انضمووووووا 😴 القناة👇👇👇


خاصة بـتجميعات م.الثورة


https://t.me/Althorahospital22332

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تجارب الجمهوري

The boundaries of hesselbach triangle:
✨inferior epigastric aretery
✨inguinal ligament
✨lateral border of rectus sheath

الــ floor عبارة عن:
✨fascia transervalis
✨conjoint tendon

✨✨✨✨✨

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

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

🌸 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

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4. (Ulcer)
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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

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)

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5. Varicoce
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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
💠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)

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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

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

〰️〰️〰️〰️〰️〰️〰️〰️〰️
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

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