BATCH 23 MEDICAL UST #دفعة الدكتور حسن العريفي

#اختبار_الجراحه_العملي_بكالريوس_الدفعة_23 اختباري كان في الجمهوري Long case: acute cholecystitis ‎كانت مع الدكتور لؤي سمع الهستوري كامل Positive findings in examination DD, investigation (lab. And imaging), treatment ( سأل عن نوع المضاد الحيوي) Absolute and relative contraindications of laparoscopic cholecystectomy Short case :مع الدكتور عبد الملك nasogastric tube (indication, contraindication and complication) Inspection of abdomen ( name of appendectomy incisions) Dextrose 5% in normal saline ( indication and contraindication) Oral:مع الدكتور محمد البعداني nasogastric tube (indication, contraindication and complication) Types of shock Grades of hemorrhagic shock Complications of cholecystectomy

#اختبار_الجراحه_العملي_بكالريوس_الدفعة_23 حالتي post operative cholecystectomy ناقشت مع دكتور لؤي 🥹 المناقشه يسمعك للاخير وبعدين طلب DDx والتحاليل وايش most common diagnostic....abdominal u/s ...ويسأل ليش اول شي من imagine نسويها طلب complications Most common...pancreatitis الاورال د.البعداني types of appendicitis Complications Factor effecting wound healing Types of surgical wound With example الشورت دكتور ماعرفته سأل types of iv fluid....وكان الموجود DNS وكان يشتي اقول انه مخلوط ويستخدم بالحروق والshock IV canula size ..site ...therapeutic and diagnostic....زي bariam...blood sample Parkland's formula of burns وكم في اليوم الاول وكم باليوم الثاني وبقيه الايام وش نعطيه وتم بحمد الله تعالى 🥹😩✋🏻 بالتوفيق ي عزيزاتي الاختبار حاجات baisic ويشتي بس تركزي بكلام الدكتور وش هو يقصد 🤗

Examination: 💠 Great , introduce, Permission , wash , privacy 💠 Position and exposure: both standing "first " & sitting 💠 Exposure: from umbilicus to mid thigh 🟫Inspection: 1⃣Compare both testis ( both present, larger , vertical , higher ) 2⃣Swelling: ▪️site: one or both ▪️size: ( unilateral, pure scrotal / inguinoscrotal , relation to the testis , cord , penis ) ▪️Shape ▪️Surface ▪️Skin ( regosities, redness, edema, ulcer, scar, sinus, pigmentation) 3⃣ask the pt to cough 🟫Palpation: 1⃣Ask about pain 2⃣Assess tenderness and temperature, start by normal 3⃣The swelling ▪️Shape ▪️Surface ▪️Edge ▪️consistency ( soft,firm, hard, cystic) ➡️ fluctuation test + translumination + reducability + cough impulse 4⃣Scrotal neck test: feel the cord ▪️Pull the tail of scrotum between thumb & other finger behind ▪️can you get above it : Yes > pure scrotal No > ingiunoscrotal ; hernia ▪️Hinge test? 5⃣Can you feel the swelling separate from the testis ▪️Yes : it could be ➡️ 1. Epididymal cyst ( upper pole, translucent) 2. Spermatocele ( smooth, opaque) 3. Hydrocele of the cord (translucent) 4. Varicocele ( bag of worm, opaque, standing) ▪️No : it could be ➡️ 1. Hydrocele ( soft + fluctuating) 2. Hematocele ( above + tender ) 3. Tumor, gumma, chronic hematocele ( irregular mass , not tender) 6⃣ Relation to the cord: traction test if look separate from the testis 7⃣ Does it transulminate: ▪️If Yes ➡️ 1. vaginal hydrocele 2. hydrocele of the cord 3. epididymal cyst ▪️If No ➡️ 1. tumor , 2. gumma ( no fluid) 3. hydrocele 4. hematocele 🟫Examine contralateral side ( for swelling or any abnormality) 🟫Complete examination: Full abdominal examination , PR, LN

〰️〰️〰️〰️〰️〰️〰️〰️〰️ 7. Scrotal swelling 〰️〰️〰️〰️〰️〰️〰️〰️〰️ History: 💠 Great , introduce, Permission 💠 Personal data: 1. Name 2. Age Children ➡️ primary hydrocele ; patent process vaginalis (20-40) ➡️ secondary hydrocele ; trauma , infection , neoplasm ( > 40 ) ➡️ primary, idiopathic 3. Residence 4. Occupation 5. Marital status 💠 C/O + duration: increase size of testis/ swelling in the scrotum 💠HPI : 🔸onset and progression بالليل كيف ، بالصباح كيف ، مع اللعب ، هل بالليل بتختفي 🔸Pain : socrates ▪️Painful : Mild : secondary hydrocele Severe : child - adolescence > torsion Elderly > epididymo- orchitis ▪️Painless: idiopathic hydrocele/ tumor 🔸Micturaion problem ( burning - frequency ; epididymo- orchitis ) 🔸Trauma > hematocele 🔸Loss of weight, appetite + malaise > tumor 🔸Sexual and social problem 💠past medical hx 💠family hx 💠social hx 💠drug hx all as usual

Abdomen Examination 💠 Great, introduce, permission, privacy, wash 💠 Position: supine 💠 Exposure: from nipple to upper thigh 💠general ex ▪️Well flat comfortable ▪️Hand: 1. palmar erythema 2. dupuytene contracture 3. palar 4. clubbing 5. koilonychia 6. leukonychia 7. asterixis 8. pulse 9. bp ▪️Head 1. palar 2. jaundice 3. parotid swelling ▪️Chest 1. spider navii 2. gynecomastia 🟫Inspection Movement Contour Flanks Umbilicus Scar Striae Pulsations Prominent veins Hernial orifice 🟫PALPATION : Ask him about pain 🔸Superficial palpation ▪️mass ▪️tenderness ▪️temperature If you find mass: elevate the leg if it disappear➡️ from visera not disappear➡️subcutaneous 🔸Deep palpation for liver +liver span 🔸Deep palpation for spleen (if palpable mention its charter) 🔸Deep palpation for kidney 🔸Deep palpation para aortic 🔸Sucussion splansh(م. ناصر) 🔸Murphy sign 🟫 PERCUSSION Percussion for ascitis Fluid thrill for massive ascitis 🟫 AUSCULTATION : bowel sounds added sounds Renal bruit Venous hum Splenic and hepatic rub in Hepatosplenomegally 🟫BACK Sacral edema Spider navii 🟫Compelete examination by PR , examine genitalia anf lymph node

〰〰〰〰〰〰〰〰〰〰 6. abdomen 〰〰〰〰〰〰〰〰〰〰 History 🟣1. Cholecystitis 💠great, introduce, permission 💠complain/duration 💠HPI: 🟫 Pain: socrates 1. Site: cholicystitis➡️ rt upper quadrant biliary colic➡️ upper abdomen 2. Onset: sudden 3. Character: ▪️colicky; stone ➡️ ▪️dull burning; cholicystitis ➡️ ▪️throbbing; pyocele? ➡️ ▪️stabting 4. Radiation tip of the rt shoulder 5. Association ▪️nausea ▪️fever/chills ▪️jaundice/itching 6. Timing more than 6 hours➡️cholicystitis less than 6 hours➡️ biliary colic (biliary colic is constant and not true colic) 7. Exacerbating ▪️fatty food ▪️breathing/movement Relieving ▪️biliary colic➡️only strong analgesic 8. Severity ▪️impair activity ▪️or from 10 🟫 GIT Vomiting, Constipation, Diarrhea, Dystension, Dyspepsia, Dysphagia Bloody stool Appetite Weight loss 💠Systemic Review Cardiovascular: chest pain, dysnea, hemoptysis Urinary: color, amount CNS: drowsness, 💠Past Medical History 1. Similar condition 2. admission 3. blood transfusion 4. surgery 5. history of jaundice, recurrent malaria, anemia, IHD, asthma, HTN, DM 💠Family hx Similar condition 💠Social hx smoking alcohol insurance 💠Drug hx current chronic: contraceptive pills allergy

Examination 💠Great, introduce, permission, privacy wash 💠Position: Standing 💠General: well, standing comfortable 🟫Inspection for the veins 👉There is abnormal superficial elongated dialated tortuous vien/s 1⃣Site 🔸anterio-medial thigh and calf➡️ Great saphenous vein 🔸anterio-lateral thigh➡️ accessory saphenous vein 🔸Posterio-lateral of the calf➡️ Small saphenous vein 🔸above the inguinal ligament➡️ superficial circumflux iliac, superficial pudendal, superficial epigastric veins 🔸Other sites ➡️ Stray varicosit 2⃣Extent 3⃣Blow out + Saphena varix (if +ve ask the pt to cough) 4⃣Raise the leg for collapsibility 🔸collapsed: primary 🔸not collapsed: secondary eg: DVT, pelvic tumor, & AV malformation 5⃣while the leg is raised ask the pt to cough➡️ morrissey test 🟫 Inspection for signs of venous hypertension "THe PEAU D'orange" 1. Thicking or atrophic changes 2- Hemorrhage 3- Pigmentation 4- Edema: pitting and start distally 5- Ankle flare: small dilated venules (incompetent perforators) 6- Ulceration: over gater area 7- Dermatitis 8- Deformites: Talipes equinovarus (chronic ulcer▶️contracture) and ankylosis of the unkle 🟫Palpation 1⃣Temperature 2⃣Tenderness 3⃣Thrill ➡️ saphenofemoral junction & behind the knee while coughing 4⃣Lower third of the leg for ▪️thicking➡️ lipodermatosclerosis ▪️edema ▪️tenderness ▪️base of the ulcer if found 5⃣palpate for peripheral pulses 🟫 Percussion (Shwartz's test): if +ve ➡️ incompetent valves 🟫 Auscultation 💠percuss proximally and auscultate distally if +ve ➡️incompetent valve 💠 Bruit: machinary continous (AV malformation) 🟫 Special Tests ◾️Trendelenburg test ◾️Mutlipe trendelenburg test ◾️Perthe's Tests 🟫Complete the examination by: 1. Abdominal Ex: for ▪ dilated collateral, do harvest test ▪ masses 2. Scrotum for varicocele and masses 3. Per-rectal & Per-vaginal Ex for ▪️️masses ▪️coexistnce hemorrhoids (note: read about; Tredelenburg test, Mutlipe trendelenburg test, Perthe's Tests & shwart's test)

〰〰〰〰〰〰〰〰〰〰〰 5. Varicoce 〰〰〰〰〰〰〰〰〰〰〰 History: 💠 Great, introduce, Permission 💠 Personal data 1. Name 2. Age ➡️ All age groups 3. Sex ➡️ 10:1 F:M 4. Occupation ➡️ job involve long standing 5. Residency ➡️ more in Europe and north america 6. Marital status 💠 Complain/Duration: 1. Disfiguring effect of the viens 2. Pain 3. Mild swelling at the end of the day 4. Night crumps and itching 5. Pain ful lumps 💠History of present illness: 1⃣Onset ➡️ gradually 2⃣Progression ➡️ 1. how discovered , 2. disappear? , 3. difference between start and now 3⃣Aggravated by: 4⃣Associted with ▪️Pain: 1. Site : calf or lower leg 2. Onset 3. Character : dull , Night crumps or heaviness 4. Radiation 5. Aggravate: standing 6. Relieve: lying down 7. Association : fever 8. timing: night 9. Severity ▪️Itching ▪️Swelling ▪️Skin changes / ulcer 5⃣Other sites 6⃣Risk factors: 🔸long standing 🔸trauma 🔸DVT 🔸multiple parity 💠Systemic review: Abdomen: pain, distention " asictes, pregnancy " 💠Past medical history: Admission , blood transfusion, surgery , DVT , clotting disorders , pelvic tumors , DM or HTN 💠Family history: similar condition 💠 Social history: Smoking , alcohol, health insurance 💠Drug history: current , chronic, allergy

Examination 💠Great, Introduce, Permission, Privacy, Wash 💠Exposure: both legs 💠General examination: well, flat, comfortable, pale & jaundice 🟫Inspection: 1⃣Site 2⃣Size and depth 3⃣Shape 4⃣Single or multible (look between the toes) ______ 5⃣Floor: 1. discharge 2. granulation (healthy or not) 3. sloughs 4. color 6⃣Margin: regular or not 7⃣Edge 1. flat (sloping) ➡️ shallow, traumatic, healing, venous 2. punched out ➡️ trophic ucler, ischemia, DM, tertiary syphilis, chronic infection 3. Undermined➡️ TB, bed sore 4. Elevated➡️ carcinoma 5. Rolled (raised)➡️ Basal cell carcinoma ______ 8⃣Skin changes: 1. Trophic changes: 🔸loss hair 🔸shiny skin 🔸muscle wasting 🔸nail changes (brittle) 2. Other changes 🔸Dilated viens or venous guttering 🔸Discoloration: Hyperpigmentation (venous) Hypopigmentation (non healing) 🔸Deformity 🔸Bruising 🔸Blisters 🔸Gangrene 🟫Palpation 1⃣Tenderness 2⃣Temperature _____ 3⃣Floor (exposed surface of the ulcer) for consistency 4⃣Base (tissue in which ulcer rest) feel around the margin for consistency if firm (indurated)➡️ inflammation 5⃣Edge 1. Discharge 2. soft: healing 3. firm: non-healing 4. hard: malignant 6⃣Fixity to underlying structure ____ 7⃣Neurological ex 1. proproiception 2. light tough 3. pain (by 10 gram monofilament test) 4. motor 8⃣Peripheral pulses 9⃣LNs 🟫complete by 1. examining the other limp 2. Cardiovascular ex 3. Special tests 🔸if Ischemic ulcer➡️ Burger's test & Ankle brachial index 🔸if Varicose ulcer➡️Tourniquit(Trendlenburg test)

〰〰〰〰〰〰〰〰〰〰〰 4. (Ulcer) 〰〰〰〰〰〰〰〰〰〰〰 History: 💠 Great, Introduce, Permission 💠Personal data 💠 Complain+duration 💠 History of presenting illenss 🟫History of the ulcer ◾️how discovered ◾️progression (eg: change in size) ◾️associated symtoms: pain, fever, discharge (analyse it) ◾️ulcer in other area ◾️action taken ◾️ulcer in the past: analyse it: site, association, continue for how long, what did for it? ◾️The cause: 1. trauma 2. hx of dilated vien (varicose) 3. Heart diseases 4. pain during exercise(claudication) distance? 🔸This distance like the past? 🔸For how long you stop for rest? 🔸Rest pain? 🔸Socrates 5. Diabetes (then jump to the hx of Diabetes below⬇️) 🟫 History of Diabetes ◾️For howe long ◾️Medications/dose ◾️Adherence to medications ◾️Follow up and last blood sugar chack up 🟫 Systemic effects of DM (systemic review) CNS: Loss of sensation, Weakness, numbness, blurred vision Cardiovascular: chest pain, dysnea, cough ️GIT: abdominal pain (after meals!), constipation, diarrhea, jaundice Urinary: urine color, amount, frequency 💠Past medical history: 1. similar condition 2. ️admission 3. ️blood transfusion 4. ️surgery 5. ️amputation 6. ️revascularization 7. ️chronic dx: HTN, Asthma, renal dx, stroke or ischemic heart diseases 💠Family History Family hx of similar condition ️Family hx of DM, HTN, Stroke, IHD, Kidney dx 💠Social Hx ️Smoking ️Alcohol ️Health insurance 💠Drug Hx Current drugs Chronic drugs ️Allergy

🌸 Snake bite 🌸 🔰 Analgesics are contraindicated in snake bite 🔰 No cover it 🔰 No use cautery 🔰 No sucking 🔰 No use tourniquet 🔰 Calm the patient because stress increase toxicity and reached to heart 👌 🔰 Snake bite( dry_ moist) 🔰 may come with hypovolemic shock 🔰 May complicated by compartment syndrome and treated by fasciotomy and use vaccine في العلاج نهتم بالتالي التي نعطيها أو نراقبها 👇 RR, UOP, conscious , vaccine, Antibiotics, fluid كلما كانت العضه قريبه من الرقبه تكون خطيره وقاتله

What is the differential diagnosis of a groin mass? Lymphadenopathy, hematoma, seroma, abscess, hydrocele, femoral artery aneurysm, EIC, undescended testicle, sarcoma, hernias, testicle torsion.

What is the diferential diagnosis of a thyroid nodule? Multinodular goiter Hyperfunctioning adenoma Cyst thyroiditis Carcinoma lymphoma

The boundaries of hesselbach triangle: ✨inferior epigastric aretery ✨inguinal ligament ✨lateral border of rectus sheath الــ floor عبارة عن: ✨fascia transervalis ✨conjoint tendon ✨✨✨✨✨

Difference between radiate and referred pain😉