•Difference between submandibular lymph node and submandibular gland swelling:

1. Nodes usually are multiple while gland single swelling
2. Node could be over rided the body of mandible while the gland is not
3. Gland could be palpated bimanually
(From the skin and from the floor of tongue )
4.gland swelling and pain may increase during induce sour food while node show no changes
5. As the most common cause of submandibular gland swelling is duct stone we may feel it by palpation.

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Classification of claudication.

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•Indirect inguinal hernia:

-Inside the spermatic cord
-Usually extend to the scrotum
-Narrow neck of the hernia sac
-Lateral to the inferior epigastric artery
-More common
-Occurs in babies and adult
-Enters from the deep ring
-Goes out from the superficial ring.

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•Direct inguinal hernia:

-Outside the spermatic
-Not or rarely extend to the scrotum
-Wide neck of the hernia sac
-Medial to the inferior epigastric artery -Less common
-Occurs in old age
-Not enter from the deep ring
-Goes out from the superficial ring.

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Bilirubin (serum):

Conjugated: 01-0.3 mg/dL
Total: 0.2-1.3 mg/dL

 Serum glutamic-pyruvic transaminase (SGPT) 👉🏼Alanine transaminase "ALT"

Serum glutamic-oxalic transaminsae (SGOT)👉🏼 Aspartate transaminase"AST".

Normal is up to 45 IU/L.

Alkaline phosphatase 👉🏼 45-115 IU.

#Medicine

Canula.

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Types of suture.

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Systemic inflammatory response syndrome (SIRS):

Core body temperature <36°C or >38°C; heart rate >90/minute; respira tory rate >20/minute or PaCO2 <32 mmHg; WBC count <4,000 cells/ mm3 or >12000/mm3. If SIRS is present >48 hours the patient is likely to have severe pancreatitis.

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•Sepsis: ≥ 2 SIRS criteria PLUS a suspected or confirmed underlying infection .

•Severe sepsis: sepsis PLUS dysfunction of at least one organ or system .

•Multiple organ dysfunction syndrome (MODS) :
-Progressive, but potentially reversible, dysfunction of several organs and/or systems .
-The more organs that are affected, the greater the mortality risk.

•Bacteremia: the presence of viable bacteria in the bloodstream, with or without clinical signs of infection .

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#Surgery

•Sepsis:
-It is a severe, life-threatening condition that results from a dysregulation of the patient's response to an infection, causing tissue and organ damage and subsequent organ dysfunction.

•Septic shock:
-It is a sepsis syndrome accompanied by circulatory and metabolic abnormalities that can significantly increase mortality .

Diagnostic criteria:

-Persistent hypotension: Vasopressors are required to maintain mean arterial pressure(MAP) ≥ 65 mm Hg.

-Persistent lactic acidosis: lactate > 2 mmol/L(18 mg/dL) despite adequate fluid resuscitation.

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#Medicine

Systemic inflammatory response syndrome (SIRS) :

-a group of physiological and immune-mediated reactions that are triggered in response to an infectious or noninfectious insult (e.g., an acute inflammatory process or trauma) .

•SIRS is diagnosed if ≥ 2 of the following 4 criteriaare fulfilled:
-Temperature: > 38°C or < 36°C
-Heart rate: > 90/min
-Respiratory rate: > 20/min or PaCO2 < 32 mm Hg
-White blood cell count: > 12,000 mm3, < 4000/mm3, and/or > 10% band cells.

#Infections

INDICATIONS OF CBD EXPLORATION:

1. History of charcot’s triad
2. USG proven stones in CBD
3. Dilated CBD (>1cm)
4. OTCshows filling deffect
5. Palpable stones in CB.

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Neurapraxia is a disorder of the peripheral nervous system in which there is a temporary loss of motor and sensory function due to blockage of nerve conduction, usually lasting an average of six to eight weeks before full recovery. 

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•When the appendix is behind the caecum, the tenderness may be experienced in the lateral part of the lumbar region – the flank.

•When a sub-hepatic appendix produces pain and tenderness below the right costal margin, it must be differentiated from acute cholecystitis.


•An appendix abscess should be suspected if the temperature is high and the mass is very tender.


•Bowel sounds are present unless perforation and general peritonitis have caused a paralytic ileus.

#Appendix
#Surgery

Mesenteric adenitis:

-The pain can sometimes be shown to be move when the patient is placed in the lateral decubitus position as the glands move over with the mesentery.

-Browse notes
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Because gallbladder pain often radiates through to the tip of the scapula, the affected dermatome may be hyperaesthetic, a change detected by lightly drawing a pin down the back of the patient’s chest. This is called Boas’ sign.

-Browse notes
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-Beware After 4–6 hours, the acid in the peritoneal cavity becomes diluted and the pain and guarding decrease.
-Patients think they are improving, but they are in fact getting worse.
-The peritonitis is progressing and hypervolaemia is developing.
-An increasing tachycardia and absent bowel sounds associated with increasing abdominal distension and sunken eyes indicate that the patient is becoming extremely ill.

-Browse notes
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Hypokalemia is generally defined as a serum potassium level of less than 3.5 mEq/L (3.5 mmol/L).

Moderate hypokalemia is a serum level of 2.5-3.0 mEq/L, and severe hypokalemia is a level of less than 2.5 mEq/L. Hypokalemia is a potentially life-threatening imbalance that may be iatrogenically induced.

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#Medicine

Causes of unhealed fistula:

His Friends
H_high output fistula
S_steroid use
F_foreign body
R_radiation
I_IBD
E_epithelialization
N_neoplastic
D_distal obstruction
S_site( gastric, duodenal).

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