BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

1. Esinmenger Syndrome: 6. What is the Advantages & Disadvantages of

Complication caused by CHD (VSD, ASD, PDA) where Breast Feeding?
pulmonary hypertension causes ↑P in the R heart side. Advantages
This reverses shunt to R-L shunt (systemic pulmonary) ✓ More economical & convenient.
causing cyanosis. Blood Flows from RA →LA ✓ Provides all necessary nutrients for full term
Signs & symptoms:
infant including taurine & polyamine & other
i. Severe hypertension.
compounds that are essential in growing
ii. Pulmonary resistance exceed systemic.
iii. Right to left shunt. infant.
iv. Cyanosis. ✓ Better at preventing from infections.
✓ Better in digestion & absorption.
2. Dukes Classification of Colo – rectal Cancer: ✓ Allergic reactions like atypical eczema & GI
Stage A: Depth of invasion limited to muscular symptomatology are less frequent.
layer; no lymph nodes metastasis. ✓ Promote feeling between infant & mother.
Stage B: Depth of invasion to all layer; no lymph Disadvantages
nodes metastasis.
Stage C: Depth of invasion to any layer; with lymph ✓ Underfeeding:
nodes metastasis. o Restless.
Stage D: Distance metastasis. o Crying.
o Failure to gain weight.
3. How to Diagnose Simple Type Nephrotic ✓ Overfeeding:
o Regurgitation, vomiting are less frequent
Syndrome (NS)?
symptoms.
Excessive proteinuria > 50 mg/kg.d
o Constipation.
Serum albumin < 25 g/L
Protein cholesterol > 5.7 mmol/L 7. What are the Contraindication for Breast Feeding?
Edema ↑ i. Drugs taken by mother.
ii. Acute illness in the mother E.g.: Septicemia,
4. Diagnosis of Bronchopneumonia: typhoid, active TB, nephritis.
5 key points: iii. Profuse hemorrhage.
✓ Fever. iv. Malaria.
✓ Cough. v. Chronic poor nutrition.
✓ SOB or dyspnea. vi. Severe neurosis, postpartum psychosis, convulsive
✓ Fixed middle rales. disorder.
vii. Baby having galactosmia or phenylketonuria.
✓ Fine moist rales in the lungs.
viii. Premature baby cannot suck breast milk.

5. Diff. Between Bronchopneumonia & Bronchitis:

8. Kawasaki Disease Diagnostics Criteria:
BRONCHOPNEUMONIA BRONCHITIS i. Fever with unknown reason persisting 5+ days
Affect alveoli & relaxed Affect major bronchi ii. Other principle clinical features:
bronchioles. proximal bronchioles. ✓ Polymorphus exanthem.
Cause edema and fluid Cause edema and scoring ✓ Bilateral conjuctival congestion (w/out exudate).
collection in the alveoli. of air passage. ✓ Erythema, dryness, cracking (bleeding) of lips.
Cause high fever with chills. Cause mild fever. ✓ Strawberry tongue, diffuse congestion of the oral
Treatment based on Based in alleviating pain & & pharyngeal mucosa
antibiotics. reducing edema.
✓ Cervical lymphadenopathy (without suppuration)
Resolved soon. Long term cough with long
≥ 1.5 cm.
treatment.
iii. Changes in extremities:
✓ Erythema of palms & soles, edema of hands &
feet.
✓ Periungual peeling of fingers & toes.

Page 1 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

9. Immunization Course in Infancy (< 1 year old): 12. Treatment of Nephrotic Syndrome:
i. General Therapy
AGE (MONTHS) VACCINE
Support Care:
After Birth BCG, Hep. B vaccine
✓ Bed rest.
1 Hep. B vaccine (intensify)
✓ Diet (limit of protein intake 0.8 – 2.0 g/kg/d; limit
2 TOPV Poliomyelitis pill (1st)
of salt intake < 3g/d)
3 TOPV Poliomyelitis pill (2nd), DTP (1st)
4 TOPV Poliomyelitis pill (3rd), DTP (2nd) ✓ Prevention & treatment of infection.
5 DTP (3rd)
6 Hep. B vaccine (intensify) ii. Diuretic:
8 Measles vaccine ✓ Furosemide: 1 – 2 mg/kg.time I.V or I.M
12 Variant B encephalitis vaccine ✓ Hydrochlorithiazide: 1 – 2 mg/kg.time P.O
✓ Protein therapy: Albumin 0.5 – 1.0 g/kg.time
10. Physiological vs. Pathological Jaundice: ✓ Low molecular dextran or plasma: 5 – 10 ml/kg

iii. Steroid therapy: (specific therapy, the 1st choice of

inducing NS remission)
= Refer to Q.12 for elaboration =

iv. Relapse therapy:

✓ Prolong steroid therapy.
✓ Immunosuppresent therapy (CTX).
✓ Immune regulator: Thymic Peptide, IgG.
✓ Others: ACEI, Anticoagulant (Heparin, Urokinase,
Dipyridamole).
✓ TCM.

11. Diagnosis of Nephrotic Syndrome: 13. Long & Short Term Steroid Therapy:
The Standards of NS Diagnosis: i. Short Term Therapy: 8 weeks.
i. Excessive proteinuria: Cont. > 2 weeks. Prednisone: 2mg/kg.d (max. 60 mg/d), TID 4/52.
Quantity of urine protein > 50mg/kg.d or 3+ ~ 4+ 1.5mg/kg morning dose alternating for 4 weeks.
ii. Serum albumin < 25 g/L. Total course: 8 weeks.
iii. Plasma cholesterol > 5.7 mmol/L. Less side – effect, but relapses are common.
iv. Edema.
ii. Middle or Long Term Therapy:
Diagnosis of Clinical Types: Prednisone 1.5 – 2mg/kg.d (max. 60mg/d) TID P.O
i. Simple Type NS: until protein free for 2/52 (need 4 – 8 weeks),
✓ Excessive proteinuria: > 50 mg/kg.24hour. Followed by 2mg/kg morning dose alternating for 4
✓ Serum albumin < 25 g/L. weeks.
✓ Plasma Cholesterol > 5.7 mmol/L. If the proteinuria free, then gradually ↓dose.
✓ Edema ↑. Total course: 6 months (middle term therapy).
9 months (long term therapy).
ii. Nephritic Type NS:
✓ Besides the 4 features, in addition to hematuria 14. Please Write Down the Pathophysiology of
or HTN or azotemia or ↓ complement C₃. Primary Nephrotic Syndrome:
o RBC in urine > 10/HP. i. Excessive proteinuria (>50mg/kg/d):
o HTN: Preschool child > 120/80 mmHg. ↑Permeability of protein in GBM.
School child > 130/90 mmHg. ii. Hypoproteinemia: Protein loss.
o Azotemia BUN iii. Hyperlipidemia: ↑ MW lipoprotein, ↓lipase
o Low complement level (↓C₃). activity.
iv. Edema.

Page 2 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES
15. Classification of Congenital Heart Disease:
i. Latent Cyanosis Type (Left to Right Shunt):
ASD, VSD, PDA
ii. Cyanosis Type (Right to Left Shunt):
TOF, Transposition of the great vessels.
iii. Acyanosis Type (Non shunt Type):
Pulmonary stenosis, aortic stenosis, coartation
of aorta.
16. Paroxysmal Hypercyanotic Attack (Paroxysmal
Hypoxia Spells):
i. Occurs 1st 2 years of life.
ii. Most frequently in the morning after infant has
woken up from sleep or after feeding, crying or
bowel movement.
iii. Child becomes dyspnea & restless, RR ↑,
gasping respiration & cyanosis ↑.
iv. Followed with or without syncope.
v. Rarely fatal.
vi. One attack/spell last from few min. to few
hours.
vii. Followed by generalized weakness & sleep.
viii. Sometimes convulsions.
ix. Due to ↑CO₂ in blood resulting hypoxia.
17. Physiological Function of Vit. D:
i. Bone:
a. Induces expression of Osteoclacin.
b. Stimulate osteoclast differentiation → Ca & P↑
c. Deposition of Ca & P.
ii. Intestine:
a. Stimulate expression of calbindin.
b. Enhance absorption of Ca & P.
iii. Kidney:
Stimulate renal tubular reabsorption of Ca & P.
iv. Cell Differentiation: Collagen & skin epithelium.
v. Immunity: Cell mediated immunity & coordination
of the immune response.
Page 3 of 21
06/18/2016
18. Clinical manifestation of Ricket:
i. Early Phase of Rickets:
✓ Usually < 3 – 6 month.
✓ Symptom: Nonspecific neuropsychic symptoms.
✓ Irritability (restless ness, sudden crying at night).
✓ ↑sweating particularly around the head.
✓ No changes in growing skeleton.
ii. Intense Period: Skeletal Changes & Motor Dev.
Delay.
✓ < 6 months – craniotabe (Ping – pong ball
sensation).
✓ > 6 months:
o Head – Frontal bossing, boxlike skull, wide
open ant. frontanel.
o Teeth – Delayed eruption, abnormal order,
defects.
o Chest – Rachitary Rosary, Harrison’s groove,
pigeon chest, funnel – shaped chest.
o Spinal Column – Scoliosis, kyphosis, lordosis.
o Extremities – Enlarged wrists/ankles, bow leg &
knock – knee.
o Rachitic Dwarfism.
o ↓Muscle tone (potbelly), retarded motor dev.
19. Factors Influencing Rickets due Vit. D Deficiency:
Etiology of Rickets:
i. Inadequate direct exposure to sunlight.
ii. ↑Vit. D requirement (Rapid Growth).
iii. Inadequate intake of Vit. D.
iv. Improper ratio Ca:P in diet.
v. Vit. D deficiency in prenatal period (preterm, LBW)
vi. Disease & Medicine Role:
a. GI affection → Interfere with Vit. D absorption.
b. Liver/Kidney Disease → Disturbance of Vit. D
hydroxylation.
c. Drug → Interfere with Vit. D metabolism.
20. Please Describe the Typical CSF Change of
Purulent Meningitis:
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES
21. Please Write Down the Etiology of Purulent
Meningitis in Different Age Group:
i. Neonatal Period:
✓ Group B strep.
✓ Staphylococcus.
✓ E.coli & other gram stain – ve enteric bacilli.
ii. 2 month to 4 years of age:
✓ H.influenza.
✓ Step. Pneumonia.
✓ Meningococcus.
iii. Older Children:
Meningococcus, Strep. Pneumonia.
22. Treatment of Purulent Meningitis:
i. Antibiotic Therapy – Antibiotic sensitive to
meningitis
a. Pass BBB, Early & in time, adequate dosage &
course of treatment, IV.
b. Organism not confirmed – Ampicillin &
Chloramphenicol/Penicillin. (iv)
c. Organism resistant to C. & A. – 3rd Gen.
Cephalosporin
✓ (Ceftriaxone, Cefotaxime, Vancomycin)
d. Penicillin Sensitive Pneumococcal Meningitis – IV.
PN 3rd Gen. Cephalosporin
✓ If also 3rd Gen. Cephalosporin resistant –
Vancomycin
e. H. Influenza Meningitis – Ampicillin, 3rd Gen.
Cephalosporin
f. Meningococcal Meningitis – PN.
g. E. Coli Meningitis – 3rd Gen. Cephalosporin
ii. Control Convulsion – Sodium Barbital & Valium
iii. ↓Intracranial P – Dexamethasone, 20%
Mannitol, Furosemide
iv. Anti – Symptomatic & Supportive Therapy
23. Complication & Treatment of Purulent Meningitis
i. Subdural Effusion of Empyema
Rx: Absorption (Subdural aspiration & neurosurgical
intervention).
ii. Hydrocephalus
Ventriculoperitoneal & Ventriculoarterial shunt.
Page 4 of 21
06/18/2016
iii. SIADH (Syndrome of Inappropriate ADH
Secretion)
Rx: Fluid restriction.
iv. Ependymitis
Rx: Antibiotics (IV), Continuous ventricular drainage
24. Describe Blood Smear & Bone Marrow Changes of
Nutritional Megaloblastic Anemia:
i. CBC: Macrocytic Anemia
ii. Blood Smear: RBCs inequality of size, majority are
large cells, megaloblastic changes, neutrocytes
neutrocytes hypersegmentation thrombocytopenia
iii. Bone Marrow: Hypercellular, ↑ basophilic
normoblast & polychromatic normoblast. Giant
metamyelocytes. Hypersegmented neutrophils &
megakaryocyte.
25. Physiological Anemia:
✓ Onset 2 – 3 months after birth.
✓ Exaggerated in infants of LBW & with a history of
perinatal blood loss or hemolysis.
✓ Causes:
i. ↑O₂ → EPO↓ Reticulocyte # ↓
ii. ↓Life Span of RBC
iii. ↑↑ Circulating Volume
✓ RBC & Hb concentration: RBC 3 x 10⁹/L, Hb: 100g/L.
✓ Symptom: Not typical.
✓ Prognosis: Self – limited.
26. Extramedullary Hematopiosis:
✓ Type of postnatal hematopoiesis that occurs
outside medulla of bone.
✓ Does not happen just because of ↑requirement of
hematopoiesis (infection, hemolytic):
i. Site at liver, spleen, lymph node.
ii. Begins with severe infection & hemolysis.
iii. Cells – E & immature G.
iv. Neutrophilia in peripheral blood.
✓ When infection & anemia controlled → disappears.
27. Clinical Manifestation of Pneumonia:
i. Diagnostic Points: Fever, cough, SOB/dyspnea,
fixed middle or fine rales in lung.
ii. Clinical Symptoms:
✓ Main Symptoms: Fever, Cough, SOB, Chest Pain
(Elder Children).
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

✓ Additional Symptoms: Loss of appetite, excessive 31. Composition of ORS. Indication for ORS:
fatigue. ✓ Indications:
o Moderate/Mild dehydration.
iii. Signs: o Vomit mildly.
✓ Rapid, Shallow, Breathing (Dyspnea). o Prevention.
✓ Retractions – Supraventricular, intercostal, o Sustaining of IV transfusion.
subcostal areas.
✓ Abnormal Breathing Sounds – Wheezing, stridor, ✓ Composition:
coarse/middle/fine moist rales.

28. Diagnostic Point Congestive Heart Failure in

Pneumonia or Cardiac Failure due to Pneumonia:
Diagnostic Points of CHF in Pneumonia
i. Restless, Dyspnea becomes severe suddenly,
Paleness/Cyanosis.
ii. HR > 180/min (infants) or 160/min (children). Heart
sounds low & dull. Gallop rhythm.
iii. Liver enlarges > 2 cm in short time.
iv. Edema of face/feet maybe seen.
v. Oliguria or Anuria.

29. Clinical Features of Rotavirus Enteritis: 32. The Quality of Dehydration:

✓ Season: Autumn & Winter.
✓ Incubation: 1 – 3 days.
✓ Age: 6 – 24 months.
✓ Stool nature: Yellow watery or egg – soup like.
✓ Symptoms: Acute onset, accompanied with URT
symptoms, vomit at 1st.
✓ CNS symptom: Convulsion, myocardium 33. Clinical Finding of Hypoxic – Ischemic
involvement. Encephalopathy (HIE):
✓ General toxic symptom: Not obvious.
✓ Dehydration, acid – base disturbance, hypokalemia:
Very common.
✓ Prognosis: Limited to oneself.

30. Pneumonia Caused by Bacterial, Viral & Atypical

Organism:

✓ Summary of Clinical Manifestation:

o Mild: Hyperalertness, uninhibited reflexes,
sympathetic overactivity, duration < 24 hours.
o Moderate: Lethargy – stupor, hypotonia, suppressed
primitive reflexes, seizures.
o Severe: Coma, flaccid tone, suppressed brainstem
function, seizures, ↑ICP.

Page 5 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

34. Factors Influencing the Growth & Development: iv. Height/Length:

i. Hereditary: Important factor. Hereditary info of Birth (50cm), 3mon (61 – 62cm), 1yr (75cm), 2yr
parents decides: (85cm), >2yr to preadolescence (5-7cm/yr)
o “Trajectory” of Growth & Development. ✓ 2 – 12 yr: Ht. = Age (yr) x 6 + 77
o Characteristics.
o Potential. v. Head Circumference:
o Tendency. Birth (34cm), 3mon (40cm), 12mon (46cm), 24mon
ii. Environmental Factors: Natural & Social (48cm), 5yr (50cm), 15yr (53 – 54cm)
environment. Nutrition, Diseases & Other.
vi. Chest Circumference:
35. General Principle of Growth & Development: Birth (32cm), 1yr (46cm), >1yr [CC + (age – 1)]
From:
i. Up to Down. vii. Upper Arm Circumference:
ii. Proximal to Distal. 1 – 5 years old:
iii. Gross to Fine. ✓ >13.5cm, good nutritional status.
iv. Junior to Senior. ✓ 12.5 – 13.5cm, moderate nutritional status.
v. Simple to Complex. ✓ <12.5cm, malnutrition.

36. Supplement Food Principles:
✓ Schedule for Supplement of Additional Foods:
AGE INFANT FOOD
(Months)
1–3 Cod liver oil, juice, vegetable soup
4–6 Thin porridge, yolk, mashed vegetables & fruit
7–9 Whole egg, porridge, tender noodle, biscuit
10 – 12 Tender rice, noodle, finger foods, toast, crackers
37. Please Write Down the General Principle of
Weaning:
i. Providing a diet that has optimal nutrients for the
growth & energy needs of the child.
ii. Continuing to introduce new foods, with decreasing
emphasis on milk or formula as the major nutrient.
iii. Fostering behavior that will lead to a life – long
appreciation of nutritious foods in reasonable
amounts.
39. Diff. between Full – term & Pre – term infant:
i. Preterm Infant Outlook:
✓ Vernix – None or little.
✓ Breast nodes – None or <4mm.
✓ Skin – Thin & transparent. Blood vessels easily
seen (esp. abdomen).
✓ Hair – Lanugo covers entire body.
✓ Thenar (Plantar Surface) – Smooth & glossy.
Little/no crease.
✓ Ear form & Cartilage – Not well developed. Ears
don’t stand out from head.
✓ Genitalia – Testes not descend towards scrotum.
Labia major not cover minora/clitoris.
✓ Other Aspects – Resp., circulation, digestion,
nerve & immunological systems not well dev.
o Breath rate & Heart beat faster.
o Few nerve reflexes weaken.
o Resp. – Periodic resp. Apnea (pause >20s).
HR <100/min → cyanosis.

38. Please Describe the Common Evaluation ii. Full-term Infant

Indicators of Body Growth in Child & Their Normal
Values:
i. Weight:
Birth (3kg), 3mon (6±), 12mon (9±), 24mon (12±),
>2yr to preadolescence (2kg/yr)
✓ <6 months (kg) = BW + month of age x 0.7
✓ 7 – 12 months (kg) = 6kg + months of age x 0.25
✓ 2 – 12 years (kg) = age x 2 + 7/8
ii. Sitting Height (Crown – Rump Length):
iii. Subcutaneous Fat:
Page 6 of 21
✓ Proportion contour & Posture – Trunk cylindrical,
Head (32 – 34cm) > Chest (30 – 32cm).
✓ Skin – Covered with vernix. Lanugo (shoulder,
forehead, back, cheeks).
✓ Head – Fontanels easily palpable.
✓ Ear – Cartilage developed well → ears form →
stand out from head.
✓ Mouth – Inclusion cyst & Epstein Pearls.
✓ Chest/Lung – Anteropost = Lateral diameter. Ribs
flexible. Breast nodes >4mm (7mm).
✓ Abdomional Respiration. Can see shallow
respiration/momentary apnea.
✓ Heart – 90 – 160/min, hear some murmur (PDA).
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES
✓ Abdomen – Palpable liver edge 2cm below R
costal margin. Spleen tip, kidneys.
o Umbilical cord slough frm attachment in 1wk.
o Discharge stool in 24hrs. Urine in 24 – 48hrs.
✓ Genitalia
o Male – Scrotum small & edema of wall. Testes
palpable.
o Female – Labia majora covers minora.
✓ Blood – Vit. K deficiency. Give i.m injection.
✓ CNS – Brain 370g (10 – 20% BW).
✓ Reflexes – Rooting/sucking. Grasp/Moro reflex.
Traction response.
40. Oral Iron Preparation:
✓ Oral iron – first choice: Divalent iron.
✓ Dosage – Ferrous sulfate 1.5 – 2mg/kg tid.
✓ How to use – Time, Notice side effects.
✓ Intravenous iron: Anaphylaxis, prudent.
41. Perinatal Period:
The fetuses & infants from the 28th week of gestation to
the 7th day of life.
42. Classification of Newborn by Birth Weight:
43. Classification by Gestational Age:
44. Classification by Birth Weight & GA:
Page 7 of 21
06/18/2016
45. How Many Stages Are There in Children?
What are they?
There are 7 Pediatrics age group during childhood:
i. Fetal Period (Intrauterine Period).
ii. Neonatal Period (the 1st 4weeks of life).
iii. Infant Period (the 1st 1year of life) – Baby grows
most rapidly in this period.
iv. Toddler’s Age (1year old – 3year old).
v. Preschool Age (3year old – 6~7year old) – Intelligent
development increases.
vi. School Age (6 /7y.o – starting of adolescence phase)
vii. Adolescent Period – Girls (11/12 – 17/18year old),
Boys (13/14 – 18/20year old). Rapid ↑ in growth.
46. Classification of Hemorrhoid:
Def.: The congestion, dilation, varicose of venous plexus
beneath recta. Mucosa or epithelium of anal canal.
i. Internal Hemorrhoid – a plexus of veins above dental
line.
✓ Covered by mucosa.
✓ Often occur in 3 primary positions: Rt. Anterior,
Rt. Posterior, Lt. Lateral.
✓ Internal hemorrhoid drain to the superior
hemorrhoid vein & to the portal vein.
ii. External Hemorrhoid
✓ Occur below dental line, in the tissue beneath the
anal epithelium of the anal canal.
✓ Blood drain into the systemic circulation.
iii. Mixed Hemorrhoid – 2 plexus of internal & external
hemorrhoids anastomosis & mixed together.
47. Structure Hernia:
Consist of:
i. Hernia ring.
ii. Sac.
iii. Contained viscera.
iv. Covering tissue.
The name of hernia was generally from the position of
hernia ring.
48. Acute Appendicitis Pathology & Clinical Type:
According to different pathologic changes during
development of appendicitis.
1. Acute simple appendicitis. (Early Uncomplicated
Appendicitis)
2. Acute suppurative appendicitis.
3. Gangrene and perforated appendicitis: Pathogenic
changes progress further more severe.
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

49. How to Diagnose Primary Liver CA: 52. Incarcerated Hernia:

i. Specific Markers: Def.: The contents of the hernia cannot be returned to
✓ Serum Bilirubin: Elevated in 1/3. the cavity from which they came.
✓ About 75% of pts are +ve for HBsAg or Hep. C.
✓ Enzymology & Tumor markers: 𝛾 – GT, ALP, LDH, 53. Strangulated Hernia:
nucleoside phosphate diesterase, antitrypsin, Def.: The blood supply to the herniated tissue is
ferritin & isoprothrombin may be ↑.
disrupted causing ischemia & tissue death.
✓ AFP – Specific for diagnosis of hepatic cellular
Femoral > Indirect Inguinal > Paraumbilical
carcinoma. Value >400μg/L. Prognosis is worse
in very high AFP level, which is related to lack of
54. Inguinal Canal:
differentiation histologically.
Approximately 4cm in length & located 2 – 4cm
cephalad to the inguinal ligament.
ii. Imaging Study:
✓ BUS: Size (2 - <2cm) about 84% (+ve). Contains: Either spermatic cord or the round ligament of
✓ CT: About 2cm in diameter, contrast enhanced the uterus.
CT, 90% (+ve).
✓ Selected Angiography: Hepatic artery, Best Boundaries:
choice for smaller tumors. 90% (+ve) in <2cm
✓ Superficially: External oblique aponeurosis.
tumors.
✓ Cephalad wall: Internal oblique muscle, transverse
✓ Radionuclide Scan: 85 – 90% (+ve) in >3cm
abdomonis muscle & aponeurosis of these muscles.
tumors.
✓ Inferior wall: Inguinal ligament & lacunar ligament.
✓ X – ray: Enlarged liver. Rt. Elevated diagphram.
✓ Posterior wall (floor): Transversalis fascia.
✓ MRI: The best way to show extension into the
hepatic veins.
✓ Liver Biopsy: Very rare.
55. Complication of Acute Appendicitis:
i. Perforation;
✓ Accompanied by more severe pain and higher
50. Surgical Treatment of Inguinal Hernia:
fever than in appendicitis.
Principle of Operation:
ii. Peritonitis:
i. High Ligation: Child, strangulated hernia
✓ Increasing tenderness and rigidity, abdominal
(emergency case).
distention & adynamic ileus are obvious in
patients with diffuse peritonitis.
ii. Herniorrhaphy: Repair of the deep & superficial
iii. Abscess (appendiceal abscess):
rings. Enhance the anterior or posterior wall of
✓ Clinical presentation: The usual findings in
inguinal canal.
appendicitis + right lower quadrant mass.
✓ Ferguson’s ✓ McVay
✓ Do U/S or CT scan.
✓ Bassini’s ✓ Shouldice’s
iv. Pylephlebitis;
✓ Halsted
✓ Suppurative thromobophlebitis of the portal
iii. Tension Free Herniorrhaphy: venous system.
✓ Lichtenstein. ✓ S&S: Chills, high fever, lower-grade jaundice,
✓ Stoppa (Giant prosthetic reinforce of the and, later, hepatic abscesses.
visceral sac). ✓ Do CT scan.

iv. Laparoscopic Herniorrhaphy. 56. What are the Sign & Symptom of the Acute
Appendicitis?
51. Causes of Upper GI Bleeding: Clinical symptoms:
✓ Peptic ulcer. i. Pain.
✓ Portal hypertension. ✓ Severe & persistent.
✓ Hemorrhagic gastritis. ✓ Begins at epigastrium / around umbilicus.
✓ Hemobilia. ✓ Becoming rather sharply localized and causing
✓ Gastric carcinoma. discomfort; pain aggravating on moving,
walking and coughing.

Page 8 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

ii. Gastrointestinal symptoms. Terminal Stage

✓ Loss of appetite, nausea, vomiting and
constipation or diarrhea.
iii. Systemic Symptoms (whole body).
✓ Headache. ✓ Malaise.
✓ Asthenia. ✓ Low - grade fever or
high fever.
Signs (abdomen):
✓ Well-localized tenderness to one-finger palpation Rt.
lower quadrant (often on MC Burney’s point).
✓ Muscular guarding/rigidity & rebound tenderness.
i. Rovsing’s sign. (Pain felt in the right lower
quadrant on palpation of the left lower quadrant).
ii. Psoas sign. (Pain at the waist with extension of the
right hip and leg related to an inflamed pelvic
appendix).
iii. Obturator sign. (Pain with flexion and medial
rotation of the right leg – related to an inflamed
appendix in a pelvic location).
57. Clinical Features of Acute Peritonitis:
Reactive Stage
• Sharp intensive pain.
• Forced patient's position in bed.
• Tachycardia 100-120 /min.
• Dryness of tongue.
• Abdominal tension over the site of inflammatory
process or desk – like abdomen.
• Peritoneal signs (Blumberg’s sign).
• ↓ of peristalsis.
• X-ray → pneumoperitoneum, pleurisy, Kloiber's
cups, intestinal pneumatisation, lung atelectasis.
• Disturbanses of CNS (adynamia, euphoria,
psychomotoric excitement).
• Facies Hyppocratica (prostration, face with drawn
features, hollowed eyes).
• Anuria.
• Shallow breathing.
• Fecal vomiting, absence of peristalsis, abdominal
distension paralytic ileus.
• Positive peritoneal signs (Blumberg’s sign).
• Thread-like pulse (impossible to count), hypotonia.
• Cardiac arrhythmia, cardiac failure.
• Disturbances of blood coagulation
58. Early Gastric CA:
The tumor invasion was limited to mucosa or
submucosa, with or without lymph node metastasis.
✓ Type I: Protruded type.
✓ Type II (superficial): Superficial elevated type, flat
type, superficial depressed type.
✓ Type III: Excavated type.
59. The Classification by Gross Appearance of
Advanced Gastric CA:
Borrmann Classification:
✓ Type I: Polypoid tumors.
✓ Type II: Ulcerated carcinomas with sharply margin.
✓ Type III: Ulcerated carcinomas w/out definite limit.
✓ Type IV: Diffusely infiltrating carcinomas.
60. The Typical Finding of the BPH:
i. Obstructive symptoms include:
✓ Hesitancy.
✓ Loss of force & ↓ caliber of the stream.
✓ Sensation of incomplete bladder emptying →
double voiding.
✓ Postvoid dribbling (“terminal dribbling”).

Toxic Stage ii. Irritative symptoms include:

✓ Urgency.
• ↓ of pain. ✓ Frequency.
• Intensive vomiting. ✓ Hesitancy.
• Positive peritoneal signs (Blumberg’s sign) ✓ Nocturia – several times.
• ↓ of abdominal tension, abdominal distension.
• Absence of peristalsis, paralytic ileus.
61. Surgical Indication of BPH:
• Tachycardia >120 /min.
Absolute surgical indications:
• Hypotonia.
✓ Refractory urinary retention.
• Tachypnea.
✓ Recurrent gross hematuria from BPH.
• Increase of body t° (> 38° C).
✓ Bladder stones from BPH.
• Dry tongue (like a brush).
✓ Renal insufficiency from BPH.
• Euphoria.
✓ Large bladder diverticula.

Page 9 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES
62. Diagnosis of Bladder Tumor:
Symptoms and signs:
✓ Gross hematuria.
✓ Diffuse superficial tumors, esp. carcinoma in situ,
may have urinary frequency and urgency.
✓ Symptoms of cystitis.
✓ Pain.
✓ Both ureters obstructed → azotemia with
attendant secondary symptoms.
✓ External physical examination: Superpubic mass
may be palpable.
✓ Rectal examination: Large tumors → invaded the
pelvic side walls.
✓ Bimanual examination: Part of staging evaluation.
Laboratory findings:
✓ Microscopic hematuria is the only consistent
diagnostic finding.
Endoscopic findings:
✓ Cystoscopy examination should detect nearly all
tumors in the bladder.
63. The Therapeutic Principle for Bladder CA:
i. Transurethral resection, fulguration & laser therapy
✓ Endoscopic transurethral resection of
superficial and submucosally invasive low-
grade tumors (Ta, T1) can be curative.
ii. Surgical therapy:
✓ Invasive lesions (T2a, T2b) localized to an area
in the bladder wall away from the bladder base
→ Partial cystectomy.
✓ Patients with high-grade or invasive (T2a, T2b
& T3) lesions w/out distant spread or a fixed
pelvis on bimanual examination → cystectomy
and pelvic lymph node dissection.
iii. Intravesical chemotherapy: Recurrent low
grade, low stage (Ta-T1) tumors.
iv. Radiation therapy.
64. Clinical Manifestation of Injuries to the Kidney
(Renal Injury):
✓ Gross hematuria – Injury to the urinary tract.
✓ Pain & tenderness over renal area.
✓ Hemorrhagic shock – may result from renal
laceration & lead to oliguria. Nausea, vomiting &
abdomen distention (ileus) are the rule.
Page 10 of 21
06/18/2016
65. Causes of Urinary Tract Obstruction (including
upper & lower tract):
Acquired urinary tract obstruction maybe due to:
i. Inflammatory or traumatic urethral stricture.
ii. Bladder outlet obstruction (benign prostatic
hyperplasia or cancer of the prostate), vesicle
tumor, & neuropathic bladder.
iii. Extrinsic ureteral compression (tumor,
retroperitoneal fibrosis or enlarged lymph
nodes), ureteral strictures, ureteral stones or
tumors.
66. Classification OR Grading the Renal Injuries:
Grade 1 Injury: No parenchymal laceration, aka renal
contusion.
Grade 2 Injury: It involves ruptures or tears of the
capsules & parenchyma that are <1cm in length. The
injury doesn’t involve the collecting system or the
medulla of the kidney.
NOTE: Grade 1 & 2 are classified as minor injuries &
account for 85% of all renal injuries.
Grade 3 Injury: The injury is the same as Grade 2 injury
but extends >1cm.
Grade 4 Injury: Major laceration that extends into the
collecting system & produces extravasation of urine or
involves a segmental vessel.
Grade 5 Injury: Includes severe multiple laceration,
fracture, shattering of the kidney & renal vascular injury.
NOTE: Grade 3, 4 & 5 injuries are classified as major
injuries.
67. Clinical Manifestation due to Renal Blunt Trauma:
i. If the patient is hemodynamically stable & have no
hematuria → low urinary tract injury.
ii. If the patient with microscopic hematuria is
hemodynamically stable → low risk for significant
renal injury but should be observed more closely.
iii. Patient with hemodynamically instability or gross
hematuria → significant injury & undergo more
aggressive radiologic Ax if time allows & should be
treated.
68. Dysuria:
Painful urination is called as odynuria.
It is usually related to acute inflammation of the
bladder, urethra, or prostate.
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

69. Indications for surgery during management of 74. Common Bile Duct CBD Surgical Exploration
injuries for the kidney? Indication?
During conservative treatment, i. Obstructive jaundice.
✓ Shock is persistent although routine measure Rx. ii. Palpable stone, tumor, ascarasis in CBD during op.
✓ Hematuria becomes more severe & hematocrit ↓. iii. Revealed stone by cholangiography during OP.
✓ Flank or abdominal mass becomes larger; iv. CBD dilation 1cm in diameter, inflammation w thick
✓ Injuries of the abdominal viscera are suspected. v. CBD puncture with suppurative bile, bloody, sand –
like particles.
70. Acute pyelonephritis?
Def: Acute bacterial infection of the renal pelvic & 75. AOSC Acute Obstructive Suppurative Cholangitis?
parenchyma. Suppurative Cholangitis (Pentad):
✓ Except in the presence of stasis, foreign bodies, i.Abdominal pain.
trauma, or instrumentation. ii.Jaundice.
✓ Pyelonephritis is an ascending type of infection. iii.Fever and chills.
✓ Often via an incompetent uterovesical junction. iv. Mental confusion/lethargy (sometimes before
jaundice).
71. Acute Pancreatitis? v. Shock.
Essentials of Diagnosis
i. Cholelithiasis or alcoholism (many patients). Signs:
ii. Abrupt onset of epigastric pain, frequently with ✓ Tenderness, guarding ✓ Percussion pain
back pain, Nausea and vomiting. ✓ Hepatomegaly ✓ Palpable gall bladder
iii. Elevated serum or urinary amylase.
iv. Edema or necrosis. 76. Diagnosis of Portal Hypertension?
v. Bloody ascites, increased amylase. i. History (hepatitis, alcoholism or schistosomiasis).
ii. 3 main clinical manifestations
72. Special Examination of Biliary System? ✓ Splenomegaly.
Not always
i. Ultrasound (non-invasive). ✓ Hypersplenism.
found in all
ii. Radioscopy. ✓ Hematemesis or melena.
patients.
✓ Plain abdominal film: 15% radiopaque stones, ✓ Ascites.
enlarged gallbladder, air in bile duct.
iii. Oral cholecystography: iii. Laboratory studies:
iv. Intravenous cholangiography: Not for hyper- ✓ Blood test.
bilirubinemia, replaced by PTC, ERCP ✓ In hypersplenism, blood cell count esp. WBC
v. Percutaneous Transhepatic Cholangiography (PTC): and platelets are reduced.
✓ Complication of infection, bleeding, biliary ✓ Compromised liver function. ↑ serum
peritonitis aminotransferase and bilirubin
vi. Endoscopic Retrograde Cholangiopancreatography ✓ The ratio of A/G is reversed due to ↓ serum
(ERCP) albumin and ↑globulin.
✓ Complication: acute pancreatitis & cholangitis ✓ HBV or HCV positive in posthepatitis.
vii. CT, magnetic resonance (MRI), MRCP ✓ Prolonged PT.
✓ Dilation of bile duct, stones, location number, ✓ Upper GI series.
and size of tumors ✓ BUS: Determine cirrhosis, splenomegaly &
viii. Intraoperative and postoperative cholangiography ascites.
ix. Radionuclide scan (HIDA scan) ✓ Esophagogastroscopy is the most useful
x. Choledochoscope procedure for diagnosing bleeding varices.

73. Special Examination Of Breast Cancer?

i. Screening programs (infrared scanning).
ii. Mammography (contrast medium).
iii. Fine needle aspiration: cytology.
iv. B – Ultrasonography.
v. Mo – target X-ray.
Page 11 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES
77. Diagnosis & Clinical Manifestation Hepatic
Abscess or Pyogenic Abscess or Bacterial Liver
Abcess?
i. History (infectious disease, recovery from intra-
abdominal operation).
ii. Clinical symptomatology (shaking chills, high fever,
pain, large liver).
iii. Laboratory study.
iv. X-ray, BUS, CT examination.
v. Puncture: Pus.
78. Dx: Child’s Criteria for Hepatic Functional Reserve
79. How Many Operative Methods are there for
Patient with Rectal CA?
Operation is the most effective method of the rectal CA:
i. Miles’ Operation (abdominoperineal resection):
Distance of tumor from anus is <7cm.
ii. Dixon Operation (anterior resection): Distance of
tumor from anus is > 5 – 7 cm.
iii. Trans – anal pull through & resection: Distance of
tumor from anus between 7 & 10 cm.
iv. Hartmann Operation: Anterior resection of tumor &
close of distance end of rectum, sigmoid
externalization.
v. Local resection.
80. Differential Dx of Acute Perforation of
Gastroduodenal Ulcer:
i. Acute pancreatitis: Hx of ↑ fat food, serum & urine
amlyase increase, x – ray (-).
ii. Acute appendicitis: Shift pain, the sign of peritonitis
is not so severe, x – ray (-).
iii. Acute cholecystitis: Upper right epigastric pain,
Murphy’s (+), B ultrasonic show stone.
iv. Gastric CA perforation: Age, Hx of “gastric disease”.
Page 12 of 21
06/18/2016
81. Surgical Indication for Gastric Ulcer:
i. Failed in medical treatment.
ii. Recurrent during medical treatment.
iii. X – ray showed big or high position ulcer.
iv. Possible malignant change.
v. Have the history of perforation or bleeding.
82. Types of Pneumothorax:
i. Close Pneumothorax: Air enters the pleural cavity
through a hole in the lungs.
ii. Open Pneumothorax: Air at atmospheric pressure
communicates with the pleural space through a
hole in the chest wall when patient suffer from a
penetrating thoracic injury.
iii. Tension Pneumothorax: Air continues to
accumulate in the pleural space with each
inspiratory effort because of a valve – like
mechanism.
83. Rx of Pneumothorax:
i. Close Pneumothorax:
✓ Small pneumothorax (lung collapses <30%):
No Rx.
✓ Middle pneumothorax (30% < lung collapses <
60%) & large pneumothorax (lung collapses >
60%): Thoracocentesis or a chest tube which is
placed in the 2nd intercostal space in the
midclavicular line.
ii. Open Pneumothorax: Surgical closure of chest
wounds & a tube thoracostomy.
iii. Tension Pneumothorax: Immediately
decompressed by a needle & a tube thoracostomy.
84. Dx of Lung CA:
✓ Symptom – free: General investigation of ↑ risk
group (male, > 40 years old, cigarette consumption
20/per day). Taking a x-ray film & examining sputum
for CA cell every ½ a year.
✓ Early stage of the bronchogenic carcinoma →
Tumor is still located at the bronchus ,no invade the
hilar lymph nodes, pleura as well as distant
metastases, its diameter is often <3cm.
✓ Diagnosis procedure:
i. X-ray film (–) and sputum for cytology (–) → FBC
(–) → follow up once a month /year.
ii. X-ray film (+) and sputum for cytology (+) → FBC
to identify the cancer cell type → CT, MRI →
therapy.
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

85. Rib Fracture: 88. Straight Leg Raising Test:

The main symptoms: Def.: Raising the extended leg of the supine patient
i. Pain with respiration. produce sciatica within 60°.
ii. Tenderness.
iii. Crepitation. 89. Clinical Manifestation of Fracture:
iv. SOB. i. Systemic Symptoms & Signs: Shock (hemorrhage,
v. Subcutaneous emphysema on palpation. sharp pain, infection), Temp (<38°).
vi. Deformity at the fracture site. ii. Local Symptoms & Signs:
✓ General: Local pain, swelling, disturbance of
Treatments:
movement.
Relief of pain. ✓ Specific: Deformity, abnormal motion, rubbing
sound & rubbing feeling of bones.
i. Remove of pulmonary secretions.
ii. Successfully fixation of chest wall: Localized
90. Complication of Fracture:
strapping over the flail chest or operative
i. Shock.
stabilization.
ii. Infection.
iii. Avoid complication e.g.: atelectasis.
iii. Injuries to interal organs (pelvis – urethra, bladder).
iv. Injuries to large blood vessels (supracondylar
86. What are the Rx Principle of Bone Fracture: fracture of humerus – central n. & brachial a.)
i. Reduction: v. Injury of spine cord (vertebral fracture).
✓ Manipulation. vi. Injuries to nerves adjacent to the fracture site.
✓ Reduction by continuous traction. vii. Fat embolism.
✓ Open reduction.
viii. Joint stiffness (immobilization of joint).
ii. Immobilization: ix. Post – traumatic arthritis (osteoarthritis).
✓ Immobilization by circular plaster, splints or x. Post – traumatic ossification (excessive hematoma
fracture braces. under periosteum).
✓ Continuous traction. xi. Compartment syndrome (crush injury in arm, leg
✓ Internal fixation. compartment – fascia around muscle).
iii. Functional Exercise: xii. Hypostatic pneumonia (long time immobilization in
✓ Early stage: after injury 1—2 week bed)
o Muscle constrict and relax. xiii. Pressure ulceration (immobilization –
o Prevent muscle atrophy and joint stiffness. supraposterior crest of iliac under pressure).
✓ Middle stage: Passive exercise joints of
fractured site.
91. Osteofascial Compartment Syndrome (OCS):
✓ Later stage: After clinical healing of fracture
Def.: A series of early stage syndromes and signs which
actively exercise joints.
caused by acute ischemia of muscle and nerve in
osteofascial compartment.
87. What are the Indication for Open Reduction for ✓ Consisted of bone, interosseous membrane,
Bone Fracture? intermuscular septum & deep fascia → forearm & leg.
i. Soft tissue intervene between fractured ends, ✓ Diagnosis: Impending compartment syndrome:
failure in reduction by manipulation. o Sharpe pain.
ii. Reduction by manipulation can’t get functional o Pain on palpation of the swollen compartment.
reduction (satisfactory position). o Pain → Passive stretching of the digits.
iii. Displaced intra-articular fracture. ✓ Acute OCS – 5P:
iv. Fracture accompanying vessel or nerve injury. o Pain → Painless (ischemia → loss of function).
v. Multiple fracture. o Pallor (microcirculation).
o Paresthesia (nerve).
o Paralysis (muscle).
o Pulselessness (radial a., ulna a. or dorsal pedis a.)
— not safe criteria

Page 13 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

92. Indication of Operation for TB of Bone or Joint: 95. Clinical Features of Osteosarcoma:
i. Obvious sequestrum or bigger abscess that cannot ✓ Most common primary malignant bone tumor.
be absorbed. ✓ Occurs mainly in the 5 – 20 year old age group.
ii. Sinus tract no healing for a long time. ✓ Most commonly around the knee.
iii. Pure bone or synovium TB that cannot be controlled ✓ X – ray:
by drugs will develop whole joint TB. o In metaphysis commonly around the knee.
iv. Spine TB accompanied by paraplegia. o Bone destruction.
o Sun ray & a Codman’s triangle PR.
93. General Management of Spinal TB: o Soft tissue mass.
i. Generalized Rx: o Tumor bones formed by tumor tissue.
✓ Proper hygienic surroundings. ✓ 3 forms of osteosarcoma:
✓ Well – balanced diet. i. Osteoblastic – osteoblastic changes.
✓ Fresh air. o Tumor bone formation & periosteal
✓ Support Rx. reactions.
ii. Chemotherapy: ii. Osteolytic – osteolytic.
✓ Streptomycin. o Osteolytic lesion with pathological
✓ Isoniazid. fracture.
Continue for
✓ Rifampin. o Few or no tumor bones & periosteal
2 years
✓ Pyrazinamide. reactions.
iii. Local Rx: iii. Mixture – equalization in osteoblastic &
✓ Local immobilization. osteolytic changes.
✓ Abscess paracentesis.
✓ Injection of anti – TB drugs. 96. X – ray Features of Giant Cell Tumor:
iv. Operation: ✓ Has features both malignant & benign tumors.
✓ Focus curettage. ✓ Locally invasive rarely metastases.
✓ Arthrodesis. ✓ Most commonly occur at the bony ends around the
✓ Spinal fusion or osteotomy. knee & wrist.
✓ Eccentric & expanding destructive lesion.
✓ Bony crest & cells called “feature of soap bubbles”.
94. Clinical Features of L5 – S1 Intervertebral Disc
✓ Margin: Fairly well defined.
Herniation: ✓ Cortex: Thin.
Most common cause of pain in lower back & legs. Age: ✓ Easily occurs pathological fracture.
20 – 50 years old. Man > Female.
✓ No periosteal reactions.
i. Symptoms:
✓ Intermittent low back pain.
97. Flail Chest:
✓ Sciatic pain.
Def.: Severe chest wall injury with multiple rib fractures
✓ Compression of the cauda equine.
can create chest wall instability or “flail chest”.
ii. Signs:
✓ Flail chest is a free – floating segment of the chest
✓ Scoliosis.
wall which moves paradoxically with spontaneous
✓ Limitation of lumbar movement.
respiration.
✓ Tenderness in the paraspinous area, 1cm away
from midline.
98. Osteochondroma:
✓ Straight leg raising test, Intensification test: +.
The commonest in benign tumors.
✓ Sensory, motor and reflex changes.
iii. S1 root (L5 – S1): X – Ray findings:
✓ Pain & numbness: External ankle & lateral
dorsum of foot. ✓ Grows in the metaphysis.
✓ Weakness in great toe, plantar flexion (the calf ✓ Outward protrusion of bony mass.
muscles). ✓ Grows in the opposite direction with the epiphysis.
✓ Achilles reflex may be diminished or lost. ✓ With the bony cortex by a fine stem or wide base.
✓ Bone deformity.

Page 14 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

99. What are Radiographic Appearance of the Bone 102. Femoral Neck Fracture Cause, Complication,
Metastatic Tumor? Classification & Treatment:
✓ Most common bone tumor. Originate elsewhere Causes:
usually metastasize to bones (esp. red blood i. Mostly indirect force (falling, twisting).
marrow – spine, skull, pelvis, humeri, & femori). ii. Most commonly in elderly.
i. Lytic Metastases (Most Common): Commonly iii. F: M > 4-5/1,
arise from breast, kidney, breast, & thyroid iv. A nonunion rate >30%.
carcinoma. In children from neuroblastoma or
leukemia. Complications:
✓ Well-defined or ill-defined areas of bone i. Avascular necrosis of femoral head (FH).
destruction.
✓ Without a sclerotic rim. Classification:
✓ Small holes to large areas of bone i. Subcapital Fx.
destruction. ii. Fx through neck.
✓ The medulla enlarge. iii. Basic Fx.
✓ Destroy the cortex.
ii. Sclerotic Metastases: Due to prostate (men) or Treatment:
breast (women) carcinoma. i. Conservative management: Impacted and
✓ Ill – defined areas of increased density. undisplaced Fx & skin traction for 6 – 8 weeks.
✓ Ill – defined margins.
iii. Mixed: Seen in breast carcinoma. 103. Femoral Shaft Fx: Cause, Clinical Features,
✓ Lytic and sclerotic metastases. Complication, Diagnosis, Complication Rx:
Causes:
100. Clinical Manifestation of TOF: i. Indirect force (high energy falling, torsional
Symptoms: stress).
✓ Dyspnea on exertion and the Squatting position ii. Direct force (vehicle accident, gunshot wounds).
✓ Hypoxia symptoms
Clinical features/Manifestation:
Physical signs: i. Severe pain. iii. Tenderness.
✓ Failure to thrive ii. Local swelling, + Fx specific signs iv. Crepitation.
✓ Cyanosis
✓ Clubbing of the finger. Complications:
✓ An ejection systolic murmur. i. Mass hemorrhage.
ii. Shock.
Diagnosis:
✓ ↑ RBC. Diagnosis:
✓ ↓ Arterial saturation oxygen. i. Mechanism of injury.
✓ ECG. ii. Pain at Fx site.
✓ UCG. iii. Physical exam: specific signs of Fx.
✓ Right heart catheter examination. iv. X-ray.

101.Whipple’s triad? Treatment

i. Hypoglycemia especially after fasting or heavy 1. Skeletal traction
exercise. 2. Bryant’s traction
ii. Low plasma glucose at the time of symptoms. 3. Internal fixation with compression plate.
iii. Symptom release when glucose is raised to normal.
✓ Hypoglycemia: serum level< 2.8mmol/L.
✓ Relief of symptoms by glucose.
✓ Elevated serum insulin & C-peptide.
✓ CT-scan to localize tumor.

Page 15 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

104. Tibial & Fibular Shafts Fx: 108. 3RD Degree A – V Block:
Causes: ECG Criteria:
✓ Direct force & Indirect force. i. HR: Atrial rate is normal. Ventricular rate is
slower. 40-60 bpm if back-up pacer is from the
Diagnosis: junction or 20-40 bpm if back-up pacer is from
✓ Mechanism of injury. the ventricles.
✓ Intense pain, tenderness, swelling, bruising and ii. Rhythm: P-P is regular; R-R is regular (but the
contour at Fx site. two are independent functions).
✓ Physical Ex: specific signs of Fx + pulse, sensation iii. P waves: Upright and normal.
and motion deficits. iv. PR Interval: No relationship between the P and
the QRS waves. No PR interval.
Treatment: v. QRS Width: ≤ 0.12 seconds by the junction;
✓ Manipulative reduction: Stable / incomplete / >0.12 seconds if paced by the ventricle
minor rupture Fx. + cast / splint / brace.
✓ Surgical emergencies: Instable / open / displaced 109. Types of Abortion:
Fx. + Internal Fixation / External Fixation. (* N. & B.). i. Early abortion:
✓ Occurs during 1st 12 weeks of pregnancy.
105. 1ST Degree A – V Block: ii. Late abortion:
ECG Criteria: ✓ Occurs b/w 12th – 28th weeks of pregnancy.
i. Heart Rate: Varies depending on the underlying iii. Threatened abortion:
rhythm. ✓ Refer to intrauterine bleeding 20th week of
ii. Rhythm: Atrial and ventricular regular. complete gestation.
iii. P waves: Upright and normal. One P precedes ✓ With or without uterine contraction.
every QRS. ✓ Without cervical dilation.
iv. PR Interval: ≥ 0.20 seconds and is constant. ✓ W/out expulsion products of conception (POC).
v. QRS Width: ≤ 0.12 seconds. iv. Inevitable abortion.
✓ Intrauterine bleeding before 20week complete
106. 2ND Degree (Type 1 or Mobitz 1): gestational week with cont. cervical dilatation.
ECG Criteria: v. Incomplete abortion:
i. HR: Atrial regular; Ventricular rate is slightly ✓ Expulsion some but not all POC 20th complete
slower. Typically between 60-90 bpm. gestational week.
ii. Rhythm: Atrial regular. Ventricular irregular vi. Complete abortion:
iii. P waves: Upright and normal. Some P’s are not ✓ Expulsion of all the POC 20th complete
followed by a QRS (more Ps than QRSs). gestational week.
iv. PR Interval: Progressively longer until one P vii. Special abortion:
wave is not followed by a QRS complex. After ✓ Missed abortion: Death of embryo or fetus
the blocked beat, the cycle starts again. death, complete gestational week but POC
v. QRS Width: ≤0.12 seconds retained in uterus for 8 weeks.
✓ Recurrent abortion.
107. 2ND Degree (Type 2 or Mobitz 2): ✓ Septic abortion: Infected abortion with
ECG Criteria: dissemination of bacteria via the maternal
i. HR: Atrial regular. Ventricular rate is typically ¼ circulation.
to ½ the atrial rate (depending on the amount
of blockage in conduction), 110. Mechanism of Labor for LOA:
ii. Rhythm: Atrial regular (P-P is regular). While head is descending it makes 5 movements:
Ventricular irregular. i. Flexion.
iii. P waves: Upright and normal. Some Ps are not ii. Internal rotation.
followed by a QRS (more Ps than QRS). iii. Extension.
iv. PR Interval: The PR interval constant. iv. Restitution.
v. QRS Width: ≤0.12 seconds. v. External rotation.

Page 16 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES
111. Diagnosis of Early Pregnancy:
✓ before 12th gestational week
History and symptoms:
i. Cessation of menstruation – when menstruation
delayed 10days+. Earliest symptom.
ii. Morning sickness – after 6th week of
amenorrhea. 60% have nausea, vomit, sleepy,
acidity. Usually from 6th-12th week then
disappears because of hCG effect.
iii. Frequency of urination - ↑urgency & frequency.
Symptom disappears after uterus enlarges to
reaches out to pelvic cavity.
Examination & Signs:
i. Change of breast – breast become enlarged.
ii. Change of uterus – enlarged & soft.
Assistant examination:
i. U/S – scan gestation sac (see by 5th week). Echos
by 8th week.
ii. Pregnancy tests – detect hCG produced by
trophoblast. See in blood (7-9days) or urine
(4wks).
iii. ↑Basal body temperature (BBT) – due to
progesterone, ↑0.5℃. If high for 21days,
diagnose.
112. Ectopic Pregnancy Sign & Symptom, Diagnosis:
Def.: Fertilized embryo implanted outside the normal
utero-decidual area.
Normal – blastocyst implants in the endometrial lining
of uterine cavity.
Clinical Manifestations:
Classic symptoms (3A).
(1) Abdominal pain – from hemoperitoneum and/or
distention of hollow viscus.
✓ Character:
o Early: dull pain and uncomfortable.
o Late: colicky, lacerating, tearing, referred
shoulder/chest pain (irritation of the
diaphragm).
✓ Site – uni/bilateral. Not necessary on affected
site. Low/upper abdomen.
(2) Amenorrhea – ¾ women. ¼ remaining think that
bleeding due to menses.
✓ Character – some spotting at expected
menses.
(3) Abnormal menstruation (Vaginal bleeding) –
abnormal uterine bleeding (spotting).
✓ Not heavy, menstrual-like flow. (If heavy is
incomplete abortion).
Page 17 of 21
06/18/2016
(4) Additional Symptoms:
i. Syncope – dizziness, lightheadedness.
ii. Urge to Defecate – irritation of posterior cul-
de-sac. Some patients may faint.
iii. Decidual Cast –Can mistake with intrauterine
conception.
iv. Abdominal Mass – If in ectopic due to adhesion
& hematoma.
Signs:
(1) Hypovolemic Signs – Pallor, ↑pulse, ↓BP, mild
↑temp, shock presentations.
(2) Abdominal Signs – tenderness & rebound
tenderness (affected side), rigidity, ↓ bowel
movement, shifting dullness, abdominal mass.
(3) Pelvic Signs (mass + hemoperitoneum irritation) –
vaginal bleeding, slight enlarged uterus, fullness
of Douglas’ pouch, cervical motion tenderness,
adnexal mass & tenderness.
Two Principles for Diagnosis:
(1) Rule out ectopic pregnancy – if reproductive age
with acute pelvic/low abdomen pain without
abnormal vaginal bleeding.
(2) Possible – for + pregnancy test, if tissue passed
out or curettage doesn’t have villi.
113. Causes of Post – Partum Hemorrhage:
Def.: Excessive bleeding (>500mL in vaginal delivery).
Describes event, not diagnosis.
✓ Early postpartum hemorrhage: blood lost in 24
hrs after delivery.
✓ Late postpartum hemorrhage: blood lost 24
hours - 6 weeks after delivery.
Causes:
i. Tone:
✓ Uterine atony (most common).
ii. Trauma:
✓ Laceration (vagina, cervix, uterus).
✓ Episiotomy.
✓ Hematoma–vaginal, vulva, retroperitoneal
✓ Uterine rupture, uterine inversion.
iii. Tissue:
✓ Retained placenta.
✓ Retained blood clots in an atonic uterus.
✓ Gestational trophoblastic neoplasia.
iv. Thrombin:
✓ Therapeutic anti – coagulation.
✓ Defective coagulation – DIC.
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

114. What is the Complication of Ovarian CA/Tumor? 119. Follow Up Examination Of Hydatidiform Mole?
i. Torsion of the pedicle (most common). Def.: Pregnancy characterized by vesicular swelling of
ii. Rupture of ovarian cyst (alone or with torsion). placental villi usually in the absence of an intact fetus.
iii. Infection of ovarian tumor (rare). i. Follow up should be practiced by every 3 months
iv. Malignant transformation. for 2 years after discharge.
ii. Patients with hydatidiform mole are curative over
115. Clinical Features of Myoma? 80% by treatment or evacuation.
Clinical Manifestation – diff. types have diff. features: iii. About 16% of HM become invasion moles & some
Symptoms: 2.5% progress into chariocarcinoma.
(1) Menorrhagia & prolonged menstrual period iv. The follow up after evacuation is key necessary.
(common). v. Quantitative serum hCG levels should be
(2) Pelvic pain – occurs in pregnancy if have obtained every 1 – 2 weeks until – ve for 3
degenerations / torsion of pedunculated myoma. consecutive determinations.
(3) Pelvic pressure – urinary frequency & constipation. vi. Symptoms:
(4) Spontaneous abortion. ✓ Abnormal vaginal bleeding.
(5) Infertility ✓ Cough, hemoptysis.
✓ Signs of metastasis.
Signs – palpable abdominal tumor & uterus (enlarged, ✓ Pelvic examination.
irregular, hard) ✓ hCG evaluation.
✓ ß – U/S.
116.Pathological Classification of Myoma? ✓ CXR.
CLASSIFICATION
✓ According to growth location – on uterus body 120. Lab Findings for Diagnosis of Cervical Cancer?
(90%) or cervix (10%) i. Cervical cytology (PAP Smear Test).
✓ According to the relation of uterine muscle – ✓ Detect epithelial cell abnormalities.
submucous (15%), intramural (70%), subserosal ii. Colposcopy.
(20%) iii. Cervical Biopsy:
✓ Usually leiomyomas are hybrids, not a single ✓ Colposcopic biopsy.
“pure” type ✓ Endocervical curettage.
✓ Cone biopsy.
117. Four Ligament of Uterus? iv. VIA (Visual Inspect with Acetic acid) + VILI (Visual
i. Round ligament. Inspect with Logul’s Iodine).
ii. Broad ligament.
iii. Utero – sacral ligament. 121. Distinguish Between Invasive Mole &
iv. Transverse cervical ligament. Choriocarcinoma?

118. Describe Function Of Placenta: INVASIVE MOLE CHORIOCARCINOMA

i. Enable the fetus to take oxygen and nutrients Definition Molar pregnancy Highly malignant GTD.
from the maternal blood; in which molar Can develop from
villi grow outside hydatidiform mole or
ii. Excretory organ: Where CO₂ & other waste
the uterine cavity, placental trophoblast
products pass from the fetus to the maternal
into its blood cells associated with
blood; vessels or the healthy fetus, abortion
iii. Barrier: Against the transfer of infection to the myometrium, and or ectopic pregnancy.
fetus; may extend into
iv. Secretes large amounts of hormones as hCG and broad ligament
estrogens. and metastasize
to the lungs, the
vagina or the
vulva, etc.
Villi Present Absent

Page 18 of 21
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES
122. How Can Classify Dystocia (Broad Categories):
i. Abnormal of the power (uterine contractility &
maternal expulsive effort).
ii. Abnormalities of the passenger (the fetus).
iii. Abnormalities of the passage (the birth canal).
123. What Is The Therapeutic Principle Of Pregnancy
Induced Hypertension?
Def.: Hypertension associated with proteinuria and
edema, occurring primarily in nulli paras after the 20th
week or near term.
i. Mild preeclampsia: bed rest & delivery
✓ Hospitalization or home regimen.
✓ Bed rest and daily weighing.
✓ Daily urine dipstick measurements of
proteinuria.
✓ Blood pressure monitoring.
✓ Fetal heart rate testing.
✓ Periodic 24-h urine collection.
✓ Ultrasound.
✓ Liver function, renal function, coagulation.
✓ Observe for danger signals: severe headache,
epigastric pain, visual disturbances.
ii. Severe preeclampsia:
✓ Prevention of convulsion: Magnesium sulfate
or diazepam and phenytoin.
✓ Control of maternal BP: Antihypertensive
therapy.
✓ Initiation of delivery: The definitive mode of
therapy if severe preeclampsia develops at or >
36 wk or if there is evidence of fetal lung
maturity or fetal jeopardy.
iii. Eclampsia:
✓ Control of seizure.
✓ Control of hypertension.
✓ Delivery.
✓ Proper nursing care.
124. Clinical Stages of Endometrial Cancer:
FIGO clinic staging of carcinoma of the corpus uteri
Stage I – confined to the corpus. 1a (length of uterine
cavity ≤8cm), 1b (>8cm).
Stage II – involves corpus and cervix.
Stage III – extended outside uterus but not outside
true pelvis.
Stage IV – extended outside true pelvis or obviously
involvement of bladder mucosa or rectum.
Page 19 of 21
06/18/2016
125. The Line of Demarcation Between False Pelvis &
True Pelvis:
✓ Upper border of sacral promontory.
✓ Ilio – pectineal boundary.
✓ Upper border of pubis.
126. GTD:
Def.: (Gestational Trophoblastic Disease) – A rare
disease from abnormal trophoblastic proliferation.
✓ Among rare human malignancies that cured by
chemotherapy by widespread metastases.
Types of GTD:
i. Benign:
✓ Hydatidiform mole / molar pregnancy
(complete or incomplete).
ii. Malignant:
✓ Gestational trophoblastic Tumor (GTT) or
Neoplasia (GTN).
✓ Invasive mole.
✓ Choriocarcinoma (chorioepithelioma).
✓ Placental site trophoblastic tumor.
127. Definition & Clinical Classification/Types of
Placental Abruption:
Def.: Premature separation of placenta. Partial
abruption can lead to complete abruption at any time.
Types/Clinical Classification:
i. External (80%) – blood trains through cervix.
a) Detachment of placenta usually incomplete.
b) Fewer complications.
ii. Concealed (20%) – hemorrhage confined within
uterine cavity.
a) Detachment of placenta may be complete.
b) Relatively Concealed – If incomplete placenta
concealed by intact membranes.
c) Complications may be severe (fetal demise).
iii. Mixed
128. Define Fetal Lie:
Refers to the relationship of the long axis of the fetus
to the long axis of the mother
1. Longitudinal lie: The long axis of the fetus is
parallel with that of the mother.
2. Transverse lie: The long axis of the fetus crosses
that of the mother vertically.
3. Oblique: The r/ship of the spines forms <45° angle.
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES
129. Dysfunctional Uterine Bleeding (DUB):
Def.: Abnormal uterine bleeding with no
demonstrable organic cause (genital or extragenital).
✓ Diagnosis is by exclusion.
✓ Usually occurs after menarche & at the end
reproductive years.
✓ Cases – Adolescents (20%), 40-50yrs (50%).
✓ Complains – Heavy menses, prolonged menses,
or frequent irregular bleeding.
✓ Types of DUB:
o Anovulatory (most) – cont. E2 production & no
corpus luteum formation or P production.
o Ovulatory (10%) – after adolescent years &
before perimenopausal years.
130. Utero Placental Apoplexy (Couvelaire Uterus):
Def.: Widespread extravasation of blood into uterine
musculature & beneath serosa.
✓ Seen beneath tubal serosa, in broad ligament
tissue, in ovaries & free peritoneal cavity.
✓ Features:
i. Concealed hemorrhage.
ii. Placental margin remain adherent,
hemorrhage infiltrates uterine wall.
iii. Extensive intramyometrial bleeding.
iv. Purplish and copper-colored, ecchymotic,
indurated patch on the uterus.
v. Uterus loses contractile power.
vi. Postpartum hemorrhage.
131. Define Fetal Presentation:
Refers to the part of the fetus that enters the canal first
i. Head presentation: Occiput presentation (95%),
brow presentation and face presentation.
ii. Breech presentation:
✓ Complete breech presentation.
✓ Frank breech presentation.
✓ Incomplete breech presentation: footling
presentation.
iii. Shoulder presentation:
iv. Compound presentation:
132. In Labor:
✓ Contractions become more intense and
increasingly regular.
✓ Contractions last about 30 sec or more. Occur at
regular intervals about 5~6 minute.
✓ True labor → leads to progressive
effacement/dilation of the cervix & fetal
descent.
Page 20 of 21
06/18/2016
133. Endometriosis:
Def.: Disorder where endometrium tissue is located
outside of the uterus.
✓ Endometrioma – chocolate ovary cyst caused by
ovarian endometriosis.
✓ Adenomysis – presence of endometrial glands &
seroma in myometrium.
134. Amenorrhea:
Def.: Disorder presenting with the absence of
menstruation. Either primary or secondary.
Etiology:
i. Primary Amenorrhea – failure of menarche to
occur in relation to onset of puberty.
✓ No menarche by 16yrs with pubertal
development or no development by 14yrs.
✓ Due to gonad failure (common) or
uterovaginal agenesis. Anorexia nervosa
most common cause in teens.
ii. Secondary Amenorrhea – absence of menses for
>3months in previously menstruating woman of
reproductive age.
✓ Pregnancy, hypothalamic disorders (60%),
pituitary disorder (16%), ovarian disorder
(10%), Asherman’s Syndrome (7%).
135. When Does 3rd Stage of Labor Begins & Ends?
Begins when fetus is expulsed & ends with placental
expulsion.
Average duration: 8 minutes (5-15 min).
136. Definition, Significance of CIN.
Def.: Cervical Intraepithelial Neoplasia.
Significant:
i. Precancerous change which is close related to
invasive cancer of cervix.
ii. Occasionally increased vaginal discharge with or
without odor.
iii. Sometimes contact bleeding.
137. Infertility:
Def.: Infertility in a women to conceive or in a man to
induce conception. Female infertility may be due to
failure to ovulate, obstruction of the fallopian tube or
to disease of the lining of the uterus.
138. Meigs’ Syndrome:
Def.: Triad of ovarian tumor with ascites & pleural
effusion.
 BIYE KAOSHI NOTES EDITED FROM SANDEEP NOTES 06/18/2016

139. Asherman’s Syndrome:

Def.: Secondary amenorrhea related to endometrial
scarring.

Causes:
i. Endometriosis.
ii. Aggressive curettage for purpose of removing the
products on conception such as in abortion or
removal of retained placental fragments.

140. Non – stress Test (NST):

Def.: An external electronic monitoring procedure to
assess fetal wellbeing.
✓ An acceleration in fetal HR should be evident in
response to fetal movement.
✓ A reactive normal test consist 2 or more fetal
movements occurring within 20min accompanied
by acceration.

141.Staging of ovarian cancer?

Staging of Ovarian Carcinoma (FIGO)

Stage I (Growth limited to the ovaries)

✓ Tumor encapsulated & limited to 1 ovary

✓ No spread to lymph nodes/ other body parts

Stage II (Growth involves 1/both ovaries with pelvic

extension)
✓ Cancer in 1/both ovaries + spread to the pelvis
✓ Spread to uterus or fallopian tubes
✓ No spread to lymph nodes/ other body parts

Stage III (1/both ovaries + peritoneal implants outside

pelvis + retroperitoneal inguinal nodes)
✓ Cancer in 1/both ovaries, pelvis, + spread to
peritoneum
✓ Spread microscopically throughout pelvis

Stage IV (involves 1/both ovaries with distant

metastasis)
✓ Cancer spread to distant organs
✓ Treatment – surgery / intraperitoneal
chemotherapy
✓ Spread microscopically throughout pelvis

Page 21 of 21