قناة السيمستر الثاني عشر دفعة (43) طب بشري جامعة طرابلس ❤

#Long_case #pripheral vascular occlusive disease Checklist for history • Character of the pain, severity aggravating and relieving factors • Claudication distance • History of sudden onset or gradual onset • History of smoking • History of diabetes mellitus • History of cardiac illness Ex في الشيت

#Long_case Varicose vein Checklist for history History of • Major surgery • Majorillness necessitating prolonged recumbency • Recentlong airtravel (economy classsyndrome)— deep vein thrombosis • Sudden undue strain • Drug intake—hormone containing pills (like contraceptives) • Computer professionals requiring long hours in a sitting posture—E thrombosis • Occupation demanding prolonged standing • Family history of varicose veins. Examination موجود ف الشيت #clinic

💫💎EXTERNAL FIXATORS💎💫 💎Examination💎 You may be shown a patient who is having an external fixator in situ and asked to comment. Be prepared to discuss the indications, advantages and complications of external fixators. 1. Identify the type of external fixator. 2. Comment on the bones involved and the probable fracture site. 3. Look for shortening of the affected limb, areas of bony loss, wounds and skin grafted sites. 4. Look for pin site infection. 5. Offer to assess the joint stiffness. 💎Presentation💎 This patient is having a unilateral frame type external fixator on the left lower limb probably due to underlying fracture shaft of the tibia. There is an area of bony loss in the middle of the shaft of the left tibia but no apparent shortening of the left leg. There is a superficial ulcer with healthy granulation tissue over the fracture site which is ready for skin grafting. No sign of pin site infection and he can move the affected lower limb without any pain. 💎Flashcards💎 1. Type of EF. 2. Bones involved. 3. Fracture site. 4. Shortening of the affected limb? Bony loss? Skin grafts? 5. Pin site infection? 6. Joint stiffness? 💎FAQs💎 Q1. What are the main two types of external fixators (EF)? 1. Unilateral frame. 2. Cylindrical frame (Llizarov). Q2. What is unilateral frame? Screw threaded half pins are inserted from one side of the bone and they are anchored to a rigid external bar. Q3. What is Llizarov frame? Thin transfixation wires are inserted through the bone and they are attached to fixator rings which are interconnected by longitudinal metal rods. Q4. What are the types of internal fixators (IF) you know of? 1. Plate& Screws. 2. Intramedullary nails (K nails). 3. Compression screw plates. Q5. What are the indications for external fixators? 1. For severe open fractures in tibia (Gustilo 3b,3c). 2. For open fractures with bony loss. 3. For closed fractures with severe soft tissue injury. 4. For compartment syndrome after fasciotomy. 5. As an adjunct to internal fixation. 6. For unstable pelvic fractures (in damage control surgery). 7. For limb lengthening & bone transport. Q6. What are the advantages of EF over POP? 1. More comfortable. 2. Early Mobilization possible. 3. Less joint stiffness & DVT risk. 4. Allow management of other injuries/ wounds. 5. Allow skin grafting. Q7. What are the advantages of EF over IF? 1. Can use in open or infected fractures. 2. Less expensive. 3. Need less expertise. Q8. What are the complications of EF? 1. Pin site infection. 2. Pin loosening. 3. Non union. 4. Neurovascular damage. 5. Chronic pain. 6. Joint stiffness. 💎Pictures 💎 M'd نقلا عن لجنة جت في امتحانات سابقة Dx / ex #clinic

#Long_case #(The Breast) #General information  The breasts are modified sweat glands.  Composed from lobes  lobules  lactiferous duct  Pigmented skin covers the areola and the nipple, which is erectile tissue.  The openings of the lactiferous ducts are on the apex of the nipple.  The nipple is in the fourth intercostal space in the mid￾clavicular line, but accessory breast/nipple tissue may develop anywhere down the nipple line (axilla to groin).  The adult breast is divided into the nipple, the areola and four quadrants, upper and lower, inner and outer, with an axillary tail projecting from the upper outer quadrant.  upper lateral quadrant  the most quadrant that affect by malignancy  99% of breast cancer occur in female and only 1% in male (more aggressive in male)  The breast is bounded by the clavicle superiorly, the lateral border of the latissimus muscle laterally, the sternum medially, and the infra-mammary fold inferiorly.  Conservative breast surgery  radiotherapy + removal of the breast.  If there is metastases to the spine there will be tenderness and pain on raising the leg and absent knee jerk due to damaging effects on the nerves. #Lymph nodes  Lymph drainage of the breast: o 70% to the axillary LN o 20% to the supraclavicular LN or along the internal mammary vessels o 10% to the abdominal LN  Axillary L.N divided into five groups: o Anterior (Pectoral) o Posterior (Subscapular) o lateral o Medial (Sub-clavicular) o Central (intermediate)  Surgical levels of axillary L.N: o Level I  bottom level, below the lower edge of the pectoralis minor muscle o Level II  lies underneath/posterior the pectoralis minor muscle o Level III  above/medial the pectoralis minor muscle When there is breast cancer and axillary L.N affected  means metastatic and systemic disease.  Sentinel L.N (first L.N adjacent to the cancer)  to see if there is metastases make injection of methylene blue or radioactive substance then take biopsy and examine it. #History  Questions: o How long have symptoms been present? o What changes have occurred? o Is there any relationship to the menstrual cycle? o Does anything make it better or worse?  Age: o young patient (15-25 years)  fibro-adenoma o middle age (25-40 years)  ANDI (Aberrations in the normal development and involution) due to hormonal changes like prolactin and sex hormones o old age (more than 40 years)  cancer of the breast  Questions of lump (Cause - first symptoms - onset - duration - associated symptoms – progression - multiplicity)  Presentation: discharge – lump – skin changes  History of trauma: lead to fat necrosis which appears as a mass  History of breast surgery and biopsy  Family history: 5-10% of breast cancer run in family  Risks that increase the probability of breast cancer occurrence: o Number of menstruation (increased number more risk) o Nulliparous (more risk) o Unmarried (more risk) o Lactation (protective)  Drug history: estrogen – progesterone  Obesity: increase the level of estrogen  Sex related hereditary diseases  Menstrual history: Menarche, menopause, changes during the menstrual cycle, pregnancies, lactation.  Social history: smoking – alcohol – diet (fat, animal meat, low fiber, pickles) #We should examine the following for complete breast exam:  Both breasts  The axilla  The supraclavicular LN  The abdomen for a-Hepatomegaly b-Ascites #clinic

History topics : 🏷️ Abdominal pain / abdominal distention / masses 🏷️ Bleeding ( upper GI / hematuria /epistaxis ) 🏷️ Ulcers / LL oedema+ leg pain / varicose vein 🏷️ Swelling ( breast / groin / scrotum / goiter .. etc ) 🏷️ Dysphagia / dysuria / kidney stone / infertility / urine retention / fistula 🏷️ Post operative history 🏷️ Ano-rectal pain 🏷️ Change in bowel habit 🏷️ Back pain / joint pain #clinic

⚔🪚Amputation⚔ 🪚 💎Examination💎 You may be given a patient with peripheral vascular disease (PVD) who is having an amputated limb, with or without gangrenous toes. Remember to examine the both lower limbs, especially assess the peripheral pulses of the non-amputated limb which could be vital, but easily forgotten. 1. Examine the amputation stump first. a. Describe the anatomical level of amputation. b. Comment on the skin wound. Healed completely? c. Ask the patient to flex and extend the knee in a below knee amputation ( to exolude fixed flexion deformity). d. Move the skin over the stump and check whether it is freely movable. 2. Look for the scars of previous vascular bypass surgeries. Scars may be in the abdomen! 3. Examine the peripheral pulses of the affected limb. Comment on the presence or absence of pulse and the pulse volume. 4. Examine the contralateral limb. a. Carefully examine toes (Toe amputations, Gangrenous toes, Ischemic Ulcers). b. Feel the skin temperature. c. Check the capillary refilling time (CRFT). d. Examine all peripheral pulses (femoral, popliteal, posterior tibial & dorsalis pedis) and comment on pulse volume. e. Perform Buerger's test. (Lift the straightened leg up while patient is lying flat on the bed, and look for colour change the leg to white as the perfusion drops. Then ask to lower the leg over the side of the bed and look for reactive hyperaemia). f. Auscultate for a femoral bruit. 5. Look for nicotine stains in the right hand. 6. Examine/ offer to examine comorbidities associated with PVD. a. Carotid bruit. b. Deviated heaving apex. c. Pulsatile epigastric lump (Abdominal Aortic Aneurism). ⚡️⚡️Presentation⚡️⚡️ The left lower limb of the patient is amputated at below knee level and the skin wound is completely healed. The skin over the amputation stump is freely movable and there is no fixed flexion deformity. There are no scars suggestive of previous vascular bypass surgeries. Both femoral pulses are felt and good in volume, but distal pulses are weak in the contralateral limb. There are no partial amputations, gangrenous toes or ischemic ulcerations of the right lower limb. The peripheries are warm and capillary refilling time is less than 2 seconds. Beurger's test is negative. There are no femoral or carotid bruits, no nicotine stains, pulsatile epigastric lumps and the apex beat in the normal position and it is normal in character. 💫Flashcards💫 1. Amputation stump. a. Anatomical level of amputatio. b. Skin wound healed? c. Exclude fixed flexion deformity (in below knee). d. Skin freely movable? 2. Scars of previous vascular bypass surgeries? 3. Pulses of the affected limb. 4. Contralateral limb. a. Toes (lschemic Ulcers, Gangrenous toes, Toe amputations). b. Skin temperature. c. CRFT d. Examine all peripheral pulses & comment on pulse volume. e. Perform Buerger's test. f.Auscultate for a femoral bruit. 5. Nicotine stains? 6. Comorbidities associated with PVD. a. Carotid bruit? b. Deviated heaving apex? c. Pulsatile epigastric lump (AAA)? 💦FAQS 💦 Q1. What are the Indications for amputation? 1. Dead- Dry gangrene. 2. Deadly- Wet gangrene, Spreading cellulitis, Osteomyelitis, Trauma. 3. Dead loss - Paralysis. Q2. What are the levels of amputation of lower limb? 1. Partial toe amputation. 2. Toe disarticulation. 3. Partial foot (Ray) amputation. 4. Trans-metatarsal amputation. 5. Ankle disarticulation (Syme's). 6. Trans-tibial (Below knee) amputation. 7. Trans-femoral (Above knee) amputation. 8. Hip disarticulation. Q3. What are the specific complications of amputation? 1. Haematoma formation & wound dehiscence. 2. Phantom Limb Pain. 3. Osteomyelitis. 4. Stump ulceration. 5. Stump neuroma & osteophytes formation. 6. Psychological disturbances. Q4. What is "Gangrene"? It is the tissue death due to persistent ischemia. Q5. What is "Dry gangrene"? It is a hard, shrunken, non-infected patch of gangrene with a clear line of demarcation. Q6. What is "Wet gangrene'? It is a soft, swollen, infected patch of gangrene without a clear line of demarcation. #clinic

#clinic ⬆️⬆️

General Physical Examination د.اسماعيل ابورخيص

#Long_case #lipoma discussion. 🏷️Q 1. What is your clinical diagnosis in this case? Lipoma. 🏷️Q 2. What is lipoma? It is a benign tumor arising from adult fat cells. lipoma back 🏷️Q 3. What are the diagnostic points for lipoma? 1. Lobulation 2. Slip sign 3. Soft swelling with pseudofluctuation 4. Transillumination positive if it is subcutaneous 5. The overlying skin may show prominent veins when the lesions are large. 🏷️Q 4. What is the cause for pseudofluctuation? Intracellular fat is fluid at body temperature. Therefore, the swelling will be soft and fluctuation will be elicited in one plane. For a true cyst one should elicit fluctuation in two planes at right angles to each other that is not possible in the case of lipoma and therefore, it is called pseudofluctuation. 🏷️Q 5. What is slip sign? If the edge of the lump is pressed, the swelling slips from beneath the finger. This can be easily demonstrated in the case of a subcutaneous lipoma and it is said to be pathognomonic. #clinic

#Long_case #goiter 🔖Checklist for history • Onset related to puberty, pregnancy • Residence: Endemic area or not • Ingestion of goitrogens • Intolerance to hot/cold temperature • Increased appetite with loss of weight (Hyper￾thyroidism) • Gain in weight (Hypothyroidism) • Change in menstrual cycle • Bowel habit—diarrhea (hyper), constipation (hypo) • Difficulty in swallowing • Difficulty in breathing • Hoarseness of voice • Postural cough during sleeping (retrosternal extension) • Historyofpalpitation/shortnessofbreathonexertion • Insomnia, loss of concentration (hyper) • Irritability/nervousness (hyper). 🔖Checklist for examination of thyroid • Always check the pulse for tachycardia before examining the thyroid • Look for tremor of hands and tongue before examining the thyroid • Ask the patient to take a sip of water and to hold it in his/her mouth. Then ask the patient to swallow (goiter moves on swallowing) • Ask the patient to put out the tongue (thyroglossal cyst moves up) • Stand behind the patient and palpate the thyroid (ask the patient to take another sip of water) • Decide whether it is diffuse enlargement,single nodule, multiple nodules and the nature of the surface • Decide the consistency • Look over the top of the head for exophthalmos (look for lid lag, lid retraction and other eye signs) • Check the eye movements, double vision • Now stand in front of the patient for palpation of the trachea for deviation, for assessing the lower limit by ‘getting below’ • Assess the plane of the swelling (stretch the deep fascia by extending the neck and see whether it becomes less prominent, contract the sternomastoid muscle against resistance and see whether it becomes less prominent • Do Pemberton’s test for retrosternal extension • Percuss the manubrium sterni for dullness (seen in retrosternal extension) • Palpate the carotids on both sides • Examine the regional lymph nodes • Feel the skin (dry in hypothyroidism, shiny skin in hyperthyroidism) • Look for pretibial myxedema (hyperthyroidism) • Assess the build of the patient (Thin—hyperthyroidism, obese—hypothyroidism) • Examine the palms—warm, moist and changes of acropachy in hyperthyroidism • Assess the behavior of the patient (agitated in toxic, lethargic in hypothyroidism) • Ask the patient to rise from squatting position without using hands for support (proximal myopathy in hyperthyroidism) • Test the biceps reflex and look for slow relaxing reflex suggestive of hypothyroidism. Final checklist for clinical examination of thyroid 1. Look for signs of toxicity 2. Look for signs of malignancy 3. Look for signs of retrosternal extension 4. Look for position of carotid artery 5. Look for position of trachea 6. Look for cervical lymph nodes 🔖Discussion 🏷️Why is the swelling a goiter? 🏷️How do you grade a goiter ? 🏷️How will you confirm your diagnosis of toxicity? 🏷️How you will manage thyrotoxicosis? 🏷️Why technetium is preferred over radio￾iodine for diagnostic scanning? 🏷️ What is Berry’s sign? 🏷️What is Kocher’s test? 🏷️ What are the signs of retrosternal extension? #clinic