of jaundice is preceded by Biliary colics Onset is NOT associated with pain except in late
(Painful jaundice) cases.
Other symptoms May be nausea, distention and fatty dyspepsia. May be symptoms due to metastasis.
General condition Good. May be poor (malignant cachexia) in advanced cases.
Jaundice Moderate (orange yellow). Deep (Olive green).
General May show evidence of hypercholestremia or • Distant metastasis e.g.: Troisier's sign.
examination hemolytic anemia. • Evidence of Thrombophlebitis migrans
(Trousseau's sign)
Abdominal Usually gall bladder is NOT felt, Murphy's sign The gall bladder may be felt distended, palpable
examination may be positive. (Courvoisier’s law). epigastric mass +\- ascitis.
(Courvoisier's law)
*Both conditions are sharing the following data:
· Jaundice. · Clay colored stool. · Dark colored urine.
· Steatorrhea. · Bleeding tendency. · Constipation. · Pruritus.
· Headache, irritability, drowsiness. · Bradycardia, hypotension. · Frothy urine.
· Dilated bile duct, Biliary mud, ascending cholangitis · Hydronephrosis.
White bile More common (requires long duration) Less common
2ry Biliary cirrhosis More common Less common
Acute liver cell failure Less common More common
Investigations:
A. Laboratory:
Both conditions share the same laboratory investigations which are:
1. Urine analysis: absent urobillirogen, positive billirubin & bile salts.
2. Stool analysis: absent stercobillirogen & bile salts, increased fat may be occult blood.
3. Liver function test:
-Increased total & direct billirubin, alkaline phosphatase enzyme.
-Normal liver enzymes except if prolonged obstruction.
-Gamma glutamyl transpeptidase.
-Prolonged Prothrombin time & lowered Prothrombin concentration. (Should be above 60% before surgery,
PTC, sphincterotomy)
4. Kidney function test: to exclude renal impairment.
B. Radiological: in 1. Abdominal ultrasound: investigation of 1.CT scan with IV contrast: investigation of
order of choice showing: choice showing pancreatic tumors.
importance: · Gall stones, CBD stones. 2.ERCP: diagnostic & therapeutic.
· Site of obstruction, Dilated bile ducts. · Inserting stent.
2. ERCP: diagnostic & therapeutic. · Detect level of obstruction & causes.
· Remove stone by dormia basket. 3.PTC: Especially in patients with
· Detect level of obstruction & cause. CholangioCarcinoma: show level & cause of
- PTC is NOT useful in Calcular obstructive obstruction.
jaundice. 4. Hypotonic Duodenography: shows:
· 'Inverted 3' in periempullory carcinoma.
· 'C' in cancer head of pancreas.
Treatment: 1. ERCP + laparoscopic cholecystectomy. • Operable cases:
2. Surgery: exploration of CBD & stone · Radical resection 'Whipple's
extraction. · Pancreatoduodenectomy.
3. Choledochoduodenostomy. • Inoperable cases:
-Biliary stents: either:
· Internal by ERCP.
· External by PTD.
-Surgical drainage by Cholecystojejunostomy.

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5. Discuss clinical picture, investigations & iii. ERCP: based on fact that 50% of cases of acute
pancreatitis are caused stones obstructing at
treatment of acute pancreatitis
ampulla of Vater.
Answer:
• Investigations to grade severity & assess
Clinical picture:
prognosis :
• Symptoms: Discuss ONE of the 2 systems of classification; EITHER:
- Type of patient: middle aged males or females bet 40- - Glasgow system. OR
60 years
- Ranson’s criteria.
- Symptoms: Discuss.
Treatment: Discuss.
• Signs:
6. Mention 5 causes for pain in Right iliac fossa
- General :
- For each, mention 4 symptoms or signs.
· Signs of hypovolemia
- For each, mention 2 investigations.
· CNS: anxious to drowsy
· Pulse: tachycardia (rapid, weak) thready Answer:
· Blood pressure: hypotension Causes of pain in right iliac fossa:
· Respiratory rate: tachycardia and air huger 1. Acute appendicitis.
· Temperature: hypothermia
2. Intestinal obstruction.
· Skin: pale, cold, sweaty with collapsed vein
3. Gynecological problems.
· Urine output: oliguria
· Jaundice may be present: Explain. 4. Perforated duodenal ulcers.
- Local: 5. Ureteric colics.
· Inspection: 6. Meckel’s diverticulosis.
♦ Loss of abdominal mobility with respiration. 4 symptoms or signs, 2 investigations:
♦ Discoloration of flanks (Grey-turner sign) or around 1. Acute appendicitis:
umbilicus (Cullen’s sign).
• 4 symptoms or signs: Mention.
· Palpation, percussion, auscultation, P/R: Discuss.
• 2 investigations:
• Complications:
i.Blood picture; for Leucocytosis & ↑ ESR.
- Systemic complications: enumerate systemic effects in ii.Laparoscopy: Diagnostic & therapeutic.
pathology of acute pancreatitis, P.97.
2. Intestinal obstruction:
· Acute lung injury & ARDS. · Hypocalcaemia & Tetany.
· Hypoxemia & hypoxia due to opening of • 4 symptoms or signs: Enumerate (suggestion: the 4
bronchopulmonary shunts. cardinal symptoms).
· Acute tubular necrosis & renal failure from • 2 investigations:
hypovolemia. i.Plain X-ray.
· Paralytic ileus, fluid & electrolyte imbalance, metabolic ii.CT scan with water soluble contrast.
acidosis. 3. Gynecological problems; as disturbed ectopic
· Consumption coagulopathy & DIC. pregnancy:
- Local complications:
• 4 symptoms or signs:
· Infection: causing pancreatic abscess.
i.History of short term amenorrhea.
· Pancreatic Pseudocyst: Discuss definition, pathology, ii.Vaginal bleeding.
clinical picture, complications, investigations & iii.Tenderness & rigidity in tubal points.
treatment of pancreatic Pseudocyst, P.101. iv.Cervical motion tenderness.
• Differential diagnosis from other causes of acute • 2 investigations:
upper abdomen: Enumerate. i.Ultrasonography.
Investigations: ii.HCG.
• Investigations to confirm diagnosis: 4. Perforated duodenal ulcers:

A. Laboratory: Enumerate. • 4 symptoms or signs: enumerate, suggestions:
i.Pain in epigastrium then shift to right side, Hunger
B. Radiological: in order of importance:
pain.
i. CT scan with IV contrast: Discuss.
ii.Dyspepsia.
ii. Plain X-ray: Discuss.
iii.Obliterated liver dullness. iv. Fluid on P/R.
• 2 investigations:

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i.Plain X-ray abdomen erect: air right capsular of Then enumerate other causes of a mass in left iliac
diaphragm. fossa which are the same as a mass in right iliac fossa
ii.Endoscopy. except for: appendicular mass, cancer cecum.
5. Ureteric colics: 9. Enumerate 5 causes, 4 complications of
• 4 symptoms or signs: acute septic peritonitis
i.Pain from loin to groin, radiating to scrotum or
Answer:
labia majora.
ii.Hematuria. 5 Causes:
iii.Dysuria. iv. Burning Micturation. 1.Inflamed internal organs.
• 2 investigations: 2.Leaking organ (perforated viscus).
i.Urine analysis ii. Plain X-ray 3.Direct entry by stab wound or operative.
7. Discuss Differential diagnosis of mass in 4.Blood spread.
Right Iliac Fossa 5.Primary peritonitis.
Answer: 4 Complications:
Causes of a mass in right iliac fossa: Enumerate 1. Septicemia & septic shock. 2. Paralytic ileus.
3. Localization & abscess formation e.g. subphrenic or
causes of mass in right iliac fossa including appendicular
pelvic abscess.
mass, P.117.
4. Dehydration & hypovolemia.
Differential diagnosis of Most important
10. What are the possible injuries of a stab in
causes: left hypochondrium? Discuss
1. Appendicular mass: Discuss clinical picture & investigations for this condition
investigations of appendicular mass P.116, P118.
Answer:
2. Cancer cecum: Discuss clinical picture &
investigations of cancer cecum P.142, P.143, P.144,
Possible injuries:
P.145. • Supradiphragmatic:
3. Ectopic kidney: Discuss clinical picture & - Base of left lung & pleura: causing
investigations of ectopic kidney P.12 ‘in Basics of Pneumothorax, hemothorax, lung lacerations.
special surgery’. • Diaphragmatic.
4. Tubal ovarian abscess: • Infradiaphragmatic:
• Clinical picture: · Spleen. · Stomach.
i. General constitutional manifestations. · Splenic flexure of colon.
ii. Pain & mass felt at tubal point. · Tail of pancrease. · Left kidney.
iii. Cervical motion tenderness. Investigations: Discuss urgent investigations in
iv. Fullness at lateral fornix.
management of abdominal trauma & intrabdominal
v. Purulent vaginal discharge.
bleeding, P.202.
• Investigations of choice: Ultrasonography.
11.What are the possible injuries of a stab in
8. Discuss differential diagnosis of a mass in right hypochondrium? Discuss
left iliac fossa investigations for this condition
Answer: Answer:
1. Bilharzial pericolic mass: Discuss clinical picture &
Possible injuries:
investigations of Bilharzial colitis, P.137.
2. Cancer sigmoid: Discuss clinical picture & • Supradiphragmatic: Base of Right lung & pleura:
investigations of cancer sigmoid, P.143, 144, 145. causing Pneumothorax, hemothorax, lung lacerations.
3. Diverticular disease complicated by • Diaphragmatic.
peridiverticular abscess: Discuss clinical picture & • Infradiaphragmatic:
investigations of Diverticular Disease, P.133. · Liver. · Gall bladder.
4. Ectopic kidney: Discuss clinical picture & · Hepatic flexure of colon.· CBD. · Right kidney.
nd
investigations of ectopic kidney, P.12 in ‘Basics of special · 2 part of duodenum. · Head of pancrease.
surgery’ Investigations: Discuss urgent investigations in
5. Tubo ovarian abscess. management of abdominal trauma & intrabdominal
bleeding, P.202.

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· Associated other abdominal injury.
Gastrointestinal Treatment:
1. Anti shock measures: Discuss in brief.
2. Urgent laparotomy & management: Discuss.
Emergencies 2. Discuss clinical picture & treatment of

chronic anal fissure?
Answer:
1. Discuss etiology, clinical picture,
Clinical picture:
investigations, & treatment of liver injuries
Answer: • Symptoms: Discuss.
Etiology: • Signs: Discuss P/R examination in chronic anal fissure.
• Incidence: commonest solid intrabdominal organ liable • Differential diagnosis of painful anal
for injury because of big surface area. conditions: Enumerate.
• Types of trauma: Discuss. Treatment:
Clinical picture: 1. Closed lateral sphincterotomy: Early cases without
fibrosed edge. No details are required.
• Symptoms: 2. Posterior fissurectomy: For cases with thick fibrosed
- History of trauma to upper abdomen or lower chest, edges with sentinal pile. No details are required.
Right upper abdominal pain. 3. Give an account on clinical picture,
- Symptoms of hypovolemia: enumerate investigations & treatment of piles
• Signs: Answer:
- General: Clinical picture:
o Signs of hypovolemia:
· CNS: anxious to drowsy • Symptoms: Discuss.
· Pulse: tachycardia (rapid, weak) thready • Signs:
· Blood pressure: hypotension
- Inspection: dilated, elongated & tortuous veins at 3,7,11.
· Respiratory rate: tachycardia and air huger
- Digital examination: for:
· Temperature: hypothermia i. Thrombosed piles. ii. Rectal carcinoma.
· Skin: pale, cold, sweaty with collapsed vein - Proctoscopy: to detect underling colorectal carcinoma.
· Urine output: oliguria
• Differential diagnosis: from other anal causes of
- Local:
o Inspection: fresh blood per rectum:
*Signs of external trauma: Enumerate. i. Anal fissure. ii. Anal carcinoma.
* Loss of abdominal mobility with respiration. iii. Ruptured perianal hematoma.
iv. Advanced perianal suppurations.
o Palpation:
* Tenderness & rigidity of right hypochondrium which • Complications: Enumerate.
later on becomes localized. Treatment:
* Palpable tender liver.
• For 1st & 2nd degree:
o Percussion: shifting dullness.
o Auscultation: dead silent abdomen. -
Conservative treatment: Discuss.
o P/R: fluid in Douglas pouch. -
Injection sclerotherapy: Discuss.
-
Rubber band ligation: Discuss.
• Complications: Enumerate.
-
Photocoagulation: Discuss.
Investigations: • For 3rd & 4th : Haemorrhidectomy
• Laboratory: 4. Give an account on treatment of prolapsed
i. CBC, hemoglobin & hematocrite.
ii. Coagulation profile.
Thrombosed (or strangulated) piles
iii. Arterial blood gases & electrolytes. Answer: Discuss treatment of prolapsed Thrombosed piles.
iv. Liver function test. 5. Enumerate causes of fresh blood pert
• Radiological: rectum
Abdominal & ultrasound & CT scan with contrast: Answer: Enumerate causes of fresh blood pert rectum.
for the following:
6. Give an account on types & treatment of
· Type & degree of liver injury.
· Subphrenic collection. imperforate anus
· Free fluid in peritoneal cavity. Answer: Discuss types & treatment of imperforate anus.

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• Type of patient: Discuss.
Gastrointestinal • Symptoms: Discuss.
• Signs: pointing sign, the patient localizes the point of
Miscellaneouses
maximum tenderness by 1 finger.
Investigations:
1. Discuss clinical picture & management of • Laboratory:
perforated duodenal ulcer - Gastric function test: reveals hyperacidity.
Answer: - Gastrin hormone assay: to exclude Zollinger Elison
Syndrome.
Clinical picture: Discuss 3 stages of clinical picture of
- Liver function tests & serum Ca+2:
perforated duodenal ulcer · For cirrhotic patient with hyperacidity.
Differential diagnosis from other causes of · For Hyperparathyrodism.
acute upper abdomen: Enumerate. - Investigation to detect helicobacter pylori:
· Serology.
Investigations: · Culture of mucosal biopsy from pyloric antrum.
The most important are laboratory & plain x-ray: · Radioactive carbon urea breath test.
1. Laboratory: • Radiological:
iii. CBC, leucocytosin, hemoglobin & hematocrite. - Barium meal: discuss findings.
iv. ABG, serum electrolytes & renal function tests. • Endoscopy: investigation of choice.
2. Plain x-ray abdomen erect reveals:
- Air under right copula of diaphragm. Treatment: is essentially medical.
- Multiple air fluid level. • Medical: essential line of treatment
3. Gastrografin swallow reveals: 1.Modification of life style: avoid
- Escape of dye. · Stress. · Irritant food, smoking & alcohol.
4. Sonar reveals: 2.Drugs: Enumerate & Give an example.
- Intra-abdominal fluid. - Excludes other causes. - Acid neutralizers (Antacids) e.g.:Aluminum hydroxide.
5. Peritoneal tapping. - Anticids:
6. Endoscopy. i.H2 blockers e.g.:rantidine, famotidine.
ii.Proton pump inhibitors e.g.:ameprazole.
Treatment: iii.Cytoprotictive drugs e.g.:sucealfate,De-Nol.
• Preoperative urgent resuscitation: Discuss (similar - Drugs for eradication of helicobacter prlori:
to IO). · Triple therapy: amoprazol, amoxacilline,
metronidazole.
• Operative:
• Surgry;
1.Simplest, most popular: is omental patch: Discuss.
2.Definitive ulcer treatment: 1.Vagotomy:
i. Truncal: Discuss.
- Provided that:
ii. Selective: Discuss.
· The patient is generally fit.
iii. Highly selective: Discuss.
· The surgeon is competent.
2. Billaroth I pontial gastrotomy (antrodudenectomy):
· The hospital is well equiped.
Discuss.
- So defenitive ulcer surgery should be done:
· For duodenal ulcer, do vagotomy & gastrojejunostomy.
3.Billaroth II subtotal gastrotomy:
· For gastric ulcer, do partial gastrectomy & · Discuss.
gastroduodenostomy. · This operation is NOT done nowadays (Too much
price to offer for peptic ulcer).
• Postoperative care:
3. Enumerate causes of pyloric stenosis &
- Continue preoperative care, then:
- The patient should continue on medical conservative
discuss the one due to fibrosed duodenal
treatment of peptic ulcer (antacids) provided the ulcer
simplest procedure was done. Answer:
2. Give an account on clinical picture, 1. Congenital hydrotropic pyloric stenosis.
investigations & treatment of chronic 2. Traumatic: impacted foreign body or corrosive stricture.
duodenal ulcer 3. Inflammatory: FIBROSED DUODENAL ULCER or
Answer: Crohn's disease.
Clinical picture: 4. Neoplastic: cancer pylorus, less common leoimyoma of
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5. Pressure from outside: lymph nodes, Cancer head of 3. Injection of botulinum toxin in wall of
pylorus, pseudopancreatic cyst. esophagus guided by endoluminal sonar.
Fibrosed duodenal ulcer: Discuss clinical picture, 6. Give an account on reflux esophagitis;
investigations & treatment of pyloric stenosis clinical picture, investigations & treatment
4. Discuss differential diagnosis of case of Answer: it is about sliding hiatus hernia.
pyloric stenosis Clinical picture: Discuss clinical picture of sliding hiatus
Answer: hernia.
Causes of pyloric obstruction (stenosis): - Heart burn: Most important: Discuss.
Enumerate. - Regurgitation: especially on bending.
Among the above mentioned causes, the - Dysphagea: Discuss.
- Complications: Enumerate.
most important are: · The most important of which is Barrette's esophagus.
1. Congenital hypertrophic pyloric stenosis: Differential Diagnosis
Discuss clinical picture & investigations of congenital
hypertrophic pyloric stenosis, P.19.20.
• From other esophageal causes of dysphagia:
2. Stenosed duodenal ulcer: Discuss clinical picture & enumerate
investigations of stenosed duodenal ulcer (pyloric • Causes in lumen: foreign bodies.
stenosis), P.34, 35. • Causes in wall:
3. Cancer pylorus: Discuss clinical picture & · Congenital stenosis. · Corrosive stricture.
investigations of cancer pylorus (from cancer stomach), · Functional: achlasia of cardia
P.38, 39. · Neoplastic as carcinoma.
5. Discuss clinical picture, investigations & • Compression from outside by:
treatment of achalaria of cardia · Malignant thyroid. · LNs.
Answer: · Thoracic aortic aneurysm. · Cold abscess.
· Mediastinal syndrome. · Disphagea lusoria.
Clinical picture: Discuss. • From other causes of Retrosternal pain:
Differential diagnosis from other esophageal · Ischemic Heart Disease. · Diffuse esophageal spasm.
· Pericarditis, Pleurisy. · Dissecting aortic aneurysm.
causes of dysphagea: Enumerate from page 15.
Investigations: In order of importance:
• Causes in lumen: foreign bodies.
1. PH study: Most Important Investigation: Discuss
• Causes in wall: findings.
· Congenital stenosis. · Corrosive stricture. 2. Manometric studies: Discuss findings.
· Inflammatory as reflux esophagitis. 3. Barium meal trendlenberg: Discuss findings.
· Neoplastic as carcinoma.
4. Esophagescopy: Discuss the four stages.
• Compression from outside by:
Treatment: Mainly conservative:
· Malignant thyroid. · LNs.
· Thoracic aortic aneurysm. · Cold abscess. • Conservative: Main line of Treatment: Discuss.
· Mediastinal syndrome. · Disphagea lusoria.
• Surgery:
Investigations: - Indications: Enumerate.
1. Esophageal manometric studies: investigation of - Principles: Discuss.
choice. · Floppy Nissen’s fundoplication: Discuss.
- Findings: Enumerate. 7. Discuss Differential Diagnosis of a case of
2. Barium swell: Discuss findings. Dysphagia
3. Esophegescopy: Discuss findings.
4. Classic laboratory investigations to assess fitness Answer:
for surgery: Causes of Dysphagia: Enumerate.
- CBC, hemoglobin, hematocrite. Among which the most important are:
- Serum electrolytes.
- Kidney function test. 1. Cancer Esophagus: Discuss Clinical picture &
- Fasting blood glucose. Investigation of Cancer Esophagus from p.12 & 13.
Treatment: 3 options: 2. Achlasia of Cardia: Discuss Clinical picture &
Investigation of Achlasia of cardia from p. 5.
1. Surgery (Heller's cardiomyotomy): Discuss. 8. Enumerate cause of postoperative Fever
· Most common to be used.
2. Dilatation by Plummer's hydrostatic balloon: Answer: Enumerate cause of postoperative Fever from
Discuss. p.196.

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

Distention
Answer: Enumerate cause of postoperative Distention from
p.196.
11. Enumerate cause of postoperative
abdominal pain
Answer:
i. Surgical wound infection.
ii. Abdominal distention in ileus.
iii. Intrabdominal infection, leakage causing
peritonitis or abscess e.g. Subphrenic.
iv. Gastroenteritis.
v. Urinary tract infection especially if catheterized.
vi. Basal Myocardial infarction especially if elderly.
vii. Diabetic Ketoacidosis.

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- Approach is better done anterior transperitoneal:
Urology Explain.
• Inoperable:
- Palliative radiotherapy.
1. Discuss management of renal calculi - Radiotherapy & chemotherapy.
Answer: 3. Discuss cancer bladder
Clinical picture: Answer: Discuss cancer bladder.
- Silent: discovered accidentally during examination. 4. Discuss Bilharziasis of bladder
- Pain:
· Caused by movement of stone, especially Ca oxalate. Answer: Discuss Bilharziasis of bladder.
· Character: dull aching due to stretch of renal capsule. 5. Enumerate causes of Hematuria. Discuss
· Site: renal angle.
investigations to reach diagnosis
· Radiation: anterior renal point.
- Complications: Enumerate complications of urinary Answer:
stones. Causes of Hematuria:
Investigations: Discuss. • General causes: Enumerate.
Treatment: • Local causes:
• Management of the patient during an attack Most of diseases of urinary tract can cause Hematuria, but
Most important are:
of pain: Discuss.
- Tumors: cancer bladder, cancer prostate,
• Elective treatment: Hypernephroma.
- Conservative: Discuss indications, procedure, - Trauma: to bladder, urethra and kidney.
contraindications of conservative treatment. - Stones.
- Instrumental: - Infections: particularly Bilharziasis.
· ESWL: Discuss indications, contraindications, and
complications of ESWL. Among the above mentioned causes:
· PCNL: Discuss procedures, advantages, indications, • They must be differentiated from causes of red
contraindications &complications of PCNL. coloration of urine: Enumerate causes of red urine.
- Surgery: Discuss the 5 options for surgery; incision is not · Hemoglobinuria, Myoglobinuria. · Jaundice.
required. · Intake of beer roots. · Drugs: Rifampicin.
• Metabolic work-up to prevent recurrence: • According to relation of Hematuria to act of
Discuss. Micturation, they are classified into:
2. Discuss pathology & management of - Total Hematuria: Discuss.
hypernephroma - Initial Hematuria: Discuss.
- Terminal Hematuria: Discuss.
Answer:
Investigations to reach diagnosis:
Pathology:
• Laboratory:
• Incidence, predisposing factors: Discuss. - Urine analysis:
• Site, gross picture, and microscopic picture, · Bilharzial ova. · Malignant cells.
and spread, complications, staging: Discuss · RBCs, pus cells. · Urinary casts.
(under item ‘pathology’). - Kidney function test: urea, creatinine and creatinine
Clearance.
Clinical picture:
- Blood picture: hemoglobin, hematocrite & clotting
• Typical presentation: Discuss. Abnormalities.
• Atypical presentation: Discuss. • Radiological:
Differential diagnosis from other causes of - Plain x-ray & IVU: Discuss findings in important
subjects.
renal masses: Enumerate.
- Sonar & CT scan: Discuss findings in important
Investigations: Discuss. subjects.
- Investigation of choice is CT scan with contrast. • Cystoscopy.
Treatment: 6. Causes & management of acute retention
• Operable: Radical nephrectomy: of urine
- Removal of: Enumerate structures to be removed in
radical Nephrectomy.
Answer:
Causes of acute retention of urine:

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- Obstructive causes: Enumerate. Ureters & kidney: back pressure; Hydroureter &
- Post-operative reflux retention causes: Enumerate. Hydronephrosis.
- Neurological causes: Enumerate. Effects of straining & increase intra-
- Gynecological causes: Enumerate.
Management of acute retention of urine: abdominal pressure: e.g. hernia, piles
• Diagnosis: 9. Discuss investigations & treatment of
- Acute retention of urine: benign prostatic hyperplasia
· The patient hasn't passed urine for some hours, Answer:
unable to do.
· Median Pyriform swelling in suprapubic region, Investigations: Discuss.
painful.
Treatment:
- Exclude possibility of anuria:
· Dull painful on percussion. • Medical treatment & watchful waiting: Discuss.
· By pelvic sonar, shows full bladder. • Surgical treatment:
• Treatment: - Indications: Enumerate.
- Treatment of classic cases of acute retention of - Procedures:
urine: Discuss. o Endoscopic surgery: Discuss.
- Treatment of specific cases of acute retention of o Open surgery: Just names.
urine: · Transvesical prostatectomy.
· In cancer bladder: · Retropubic prostatectomy (Millin's).
i. Urethrocathetrization. - Complications: Discuss.
ii. TUR.
iii. Urine diversion.
• Treatment of urine retention due to BPH:
iv. Uretrocutaneous implantation. Discuss.
· In cancer prostate & senile enlargement of prostate: 10.Discuss pathology, investigations &
i. Urethrocathetrization.
ii. TUR. treatment of cancer prostate
iii. Suprapubic cytocathetarization. Answer: Discuss pathology, investigations & treatment of
iv. IV hormonal therapy "estrogen” (in SEP only). cancer prostate.
7. Discuss clinical picture, complications &
indications for surgery of a case of benign
prostatic hyperplasia
Answer:
Clinical picture: Testis
• Symptoms uncomplicated cases: Discuss.

• Symptoms of complications: See later.
1. Enumerate classification of hydrocele
• Signs:
- General: Answer: Enumerate & define each type of
· Evidence of uremia. hydrocele:
· Effect of straining: e.g. piles, hernia.
1. Congenital hydrocele: persistent patency of the
- Abdomen:
whole processus vaginalis with small
· Renal mass from Hydronephrosis.
communication with peritoneal cavity.
· Suprapubic mass from retention.
2.Infantile hydrocele: Incomplete obliteration of
- P/R: 5 Ss:
processus vaginalis extends up to external ring but
· Enumerate the 5 Ss.
doesn't communicate with peritoneal cavity.
· Done to differentiate from cancer prostate.
3.Encysted hydrocele: Persistent dilatation of
Complications: Discuss secondary effect of SEP intermediate portion of the processus vaginalis
(complications). causing encysted cystic swelling at scrotal neck.
Indications for surgery: Enumerate. 4.Primary vaginal hydrocele:
- Cystic scrotal swelling, translucent, no impulse in
8. Discuss complications of senile cough, bipolar fluctuation, ill defined testis.
enlargement of prostate 5.Secondary vaginal hydrocele:
- Small soft hydrocele detected by pinching test.
Answer: 6.Hydrocele of hernial sac:
Urethral complications: Discuss. - Distension of empty henial sac which is shut off from
peritoneal cavity by omentum and adhesions.
Urinary bladder complications: Discuss.

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2. Discuss clinical picture & treatment of
primary vaginal hydrocele
Answer:
Orthopedics

Clinical picture:
· No exposit impulse on cough. 1. Discuss Supracondylar Fracture of Humerus
· Purely scrotal swelling. Answer:
· Ill defined testis.
· Translucent or Transillumination.
Trauma, Clinical Picture, X- Ray and
· Positive bipolar fluctuation test. Treatment: Discuss putting in mind General Scheme.
Treatment: Complications:
• Aspiration: is TOTALLY CONTRAINDICATED as it may 1.Local Complications: Discuss.
cause: 2.Complication of Treatment: Discuss.
- Hematocele, pyocele, recurrence, injury. Treatment:
• Surgery: just Enumeration. 1.Reduction.
- Eversion of tunica vaginalis. 2.Fixation.
- Excision of tunica vaginalis. 2. Discuss Fracture Neck of Femur
3. Discuss clinical picture, investigation & Answer:
treatment of primary varicocele Trauma, Clinical Picture, X- Ray and
Answer: Treatment: Discuss putting in mind General Scheme.
Clinical picture: Complications:
• Symptoms: Discuss. 1.Local Complications: Discuss.
• Signs: 2 items inspection, 6 items palpation. 2.Complication of Treatment: Discuss.
- Inspection: Treatment:
1. Affected side of scrotum hanges lower than normal.
2. Dilated veins beneath skin of scrotum. 1.Reduction.
- Palpation: 2.Fixation.
3. Felt as a bag of worm. 3. Discuss Colle’s Fracture
4. Soft, compressible, not tender. Answer:
5. Palpable thrill & expansile impulses on cough.
6. Veins empty on elevation of scrotum. Definition: Define
7. Small secondary varicocele. Trauma, Clinical Picture, X- Ray and
8. Examination of renal angle for hypernephroma.
• Complications: Discuss. Treatment: Discuss putting in mind General Scheme.
Investigations: Complications:
1.Semen analysis: Discuss. 1.Local Complications: Discuss.
2.Doppler & duplex scan on testicular veins. 2.Complication of Treatment: Discuss.
Treatment: Treatment:
• Conservative treatment: Discuss. 1.Reduction.
2.Fixation
• Surgical treatment:
- Indications: enumerate
4. Discuss Shaft of Femur Fracture
- Operations: enumerate Answer:
Trauma, Clinical Picture, X- Ray: Discuss putting in
mind General Scheme.
Complications:
1.General Complications: Discuss.
2.Local Complications: Discuss.
3.Complication of Treatment: Discuss.
Treatment:
1.First aid Treatment: Discuss.
2.Reduction: Discuss.
3.Fixation: Discuss.
5. Discuss Fracture Spine

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Answer: 1. Skin injury: compound fractures or skin infections.
Trauma, Clinical Picture, X- Ray: Discuss putting in 2. Muscles & tendons injury: Tears (Myositis
Ossificans is NOT included).
mind General Scheme.
3. Vascular injury: (Volkmann's ischemic contracture
Complications: is NOT included).
1.General Complications: Discuss. 4. Nerve injury.
2.Local Complications: Discuss.
5. Bone complications:
3.Complication of Treatment: Discuss.
- Osteomyelitis.
Treatment: - Malunion, delayed union & non-union: discuss
1.First aid Treatment: Discuss. table of union p.93. (Sound union is not included)
2.Reduction: Discuss. 6. Joint injury: Enumerate.
3.Fixation: Discuss. 7. Visceral injury:
4.Care of paraplegic: Discuss. • Intrapelvic rupture of bladder & urethra: Discuss
i.Care of Skin: Bed Mattress, Frequent Positioning, clinical picture of intrapelvic rupture bladder
Alcohol & Powder. p.25 & intrapelvic rupture urethra p.26.
ii.Care of Respiration: Suction of Secretions, O2
inhalation, Tracheastomy. C. Complications of treatment: Discuss.
iii.Care of Nutrition: Parentral or Tube Nutrition. 8. Enumerate 4 complications for each of the
iv.Care of Bowel: Daily Enemas. following fractures:
v.Care of Urine: Self retaining, catheter, Antiseptics.
A. Supracondylar fracture of humerus
6. Discuss Complications of Fractures
Answer:
Answer:
1. Volkmann's ischemic contracture:
A. General Complications: Discuss. - Infarction, contracture of forearm flexors due to
B. Local Complications: injury of Brachial A.
1. Skin injury: Compound fracture or Skin infection. 2. Myositis Ossificans:
2. Muscles & Tendons injury: - Following fracture, periosteal cells proliferate within
hematoma & ossify since new bone replaces hematoma.
- Tear.
- Myositis Ossificans: Discuss Cause, Site, 3. Cubitus varus or valgus: Loss of carrying angle of
Predisposing factors, Clinical picture & Treatment arm.
of Myositis Ossificans. 4. Delayed ulnar neuritis.
3. Vascular injury: B. Fracture clavicle
- Spasm, Contusion, Division causing Acute Answer:
Ischemia.
- Gangrene.
1. Malunion.
- Volkmann’s Ischemic Contracture: Discuss 2. Injury of subclaviclar A.
Definition, Pathology, Clinical picture & 3. Injury of subclavius muscle.
Treatment of Volkmann’s Ischemic Contracture. 4. Injury of brachial plexus roots.
4. Nerve injury. C. Colle's fracture
5. Bone Complications: Answer:
- Osteomyelitis.
- Avascular necrosis of head Femur. 1. Sudeck's atrophy: pain, swelling, osteoporosis &
- Malunion, Delayed union & Non- union: Discuss stiffness of hand.
table of Union P.93. (Sound Union is NOT 2. Malunion & delayed union.
included). 3. Carpal tunnel syndrome.
6. Joint injury: Enumerate. 4. Injury of extensor tendons of thumb.
7. Visceral injury: D. Fracture pelvis
- Intra pelvic rupture bladder & urethra in fracture
Answer:
pelvis: Give a Brief Note.
· Sudeck’s Atrophy: Discuss. 1. Hypovolemic shock.
C. Complications of Treatment: Discuss. 2. Rupture bladder & urethra.
3. Paralytic ileus.
7. Discuss complications of fracture pelvis 4. Complications of prolonged recumbancy.
Answer: E. Fracture neck of femur
A. General complications: Discuss. Answer:
B. Local complications: 1. Avascular necrosis.

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2. Thromboembolism.
3. Malunion causing Coxa Vera deformity.
4. Complications of healing (being elderly
Chest surgery
osteoprotic: delayed union, nonunion).
1. Give an account on clinical picture &
F. Fracture shaft of femur
Answer: management of flail chest
1. Crush syndrome. Answer:
2. Hypovolemic shock. Definition: Fracture more than 4 ribs both Anteriorly &
3. Volkmann's ischemic contracture, Myositis Posteriorly, so segment of chest wall becomes flail (loose).
Ossificans: Define. Clinical picture:
4. Fat embolism. • Clinical manifestations of respiratory distress:
9. Discuss ivory Osteoma - Dyspnea, cyanosis, diminished air entry.
Answer: • Clinical manifestation of circulatory distress:
Definition: - Tachycardia & hypotension.
- It is NOT a true benign tumor, it is a hamartoma. • Complications of rib fractures: Discuss
- Table for Differentiation between benign tumor & Complications of rib fractures p.161.
hamartoma: Discuss. Investigation: Discuss urgent investigations in the case
Pathology, Clinical picture & Treatment: of chest surgery P.160.
Discuss. • Laboratory: Discuss.

• Radiological: Discuss.
10. Discuss Osteochondroma
• Instrumental:
Answer: - ECG, Echocardiography.
- Discuss origin, Pathology, Clinical picture, Complications, - CVP. - Thoracocentesis.
Plain X-ray & Treatment of Osteochondroma.
- Bronchoscopy.
11. Discuss Osteoclastoma - Esophagescopy.
Answer: Treatment :
- Discuss Origin, Pathology, Clinical picture, Investigations
& Treatment of Osteoclastoma ‘giant cell tumor’. • First aid:
1.Support circulation by anti shock measures:
12. Discuss Osteosarcoma
Discuss in brief
Answer: 2.Support respiration :
- Discuss Origin, Pathology, Clinical picture, Investigations • General: discuss
& Treatment of Osteosarcoma. v. Maintain patient upper airway.
13. Discuss bone Secondaries vi. Analgesics.
Answer: vii. Aspirate secretions.
viii. Proper oxygenation:
- Discuss Etiology, Pathology, Clinical picture,
By:
Investigations & Treatment of secondaries.
· O2 mask. · Tracheastomy.
· Endotracheal tube & mechanical ventilation.
If:
· RR > 40/min. · PO2 < 60 mmHg.
· PCO2 > 45mmHg. · Flail chest.
· N.B.: No head trauma in this case.

• Support of flail segment by external Strapping or
positive pressure ventilation.

• Definitive treatment: Discuss P. 163.

2. Discuss Etiology & Complication of

hemothorax
Answer:
Etiology:

1. Traumatic: from injury to:
· Lung. · Intercostal or internal mammary vessels.
· Major intrathoracic vessels.
2. Pathological from:

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· Bronchogenic carcinoma · Leaking aortic aneurysm
3. Hemorrhagic blood disorders.
Complication: Neurosurgery
• General: if massive, cause hypovolemic shock. 1. Give an account on depressed fracture of
• Local:
1. Defibrination: Discuss. skull; clinical picture, investigations &
2. Clotting: Discuss. treatment
3. Organization: Discuss. Answer: Discussion of extradural hematoma is required.
4. Infection: Discuss.
3. Discuss Post-operative lung collapse Clinical picture:
Answer: • Bone fracture +/- scalp wound (Simple or
compound fracture).
Pathology: Discuss. • Clinical picture of extradural hematoma.
Clinical picture: 1.Concussion: Discuss from page 186.
• Symptoms: Discuss. 2.Lucid interval: Discuss from page 168.
• Signs: 3.Compression: Discuss from page 168-169.
4.Sings of lateralization: Enumerate from page 169.
- Inspection: affected side of chest is flattened and
immobile. Investigations:
- Palpation: Mediastinal shift toward side of collapse. 1.Plain X-ray skull.
- Percussion: dullness. 2. CT brain with IV contrast: Discuss findings of
- Auscultation: extradural hematoma.
· Diminished breath sound. - Localized biconvex hematoma.
· Tubular breathing and coarse crepitations as attack - Compression of hemisphere with compensatory
subsides. dilatation of opposite cerebral ventricle.
Investigations: 3.MRI brain.
4.Carotid angiography.
• Laboratory: Discuss.
Treatment: Discuss treatment of extradural hematoma
• Plain X-ray: Discuss.
from page 188.
Treatment:
2. Discuss Clinical picture & investigations of
• Prevention: avoid predisposing factors.
- Pre-operative, operative, post-operative causes of post- intracranial hematoma
operative pulmonary complications: Enumerate, P.171. Answer: Intracranial hematoma include extradural &
• Treatment: Discuss. subdural (Acute &Chronic) hematomas.
4. Discuss Etiology, Clinical picture and Clinical picture:
Management of Post-operative • Of extradural hematoma & acute subdural
pulmonary embolism hematoma:
Answer: - Concussion, lucid interval, compression & sings of
lateralization: Discuss from page 186,187.
Etiology: Discuss predisposing factors for DVT, P. Book 1. • Of chronic subdural hematoma:
Clinical picture: Discuss clinical subtypes of pulmonary - Manifestation of increase ICT: Enumerate from P189.
embolism. - Focal signs: Give examples.
Investigations: Discuss. - Herniation & cone formation: Discuss clinical
manifestation of cerebral herniation from page 186
Treatment: Discuss. (already discussed).
Investigations: discuss
3. Discuss Glasgow coma scale
Answer: Discuss Glasgow coma scale; definition, score &
interpretation.
4. Discuss principles of management of patient
with head injuries
Answer: Discuss management of patient with head injuries
page 190,191,192,193.

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5. Discuss clinical picture, investigations & - Look for intracranial injury: most probably
extradural hematoma: Discuss treatment of
treatment of carpal tunnel syndrome extradural hematoma from page 188.
Answer: • Simple fracture: conservative treatment unless:
Clinical picture: · > I inch. · Compress motor area.
· Causes cosmetic disfigurement. · Overlying air sinus.
• Type of patient: middle aged female. 7. Mention five signs denoting development of
• Symptoms:
intracranial hematoma
- Pain in distribution of median nerve in the hand.
· Worse by elevations of arms & at night. Answer:
· Relieved by hanging the hand over the edge of the bed. i. Deterioration of level of consciousness.
- Wasting of thenar muscles & anesthesia over ii. Change of vital signs in concussion (Cushing
lateral 3 ½ fingers in late cases. response): Respiratory rate, bradycardia,
• Signs: hypotension.
iii. Pupillary changes: Pupllioconstriction then dilatation
- Slight tenderness over the carpal tunnel by
then dilated fixed pupils.
percussion. iv. Contralateral hemiplegia.
- Increase pain if fingers & wrist are held fully v. Compression of RAS.
flexed for few minutes.
Investigations:
• Investigations for diagnosis:
- Nerve conduction study: on median nerve shows
delay at carpal tunnel.
Summary of Special Surgery
- Electromyography: to detect disuse atrophy. This is a ‘Summary of Special Surgery’ that
• Investigations for differential diagnosis: contains concise brief notes on the following
- To exclude: cervical rib & cervical spondyolosis
causing pain, tingling, and numbness in females. surgical specialties; Urology, Orthopedics, Chest
- By: plain X-ray neck; lateral & AP view. surgery, Neurosurgery and Anaesthesia. Using
Treatment: keywords, and outstanding some titles, has been
• Conservative: for mild cases, by anti-inflammatory considered in this Summary. This helps you to
& corticosteroids.
• Surgery: for severe cases, by surgical splitting of memorize topics before exam. Tables in
flexor retinaculum. different topics aim at making them easier to
6. Discuss management of fracture vault of recall.
skull
Answer:
¾ 2 types of fracture:
Fissure fracture:
- Conservative treatment unless CT brain revealed
intracranial damage.
Depressed fracture:
• Compound fracture:
- Discuss treatment of compound fracture p 182.
- Wound: discuss treatment of scalp wounds from p 181:
· Closure in 2 layers (glea to glea, skin to skin).
· If scalp defect, so rotational flap.
- Hematoma: Discuss treatment of scalp hematoma
page 181:
i. Cold then hot fomentation.
ii. Antibiotic.
iii. Aspiration or surgical evacuation (If large).
- If complications develop, there are indications for
urgent Surgery: Enumerate complications of
depressed fracture.

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General Surgery 4. Enumerate causes of immediate death in

burned patient in closed room
1. Discuss factors affecting wound healing Answer:
Answer: Discuss factors affecting wound healing. · Laryngeal edema & asphyxia.
· Carbon monoxide & cyanide poisoning.
2. How can you detect post-operative wound · Septicemia & septic shock.
infection? · Adult respiratory distress syndrome.
· Neurogenic shock.
Answer: 5. Discuss management of stab wound in
Clinical picture: femoral triangle
• General: fever at 6th, 7th day post-operative. Answer:
• Local:
1. First aid treatment: 4As.
- Red, hot, tender, swollen (signs of local · Analgesics for pain. · Prophylactic antibiotics.
inflammation) wound. · Antishock measures: Discuss in brief.
- Discharge: · Antitetanic.
· Early: serosanginous. · Late: purulent.
2. Primary survery (ABCDE): Discuss primary survery
- Wound dehiscence & gaping. in management of several trauma & multiple injured
- Burst abdomen (The most serious): Discuss it from patient, p.7, 8 Book general.
page 236, book 1.
· Definition: complete disruption of an abdominal
3. Secondary survey:
incision in early postoperative period. A. Femoral arterial injury: open with devision
· Clinical picture: (complete & incomplete):
- Warning sign: (Red sign) serosanginous Discuss clinical picture (p.90, 91) of acute ischemia,
discharges soak the dressing. investigations (p.92) & treatment (p.93) of arterial
- If intestine prolepses, so evisceration. injuries (open; complete & incomplete).
- If intestine does not prolapse, so dehiscence. B. Femoral vein injury causing DVT: Discuss
Investigations: prevention of DVT from p. 125.
- CBC: Leucocytosis. - Culture & sensitivity of discharge. C. Femoral nerve injury: According to time of
3. Enumerate different types of shock. How to presentations
• First 6 hours: primary repair.
differentiate between them from clinical • After the first 6 hours: delayed (secondary)
point of view? repair “mark both cut edges with black silk
Answer: suture then delayed repair” by:
i. Nerve graft.
Different Types of Shock: ii. Nerve transposition.
1.Hypovolemic shock. iii. Cutting of unimportant branches.
2.Cardiogenic shock. D. Muscular injury.
3.Vasogenic shock. E. Skin wound itself:
a. Septic shock. • 1st 6 hours: primary repair: Discuss.
b. Neurogenic shock. • 8-24 hours: primary suture: Discuss.
c. Anaphylactic shock.
• After 24 hours : delayed primary suture: Discuss
d. Endocrine shock.
How to differentiate: 6. Discuss management of crushed wound in
Table: How to differentiate between different types of shock: the thigh
Table How to differentiate between different types of shock Answer:
Hypovolumic Cardiogenic Vasogenic 1. First aid treatment: 4As.
Vital signs · Analgesics for pain. · Prophylactic antibiotics.
Pulse Rapid weak Rapid weak Tachycardia · Antishock measures: Discuss in brief.
BP Hypotension Hypotension Hypotension · Antitetanic.
Temp Subnormal Normal High 2. Primary survery (ABCDE): Discuss primary
Neck veins Collapsed Congested Collapsed survey in management of several trauma & multiple
CVP -ve +ve -ve injured patient, p.7, 8 Book general.
Periphery Cold pale Cold pale Warm, sweaty 3. Secondary survery:
with congested
veins A. Femoral arterial injury (closed, without
devision) contusion & spasm:

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Discuss clinical picture (p.90,91) of acute ischemia, • 1st 6 hours: by primary suture: Discuss.
investigations(p.92) & treatment (p.93)of closed • After 1st 6 hours: delayed primary suture:
(without devision) arterial injuries.
Discuss.
B. Femoral vein injury causing DVT: Discuss
prevention of DVT from p. 125.
8. Discuss management of cut wrist
C. Femoral nerve injury: according to time of Answer:
presentations: 1. First aid treatment: 4As.
• First 6 hours: primary repair. · Analgesics for pain. · Prophylactic antibiotics.
• After the first 6 hours: delayed( secondary) · Antishock measures: Discuss in brief.
repair ‘mark both cut edges with black silk · Antitetanic.
suture then delayed repair’ by: 2. Primary survey (ABCDE): Discuss primary survey
i. Nerve graft. in management of several trauma & multiple injured
ii. Nerve transposition. patient, p.7, 8 Book general.
iii. Cutting of unimportant branches. 3. Secondary survery:
D. Muscular injury: A. Ulnar & radial arterial injury: open & complete.
i. Gas gangrene: Discuss prevention of gas
B. Ulnar & median nerve injury:
gangrene from p.74.
ii. Compartmental syndrome: proper fasciotomy. • Deformities:
iii. Crush syndrome: Discuss treatment. - For Ulnar N: Claw hand syndrome.
E. Compound fracture shaft of femur: by external - For Median N: Ape hand syndrome.
skeletal fixator (Elizarof). • Management:
F. Skin wound: lacerated wound managed: - According to time of presentations
• 1st 6 hours: by primary suture: Discuss. o First 6 hours: primary repair.
o After the first 6 hours: delayed (secondary) repair
• After 1st 6 hours: delayed primary suture: “mark both cut edges with black silk suture then
Discuss. delayed repair” by:
7. Discuss management of lacerated wound in i.Nerve graft.
ii.Nerve transposition.
the calf iii.Cutting of unimportant branches.
Answer: C. Muscular injury:
1. First aid treatment: 4As. D. Wound injury: incised wound
· Analgesics for pain. · Prophylactic antibiotics. • 1st 6 hours: primary repair: Discuss.
· Antishock measures: Discuss in brief. • 8-24 hours: primary suture: Discuss.
· Antitetanic. • After 24 hours : delayed primary suture: Discuss
2. Primary survey (ABCDE): Discuss primary survey
in management of several trauma & multiple injured
patient, p.7, 8 Book general.
3. Secondary survery:
'Summary’ series
A. Tibial arterial injury: (closed without devision):
Discuss clinical picture (p.90, 91) of acute ischemia,
Summary of Special Surgery
investigations (p.92) & treatment (p.93) of closed
(without devision) arterial injuries.
Summary of Diagnostic X-Ray in
B. Calf vein injury causing DVT: Discuss prevention of
DVT from p. 125. Medicine
C. Medial & lateral popliteal nerve injury: according
to time of presentations: Summary of Clinical Pathology
• First 6 hours: primary repair.
• After the first 6 hours: delayed( secondary) Summary of ECG
repair ‘mark both cut edges with black silk
suture then delayed repair’ by:
i.Nerve graft.
ii.Nerve transposition.
iii.Cutting of unimportant branches.
D. Muscular injury:
• Compartmental syndrome: Discuss clinical picture &
treatment of compartmental syndrome.
E. Fracture shaft of tibia & fibula: by external skeletal
fixator. (By Elizarof fixator)
F. Skin wound:

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Section 3: Explain

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Estimation of free T3, T4 is more accurate than total T3, T4 It is essential to give intravenous Vitamin K to patients with
Total T3, T4 are affected by serum proteins which in turn are affected obstructive jaundice
by several diseases and conditions In obstructive jaundice, bile salts secretion in intestine is decreased
causing decreased absorption of fat soluable vitamins; the most
True cut biopsy; Not fine needle aspiration is needed for important of which is vitamin K which is essential for prothrombin
diagnosis of follicular carcinoma formation
As to diagnose follicular carcinoma, we need to see capsular and

Gas gangrene may complicate lacerated wound in gluteal
vascular invasion ; so we need true cut biopsy
region
It is recommended to give chemotherapy in premenopausal Because lacerated wound means maximal tissue damage with
females with cancer breast vascular damage making it more suitable for anaerobic organism
i. In premenopausal females, cancer breast tends to be aggressive,

Cortecosteriods impair wound healing
with high incidence of recurrence, so it is recommended to
double attack the tumor with hormonal and chemotherapy Corticosteroids:
ii. Cancer breast is a sysytemic disease from the start, spreading by i. Impair proliferation of fibroblasts
microcellular metastases all over the body, so to prevent those ii. Inhibit transformation if fibroblast into fibrocytes
microcelluar metastases from being gross metastases, iii. Interfere with neovascularization
chemotherapy is needed iv. Increase incidence of wound infection, interfering with wound
healing
Axillary Lymph node assessment is the most important
prognostic factor in cancer breast It is essential not to delay surgery in elderly patient with
bleeding peptic ulcer
i. Post-operative survival rate depends mainly on lymph node status
· Patient with negative nodes: 10-year survival rate 65% i. To prevent hypovolumea which may cause myocardial infarction
· Patient with less than 4 positive nodes: 10-year survival rate or renal shut down (acute renal failure)
38% ii. Elderly are atherosclerotic, atherosclertoic vessels will not stop
· Patient with more than 4 positive nodes: 10-year survival rate bleeding spontaneously
13% iii. Options other than surgery as IV antacids will have nothing more
ii. Exclusive theory of spread of tumor: to offer in this patient
The tumor invades both lymphatic and blood vessels at the same
time, affection of axillary nodes means systemic dissmenation Highly selective vagotomy is more physiological than truncal
Vagotomy
Mammography is needed to screen female breasts more than i.Preserves motor fibres to pylorus(Nerve of laterjet). So, NO
40 years drainage operation(gastrojejunostormy or pyloroplasty) is
required.
i. In females more than 40 years, density of breast tissue ii.Preserves hepatic branch of anterior vagus, so gall bladder is NOT
mammography is less echogenic than young females, so breast denervated with NO possibility of biliary disfunction & gall
mass can be accurately visulaized stone formation.
ii. Incidence and risk of cancer breast is increasing with age iii.Preserves ciliac branch of posterior vagus, so NO disturbance in
gastrointestinal motitity,hence NO diarrhea occurs.
Cancer male breast has bad prognosis
Amebic liver abscess is common on Right lobe of liver than the
i. No breast tissue in males, so the tumor from the start is attached
left lobe
to pectoral muscles (stage III)
ii. Cancer male breast is NON-hormone dependant, so no hormone i. Right lobe is bigger in size.
ii. Source of infection of Amoeba comes from right colon draining
treatment
into right lobe of liver; through lamellar blood flow to liver.
Foot infection is commonly seen in diabetic patient Cirrhosis is a relative contraindication for liver surgery
i. Infection: favored by increased blood sugar i. Bleeding tendency.
ii. Neuropathy: impaired sensation causing neglected minor wounds ii. Poor functional reserve of remaining liver.
iii. Ischemia: causing acidosis leading to decreased phagocytes with iii. Diminished capacity of liver cells for regeneration.
decreased antibodies
iv. Cellular: decreased cell vitality due to increased sugar contents
and ischemia
Post operative shunts are NOT used nowadays
Because of 3 Disadvantages:
High pre-operative fluid intake is recommended in patients i. Thrombosis at suture line & insufficient reduction of portal
pressure if anastomosis is narrow.
with obstructive jaundice ii. Liver cell failure due to ischemia of liver from shift of part blood
To protect the patient against hepato-renal syndrome, to give to systemic circulation if anastomosis is wide.
diuretics to wash toxins to renal blood flow and renal functions iii. Hepatic encephalopathy due to shunting of Ammonia & GABA
pre-operatively absorbed from intestine.
Patients with live cirrhosis have Haemostatic disorder

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i. Hypoprothrombinemia due to inability of liver to synthesis Based on above mentioned data, recognition of abnormal cell
Prothrombin from Vit K. division is function of B lymphocytes, & destruction of abnormal
ii. Thrombocytopenia from associated Hypersplenism. divided cells is function of cytotoxic killer cells & cytokines.
iii. Inability of liver to produce coagulation factors including
coagulation cascades.
iv. Decreased fat soluble vitamins including Vit K due to decreased Causes of disturbed hemostasis
Bile salts. Liver cirrhosis.
i.Massive blood transfusion: means banked blood lacking
Subdural hematoma is surgical emergency fibrinogen & coagulation factors, precipitating DIC.
i. It may cause cerebral herniation: Discuss clinical manifestation of ii.DIC: consumption of coagulation factors & platelets in the
cerebral herniation from page 186,187. microcirculation allover the body.
ii. If neglected, cause Herniation of brain stem causing death. iii.Obstructive jaundice.
Deterioration of patient of head trauma in ICU Patient with extensive burns needs resuscitation with large
amount of IV fluid
Enumerate the five causes of deterioration of patient of head Trauma
under observation page 193. In extensive burns:
i.There is severe fluid loss (insensible loss, evaporation from burned
areas leading to hypovolemia).
Aspirin should be stopped 10 days before surgery
ii.To resuscitate microcirculation by hemodilution to avoid
i. Aspirin is anti-platelet causing bleeding tendency due to hemoconcentration.
prevention of platelet aggregation & adhesion. iii.To increase renal blood flow to avoid renal tubular necrosis
ii. Its half life is NOT less than 10 days. (ischemia).
iii. To prevent postoperative peptic ulceration.
Bilateral orchedectomy is a palliative line of treatment of
Testicular Biobsy for testicular tumor is done through inguinal metastatizing cancer prostate
approach
i.Bone metastasis of cancer prostate is androgen dependant as
i.To prevent retrograde spread by lymphatic’s, achieved by clamp to primary tumor.
vas deferens. ii.Of poor vascularity of bone, other types of hormonal treatment will
ii.To prevent spread of malignancy to the scrotum which necessitates never be effective in controlling bony pains & pathological
removal of scrotum which can NOT be done. fracture.
- So only way to get rid of source of androgen.
Patient with testicular torsion should be treated urgently
i.Testicular torsion causes testicular infarction & gangrene, so Causes of immediate death in burned patient in closed room
causing testicular atrophy. • Laryngeal edema & asphyxia.
ii.Testicular torsion may cause disturbance in blood testicular barrier • Carbon monoxide & cyanide poisoning.
with formation of anti-sperm antibodies leading to infertility. • Septicemia & septic shock.
• Adult respiratory distress syndrome.
Cancer prostate is usually metastatic to pelvis & lower spine • Neurogenic shock.
Because of valveless venous communications between vesico-
prostatic venous plexus & emissary veins of prevertebral venous Patient with septic shock carries worse prognosis than
plexus, so there is possibility of retrograde blood flow. hypovolemic shock
Discuss pathophysiology of septic shock from p.18, 19.
Ulcers over shin of tibia heal slowly Urethral catheterization in a patient with suspected urethral
i.Poor vascularity of any skin covering directly bone. injury is contraindicated
ii.High possibility of exposure to infection & interference with healing
on surface of tibia. Because of
iii.Most of types of ulcers over shin of tibia are chronic ulcers (due to i.Possibility of introduction of infection.
varicose, ischemia ……) with fibrosed thick edges interfering ii.Possibility of conversion into complete injury.
creeping of epithelium to cause ulcer healing. iii.Possibility of creation of false passage.
Stones are more common in Submandibular gland
Hematuria is considered as a serious sign of urological i.Viscid secretions of Submandibular gland.
disorders ii.Opening in floor of mouth Æ obstruction food particles.
iii.Drains anti gravity.
Most of underlying causes are serious conditions. Cleft lip should be repaired before 8 months
i.All malignancies of UT are presenting with hematuria (late sign of
malignancy indicating advanced stage). Before dentition, to avoid forward proganthism as cleft lip affect
ii.Renal injuries are possibility especially those involving pelvicalceal development of upper incisors.
system. Cleft palate should be repaired at 1 year
iii.Severe infection like hemorrhagic cystitis & Bilharzial bladder.
- Before speaking, (as if not repaired constant are speaked by nasal
tone).
Patient receiving antirejection drugs may develop neoplasm
- Repair of cleft palate is a major surgery so we should wait until baby
Antirejection drugs interfere with: fit for the major operation:
i.Proliferation of B lymphocytes & T-helper cells. · Not less than 10 months.
ii.Action of cytotoxic killer cells. · Weight not less than 10 Kg.
iii.Formation of cytokines (IL2.IL10). · Hb not less than 10 gm/dl.

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B. What investigations are required to reach A. What is your diagnosis?

GIT Surgery B. Radiological investigations: Discuss laboratory

Vascular Surgery · Cyanosis, severe marked U edema (Compartemental

History General Local examination enumerate

Head and Neck •

Liver, Jaundice, Treatment:

• Investigations to confirm diagnosis: 4. Perforated duodenal ulcers:

Emergencies 2. Discuss clinical picture & treatment of

10. Enumerate cause of postoperative

Discuss. • Laboratory: Discuss.

General Surgery 4. Enumerate causes of immediate death in

As to diagnose follicular carcinoma, we need to see capsular and

i. In premenopausal females, cancer breast tends to be aggressive,

Patients with live cirrhosis have Haemostatic disorder

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

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Revision

B. What investigations are required to reach A. What is your diagnosis?

GIT Surgery B. Radiological investigations: Discuss laboratory

Vascular Surgery · Cyanosis, severe marked U edema (Compartemental

History General Local examination enumerate

Head and Neck •

Liver, Jaundice,  Treatment:

• Investigations to confirm diagnosis: 4. Perforated duodenal ulcers:

Emergencies 2. Discuss clinical picture & treatment of

10. Enumerate cause of postoperative

Discuss. • Laboratory: Discuss.

General Surgery 4. Enumerate causes of immediate death in

As to diagnose follicular carcinoma, we need to see capsular and

i. In premenopausal females, cancer breast tends to be aggressive,

Patients with live cirrhosis have Haemostatic disorder

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Liver, Jaundice, Treatment: