MD Exit Exam

Signs of Non-Union on X-ray 🩻 :

1. Persistent Fracture Line : A clear, visible fracture line that remains well-defined months after the injury, indicating a lack of bony bridging.

2. Lack of Callus Formation : Absence or minimal evidence of callus (new bone tissue) formation around the fracture site, which is normally expected in healing fractures.

3. Sclerosis at Fracture Ends : Hardening or increased density (sclerosis) at the edges of the fracture, suggesting the bone ends are not uniting.

4. Rounding of Fracture Edges : The bone ends may appear smoothed or rounded due to lack of healing activity.

5. Bone Gap : A persistent gap between fracture fragments, often due to soft tissue interposition or bone loss.

6. Abnormal Bone Alignment : Malalignment or displacement of fracture fragments that persists without signs of stabilization or union.

How do you describe the x-ray of the patient? 1- plan X-ray 2- site of body: ( ankle, knee...) 3- Mature skeleton or not 4- Ap or lateral view 5- label X-ray ( Name of patient, side ( right or left) ) 6- Pathology ( fracture, cyst, lesion, ....)

The first step in open fracture: 1- antibiotics (Antibiotics are started immediately and are continued for a full therapeutic course, which is 3 days. A broad-spectrum cephalosporin with an aminoglycoside, such as gentamicin, are used together to cover Gram-positive and Gram -negative bacteria as these are the most likely causes of infection after open fractures. Metronidazole should be added if soil contamination has occurred) 2-Debridement : removal of damaged tissue or foreign objects from a wound 3- stabilization : back slab 4- deal with fracture

💎 Definition of AVF : ⚔️ It's an arterialization of a peripheral vein to be safe and to give efficient blood flow so it can be used in dialysis for chronic patients. 💎 Criteria of arterialized vein : 1. Efficient blood flow 2. Increased pressure 3. Increased width 4. More elongated and tortuous 💎 Left or Right hand : - The other hand, NOT the dominant - Less liable for trauma 💎 Best site for AVF : - Radiocephalic - Most Distal site 💎 Causes of signs of inflammation : - Improper disinfection - Predisposing factors : - immunosuppressed - Risk : - malfunctioning - septicemia 💎 Causes of Hematoma : - Insufficient compression after removal of the needle. - Predisposing factors : - bleeding tendency - platelet dysfunction - excess heparin - Risk : - malfunctioning - infection (Staph. Epidermidis, Staph. Aureus ) 💎 Causes of aneurysmal dilatation : - Repeated Cannulation at the same site - Predisposing factors : - High pressure : outflow obstruction - High Volume : wide ostium - Risk : - malfunctioning - rupture : bleeding 💎 Signs of outflow obstruction by examination : 1. Aneurysmal dilatation 2. Negative arm elevation test 3. Superficial dilated veins 4. Monophasic systolic thrill 5. Monophasic systolic bruit 💎 Rule of 6 : 1. Distance between artery & vein 6mm 2. Length 6cm 3. 6-8 weeks to be mature 4. Flow 600 ml/min 5. Diameter 6 mm 6. Depth 6 mm

⭐️ Examination of AVF : 💠 Inspiection : SSHAA PD 1. SITE : - Side : Rt or Lt - Scar : - Above wrist : Radiocephalic - Below elbow & lateral : Brachiocephalic - Above elbow & medial : Brachiobasilic - Axilla To elbow : Transposed basilic 2. Hematoma 3. Aneurysmal dilatation 4. Proximal To AVF : - Neck, upper chest- obstruction - Superficial dilated veins - Unilateral facial edema 5. Distal To AVF : - Signs of Ischemia : Cyanosis - Steal Phenomena - Radial : pulse volume inequality 6. Signs of inflammation : - Redness - Pus discharge 7. Arm elevation test : - Emptying : +Ve normal - Partial emptying : partial CV obstruction - NO emptying : total CV obstruction 💠 Palptation : 3T , P , C 1. Temperature : - Hotness - Type of ischemia : ▫️Warm + blue : Venous cyanotic ▫️Cold + pale : Arterial ▫️Cold + Blue : Steal Phenomenon 2. Tenderness : inflammation 3. Thrill : - Continuous machinery - Weaker : Proximal - Biphasic 4. Pulsations : - weak pulsations : Proximal - Strong : Obstruction 5. Consistency : Soft, Compressible 💠 Auscultation : - Fistula : continuous machinery bruit - Heart : To exclude Infective Endocarditis ⭐️ Example : 1. By inspection : - It is a brachiocephalic fistula - Without Redness or Hematoma - Aneurysmal dilatation completely emptying - Distally : no ischemia - Proximally : no dilated veins or facial edema 2. By palpation : - No tenderness or hotness - Hand is warm - Continuous machinery thrill - Weak pulsations - Aneurysmal dilatation is soft and compressible

ileostomy Vs colostomy

☃️ Example : by inspection There is a stoma in the left iliac fossa, of a single lumen, which is flush with skin , with pink healthy mucosa, discharging brown semi-solid stool into one-piece, transparent, closed bag, without sign of inflammation in the surrounding skin, no sign of complication noted as partastomal hernia ,stomal prolapse …etc. By palpation No tenderness, impulse on cough or stomal stenosis. Bowel sound is heard by stethoscope

⭐️ Stoma Examination : 💠 Inspection : 1. Site : ▫️ LIF (colostomy or mucus fistula) ▫️ RIF (ileostomy or urostomy) ▫️ RH (proximal transverse colostomy) ▫️ LH (distal transverse colostomy ) 2. Number of lumen : Single or Double 3. Relation to the skin : ▫️ Raised spout in ileostomy and urostomy ▫️ Flush with skin in colostomy 4. Mucosal lining : Healthy or Ulcerated 5. Functioning or not : ▫️ Ileostomy within 48 hrs after surgery ▫️ Colostomy within 6 days after surgery 6. Stomal discharge : Colour , Amount , Consistency ▫️ Hard stool (colostomy) ▫️ Soft stool (ileostomy) ▫️ Liquid ‘urine’ (urostomy) 7. Surrounding skin : redness , excoriation 8. Observe for any complication : necrosis , prolapse , retraction 💠 Palpation : 1. Tenderness 2. Cough impulse 3. Stenosis and to check patency 💠 Auscultation

⭐️ Incision Used In Surgery :

💠 We should know the followings : 1. Contents of the tube and bottle. 2. Amount of the contents. 3. If the chest tube is functioning or not : 🔹Swinging movement of fluid in the tube, if not ask the patient to cough. 🔹 Air bubbles. ⭐️ When we should remove chest tube : A- In pneumothorax : 1. If there is no air bubbles or air leak. 2. If there is no swinging movement. 🔊 Notes : Clump the tube for 24 hr. and do X-ray, if the lung expanded open the clump and ask pt. to cough if there are air bubbles leave the tube , if not, remove it. B-In hemothorax or chylothorax or pyothorax : 1. No discharge for 24-48 hr. C-In effusion : 1. If there is Small amount of fluid we can remove the tube (large amount ➜ not remove it). 2. Depend on the fluid collection in the bottle and the X-ray. 3. Normal pleural fluid is 50-100 cc.

⭐️ Chest Tube : 1. It is closed drain. 2. To isolate the atmospheric pressure from the pleural pressure the tube should be placed in an underwater seal of about 200-300 cc of normal saline, so the air can't return back into the pleural cavity. 3. should insert in the upper border of the rib to avoid injury to neurovascular bundle. 💠 Indications : 1. Complex pneumothorax 2, Pneumothorax on positive-pressure ventilation 3. Hemothorax 4. Large pleural Effusion 5. Empyema 6. Chylothorax 💠 Contraindications : 1. Bleeding diathesis 2. Coagulopathy 💠 Site of insertion : in Triangle of safety 1. Anteriorly ➜ lateral border of pectoralis major muscle. 2. Posteriorly ➜ anterior border of latissimus dorssi. 3. Inferiorly (base) ➜ the 5 th intercostal space. 4. Superiorly (apex) ➜ the base of axilla. 5. A line is made in the triangle at the mid-axillary line and the tube is inserted at the level of this line in the 4th or 5th intercostal space.

⭐️ Chest Tube Steps of Insertion :

Types of IV Fluids :

⭐️ Confirm that the endotracheal tube is in the right place 👀 Visualizing the tube through vocal cords. 🔋 Capnography tracing (ETCO2) 🎯 Chest x-ray ⌚️ Chest movements after connecting the tube to the circuit. ⌚️ 5 point auscultation : by auscultating the apices, bases of the lungs and the epigastric area ⭐️ Indications of ETT : 1. To ensure airway patency in an unconscious patient. 2. To protect the lungs from the aspiration of gastric contents. 3. To provide positive-pressure ventilation, in the setting of respiratory failure or general anesthesia. ⭐️ Contraindications of ETT : 1. Pharyngeal obstruction : (foreign body, massive swelling of the pharynx) 2. Serious maxillofacial trauma. ⭐️ Complications of ETT : 1. Trauma to the face 2. Laryngospasm 3. Tension pneumothorax 4. Pulmonary aspiration 5. Hoarseness 6. Laryngeal edema 7. Sore throat ⭐️ Rapid sequence induction : Use Selicks maneuver (Cricoid pressure) and adminster Suxamethonium 1. When the patient has "full stomach", i.e. predisposed to regurgitation/aspiration. 2. Meal within 6 hours. 3. Sphincter incompetence suspected (GERD, hiatus hernia, nasogastric tube). 4. Increased abdominal pressure (pregnancy, obesity, bowel obstruction, acute abdomen).

🏴‍☠️ Endotracheal Tube Intubation (ETT) : Steps 1. Assemble and checks all necessary equipment 2. Choose appropriate size ET tube 🏔️ Male : 8-9 mm 🏔️ Female : 7-8 mm 🏔️ Pediatric : Uncuffed ( age/4 )+ 4mm 🏔️ Pediatric : Cuffed ( age/4 )+ 3.5mm 3. Choose appropriate type (straight or curved) and size laryngoscope blade ⌚️ Pediatric : Straight type (Miller) ⌚️ Adults : Curved Type ( Macintosh ) 4. Check light ,Tests ET tube cuff integrity 5. Insert the stylet and lubricates the ET tube 6. Place head in neutral or sniffing position (golden position) 7. Clear airway if needed (suction) 8. Hold laryngoscope in left hand. 9. Insert laryngoscope in right side of mouth, moving tongue to the left. 10. Visualize epiglottis, then vocal cords. 11. Insert ET tube to proper length for gender 🧔🏼‍♂️ 23 cm for men 👱‍♀️ 21 cm for women 12. Inflate ET tube cuff to achieve proper seal

⭐️ Surgical Procedures Notes :

⭐️ Interpretation of Lymph Node Examination : 💠 Location : 1. Localized lymphadenopathy: Suggests local causes (e.g., infection, malignancy in drainage area). Exception : Systemic diseases (plague, tularemia, aggressive lymphomas) may present locally. 2. Generalized adenopathy : Typically indicates systemic disease. - Skin lesions + adenopathy : Narrow differentials using context : - Cats ➜ Cat scratch disease - Gardening ➜ Sporotrichosis - Urban mites ➜ Rickettsialpox - Tick bites ➜ Ulceroglandular tularemia - Water exposure ➜ Mycobacterium marinum . 💠 Size : - Abnormal if > 1 cm. - Exceptions : - Inguinal LNs : Up to 2 cm may be normal. - Epitrochlear LNs : > 0.5 cm is abnormal. - Supraclavicular, popliteal, or iliac LNs : Any palpable node is abnormal. 💠 Consistency : 1. Hard : Cancers (inducing fibrosis/scirrhous changes) or post-inflammatory fibrosis. 2. Firm/rubbery : Lymphomas or chronic leukemia. 3. Soft : Acute leukemia. 💠 Fixation : 1. Normal : Freely movable. 2. Abnormal : Fixed to adjacent tissues (e.g., deep fascia) due to cancer invasion or inflammation. Nodes may be "matted" (fixed to each other). 💠 Tenderness : 1. Suggests recent rapid enlargement, stretching pain receptors. 2. Causes : Inflammation, hemorrhage, immunologic stimulation, malignancy (e.g., acute leukemia). 💠 Lymphadenopathy + Splenomegaly : Indicates systemic illness 1. Infectious mononucleosis, lymphoma, acute/chronic leukemia, SLE, sarcoidosis, toxoplasmosis, cat-scratch disease, or rare hematologic disorders.