Post- operative pt with FAHM, swelling at area of parotid… Dx: acute bacterial

parotitis.

Prevention of acute bacterial parotitis: good hydration& oral hyegine.

Pt with pain, swelling at submandibular region increase with eating… Dx:

submandibular gland stone.

1st inv: intra-oral x-ray.

If x-ray fails to reveal stone: sialogram.

TTT: incision if at duct & gland removal if at gland.

Painful rapid growing swelling of parotid gland + ipsilateral facial n. palsy… Dx:
cancer parotid.

MC complication/ MC affected n. of parotid gland surgery: facial n injury.

MC benign tumor of salivary glands: pleomorphic adenoma.

Sequence of investigations in salivary gland swelling:..vvvvimp

If solid mass:

1st inv…………..CT

Inv of choice………..Biopsy…..most accurate biopsy is excisional

If inflammation:

1st inv…………US

If stones:

1st inv…………X-Ray

Inv of choice………..sialogram.
TTT of pulp space infection: incision& drainage (don’t wait for fluctuation).

Pain at radial side of wrist with swelling, limited movement… Dx: tenosynovitis.

TTT: - mild cases: rest, NSAIDs … Resistant cases: cortisone injestion.

Flexed finger with nodule at palmar fascia on exam… Dx: dupyturene contracture.

Most common cause………alcoholism

Most imp inv for dupyturene contracture: blood glucose level.

Initial inv/ most imp inv/ inv must done before surgery: US.

Permanent shortening/ contracture of muscle after supra-condylar dracture of

humerus… Dx: volkman’s ischemic contracture.

TTT of volkman’s ischemic contracture: physiotherapy and surgery.

1st step in Pt with supra-condylar who feels severe pain after cast: cast removal.

If pain persist after cast removal: immediate exploration.

TTT of ingrowing toe nail: piece of gauze soaked with anti-septic solution &
wearing proper size of shoes ... wedge resection: for resistant and severe cases.

Swelling at neck midline moves up and down with swallowing& tongue

protrusion: thyro-glossal duct cyst

MC fate: infection.

TTT: surgical removal.

MC histological type of thyroid cancer: papillary carcinoma.

Next step If FNAB shows follicular Cs: biopsy to assess capsular infiltration.

Most fatal thyroid cancer: anaplastic carcinoma (more common in males).

Lateral aberrant thyroid……. Enlarged deep cervical LN with normal thyroid gland

Bad sign in cancer thyroid……… Hoarseness of voice (infiltration of RLN)

Main line of TTT of thyroid cancer: total thyroidectomy (LN are only removed if
affected).

Few hs after thyroidectomy, pt develops severe stridor… 1st/immediate step:

removal of all stitches “superficial & deep” and open the wound at the yard.

Immediate after thyroidectomy, pt develops tachycardia, hypertension,

hyperpyrexia & dyspnea… Dx: acute thyoid crisis.

TTT: propranolol, iv fluid, ice packs, O2, cortisone.

Prevention: good pt preparation b4 surgery (anti-thyroid medication, cortisone).

Laryngeal edema after thyroidectomy: intubation.

3-injury of RLN after thyroidectomy:

UNILATERAL………..hoarseness of voice

Bilateral complete injury of RLN ……..

Bilateral incomplete…..aphonia and stridor

Peri-oral numbness, tetany after thyroidectomy… Dx: hypo-parathyroidism.

Cause of hypo-parathyroidism: removal of all 4 parathyroid glands.

Emergent TTT: Ca glauconate 10% IV slowly.

Maintenance TTT: Ca & Vitamin D.

TTT of progressive exophthamos after thyroidectomy: tarsorhaphy.

TTT of hyperthyroidism during pregnancy: Short course on antithyroid and

propranolol till becomes euthyroid then surgery.

Time of surgery: 2nd trimester.

2nd trimester is the best time for all elective surgery.

Best TTT of thyrotoxicosis in children: anti-thyroid drugs.

Best TTT of thyrotoxicosis in cardiac pt: surgery.

Best TTT of thyrotoxicosis in pregnancy: surgery.

TTT of Malignant exophthalmos “Abruption of toxic status suddenly”:

antithyroid drugs 1st till eu-thyroid till surgery.
Fever, agitation, dyspnea in 1st d post-operative: atelectasis.

1st inv: pulse oximetry.

2nd inv: ABG then X-RAY.

1st step in TTT: O2.

Best TTT: breathing exercise.

Best way of prevention: incentive spirometry.

Fever, agitation, dysurea in 3rd d post-operative: UTI.

MC organism: E-coli.

Best ab TTT: TMP-SMX.

How to collect urine samples in pediatrics???

If more than 4 years……mid stream collection

If younger esp, less than 1 year…..suprapubic aspiration is the best

If failed….catheterization

When to say (+) sample:

Wbc's ( pus cells)…..more than 10

e-coli……..more than 100.000

Further investigation to children…..US is a must

If recurrent UTI…..micturiting cystourethrography

Dyspnea, chest pain& hemoptysis 4-5 ds after operation: PE.

Best inv: CT angiography.

TTT: LMWH then warfarin for 3-6 ms with target INR of 2-3.

Pain, red, swelling at site of surgical wound: wound inf; give abs.

MCC of hypovolemic shock: bleeding.

1st sing of hypovolmia: pulse change.

Worst sign of hypovolemia: hypotension (means loss of 20-25% of IV volume).

MCC of cardiogenic shock: MI.

Main TTT of cardiogenic shock: inotropes.

Main TTT of neurogenic shock: 1st step: IV fluids& 2nd: vaso-pressors.

Main TTT of septic shock: 1st step: IV fluid& 2nd: abs.

Main TTT of hypovolemic shock: IV fluid.

Type of fluid used: normal saline (0.9% NaCl).

If pt needs blood (e.g. hypotension): packed RBCs (O- if must be given before
cross matching).

Best solution fluid for intestinal operation: hartman’s solution.

When to give hartman’s solution: before operation (neither during nor after
operation).

Contra-indication of hartman’s solution: metabolic alkalosis.

Daily post- operative fluid requirement: 2L of 5% dextrose& 1L of normal saline.

Deficit therapy: given as normal saline.

Minimum K requirement: 20mmol/L = 60mmol/day.

Old pt with dehydration: give normal saline to make urine output> 2 ml/kg/h.

MCC that input isn’t equal to output: Error.

MCC that output is more than input in 5th d post-operative: resolution of paralytic
ileus.

1st MCC of post-operative oliguria: functional post-renal obstruction.

2nd MCC of post-operative oliguria: dehydration.

1st step in management of post- operative oliguria: catheter.

1st inv of post- operative oliguria: US.

If no urine after catheter: IV fluid (fluid challenge).

Most painful type of burn: 1st degree.

Painless, white burn: full thickness.

Soot in airway in burn pt: intubation (risk of asphyxia& airway obstruction).

Laryngeal edema in burn pt: intubation.

Burn pt, pt undergone major surgery or ICU pts: give PPI (risk of curling ulcer=
acute erosive gastritis).

MCC of death in burn pt: infection (esp. pseudomonas).

Management of eschar: escharotomy (not fasciotomy).

Most imp prognostic factor in burn pt: surface area (NOT degree of burn).

MC complication of peripheral line/ central line: infection.

MC organism: staph
If infection occurs: 1st: remove catheter then give abs.

MC complication during CVP removal: dislodgement of thrombus.

After removal of CVP, pt complains of marked congestion of face and neck… Dx:
dislodgement of thrombus… Inv of choice: CT with contrast.

Main TTT of necrotizing fsciitis: debdidement.

Main TTT of gas gangrene: debdidement.

Most imp vaccine for pt with splenectomy: pneumococcal vaccine.

Pt with splenectomy is at risk of septicemia from encapsulated organisms.

Serosanguineous discharge from wound of abdominal surgery+ just dehiscence…

observation (abdominal strapping).

Serosanguineous discharge from wound of abdominal surgery+ evisceration…

emergent surgery.

1st step in TTT of lacerated deep wound: debridement… then,

Tetanus toxoid and IVIG “TIG” according to the schedule:

If lacerated wound ( majority of cases in the exam):

1-If vaccinated:

TIG………..NOOOOOOOOO

Tetanus toxoid…….if last dose more than 5 ys

2-if NOT vaccinated or unknown or less than 3 doses:

TIG…….YES

Tetanus toxoid….yes

If clean wound ( NOT common in the exam):

:if vaccinated-1
TIG………NOOOOO
Tetanus toxoid……….if last dose more than 10 ys

:if NOT vaccinated or unknown or less than 3 doses-2

TIG…………NOOOOO
Tetanus toxoid…….yes
????When to give IVIG over all
‫و الزم الشرطين يكونوا موجودين‬

lacerated wound-1
if NOT vaccinated or unknown or less than 3 doses -2

????What if patient received booster dose in the last 4 weeks

:If lacerated wound-1
Vaccinated patient…………NO TTT
Un vaccinated patient……..TIG only

????What if kid less than 10 ys

:If NOT fully vaccinated-1

TIG……………NOOOOOOO
Tetanus toxoid……….NOOOOOO
Only DTPa

:What if fully vaccinated-2

TIG………NOOOOO
Tetanus toxoid…..NOOOOO
DTPa………NOOOOO

Old smoker with any complaint of his tongue has cancer tongue until proven
otherwise.

Most imp complain of cancer tongue pt: blood- stained saliva, otalgia.

Inv of choice of tongue cancer: biopsy.

White patch on tongue not removed by scraping= oral leukoplakia (pre-

malignant).

Next step in Old smoker with new onset of hoarseness of voice: laryngoscopy (risk
of laryngeal cancer).

Old age male with dysphagia, regurge, halitosis and bulge in neck… Dx: zenker
diverticulum.

Inv of coice of zenker diverticulum: barium swallow.

Timing to give antibiotics before the operation…….one hour

Most imp sign after head injury…..level of consciousness

Least cancer causing metastasis to the brain….prostate

Most imp inv in preoperative staging of gastric adenocarcinoma is ……..

PET scan.
Main TTT of lung abscess: clindamycin.

If pt not improved: trans-pleural drainage.

Persistent symptoms of pneumonia after TTT with abs… Dx: empyema.

TTT of empyema: chest tube & continue abs.