https://t.me/Gomhorihospital


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
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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

#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 🤗

#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