محاضرة العملي اليوم للدكتور عبد الغني ناشر Neurologist
ال
Management
المطلوب من كل طالب امتياز أن يطبقه في حالة Spinal Cord injury

أهم النقاط اللي ركز عليها الدكتور وليد غيلان...

Jaundice :
له ٣ أنواع ولكن المهم في الجراحة هي obstructive jaundice معظم حالات القسم

في قسم الباطنة المهم :
Hemolytic j.
Hepatocellular j.

كيف تعرف الobstructive jaundice ؟
Severe jaundice
Severe itching
Pale stool
Coco-cola like urine ( or tea like urine )

ينتج الobstructive jaundice بسبب انسداد ال CBD بسبب :
● GB stone :
Pain in RUQ refered to shoulder.
Intermittent course of symptoms of obstructive jaundice.

● Malignancy as cancer head of pancrease comes with :
° old age
° wheight loss
° progressive course of symptoms of obstructive jaundice.

● Iatrogenic:
° During cholecystectomy or other operations near CBD may injury of CBD and cause fibrosis & stricture.

أماكن ظهور الjaundice بالترتيب ومستوى الseverity :
1st : it appears in the sclera( mild jaundice ); why ?
لإن الsclera بيضاء اللون فتعتبر أول مكان تعكس لون الصفار
2nd : it appears at mucous membranes ( moderate jaundice ) espacially at soft palate and under tongue.

3rd : it it appears at skin ( severe jaundice ).

☆ Investigations of obstructive jaundice :

1. LFT :

Bilirubin( Total and direct)
ALP اكثر من 180
بينما ال AST و ALT غالبا يكونوا طبيعي

2. US
3. MRCP and ERCP
4. CT only if suspect carcinoma.

☆ NOTES :
● ليس كل obstructive jaundice معه itching.

● قد يكون لون البراز normal وليس pale في حالة partial obstruction of CBD.

● كمية الbile المنتجة في اليوم من ٧٠٠ - ١٠٠٠ مل ، تقريباً ١٠٠٠ مل = ١ لتر.

● في حالة الobstructive jaundice نسوي monitoring للحالة من خلال ال LFT قبل العملية لأيام لحد ما يخف الjaundice لما ترجع الحالة well ؛ لانه يؤثر على PT & PTT وممكن يحصل sepsis ويعمل delay of healing and fistula.

💢مُلاحظات العملي الأسبوع الثاني :-

-الدكتور طه القحوم.
-اليوم: الإثنين 15.7.2024 .
-مُستشفى الكويت.

💢طريقة الدكتور يأخذ عدة History منّ أي طلاب جاهز حقهم ال History، ويشرحهم ويناقش على مواضيعهم الدكتور، ويرجع يشرح لنا موضوعه الأساسي والذي كان Hydrocephalus .

💢في ال History الأول أهمّ مُلاحظات الدكتور:

🔹الدكتور بيّركز أنّه ال Duration of Cheif complaint يُفضل نكتب ال severity خلال (ساعات، يوم، يومين، ثلاث أيام .. أسبوع، بحيث مايتعدى الأسبوع) مش أكثَر .

🔹Most common differential diagnosis of yellowish discoloration of skin:
-Jaundice & Liver disease.

🔹Types of Jaundice :-
1. pre-hepatic(Hemolytic jaundice).
2. Hepatic jaundice.
3. Post-hepatic ( obstructive jaundice).

🔹بعض مُلاحظات الدكتور:
-In obstructive jaundice there is (Itching, Fever, Dark urine, Pale stool).
🔹نفرق بين أنواع ال jaundice عنّ طريق ال investigation.
🔹Haemolytic jaundice results from an increased breakdown of red blood cells(Hemolytic jaundice there is anemia) HB is low.
🔹Alkaline phosphatase in obstructive jaundice there is moderate increase.
🔹Obesity is a risk factor for many heart diseases & respiratory diseases.
🔹Oral contraceptive use is associated with a slightly and transiently increased rate of gallbladder disease.
🔹Acute cholecystitis and chronic cholecystitis associated with fever and sever pain.
🔹Obstructive jaundice,female, obesity, more in gall bladder stone.
🔹Acute cholecystitis and chronic cholecystitis associated with fever and sever pain emergency admission.
🔹Acute cholecystitis, chronic cholecystitis & Gall bladder stone ( More in female, middle&old age).

🔹Most common Component of stone in gall bladder stone: حسب الذي ذكرهم الدكتور
cholesterol(most common), phospholipid, Hemoglobin destruction, calcium bilirubinate, inorganic calcium salts..

🔹Gall bladder stone is radiolucent 85%-90%.
🔹Renal stone is radiopaque 90%.
🔹Renal stone ➡️Refer pain ( flank to groin).
🔹Gall bladder stone ➡️most people feel gall bladder stone in Upper right quadrent abdomen, and sometimes radiate to the right arm or shoulder or in their back between their shoulder blades.

🔹Treatment of gall bladder stone حسب الذي ذكرهم الدكتور :
-Antibiotics 3rd generation ( cephalosporins) cefuroxime, metronidazole.
-Analgesics
- Open cholecystectomy Resection bile.
🔹T-tube معه right and left , during open cholecystectomy is usually a simple procedure that is used to control biliary drainage and can be helpful for radiologists, once the fistulous tract is formed, to remove stones that may remain in the biliary ducts( أي accumulation بيخرج مع ال T-tube)
عدة أيام لما يتوقف لحدود ١٠ أيام إلى أسبوعين لحد مايكون مافي أي accumulation .

🔹Murphy's sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If a person stops deep breathing and feels pain, when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive .
لما نتأكد إنه صح نعمل لل other side اذا مافيش يعني ال test صحيح.

-------------------------------------------

💢ال History الثَاني أهم مُلاحظات الدكتور فيه:

🔹lumber region ➡️Say (The low back pain).
🔹Flank organs➡️Say(Flank pain).

🔹هنا نسأل عنّ drugs history عشان بعضهم يعملوا
Change Color of urine ( Rifampcin and erythromycin).

🔹Cause of renal stone:
Low intake water ( Dehydration) most common.
Hypoparathyrodism.
People who live in warm, dry climates and those who sweat a lot may be at higher risk than others المناطق نسبة الملوحة عالية.

🔹Examination of renal stone أهم شيء فيه Flank test.

🔹Investigation : الذي ذكرهم الدكتور
-CBC .
-Creatinine .
-Ultrasound ➡️ radiopaque 90%.
-X-ray.
أي فحص يحتاج صبغة لازم نعمل فحص لِ Creatinine.

🔹Treatment الذي ذكرهم الدكتور فقط
Size of stone if small <2 ننصح المريض يشرب ماء أكثر
Sustol,Ddiuretic,Antibiotics,Analgesics, Cystolithotomy.

--------------------------------------------------

💢وَبعدين الدكتور دخل موضوع ال Hydrocephalus مُهم جداً، بَكمله بِمنشور ثاني غيّر هذا 👇🏻👇🏻👇🏻..

.

💢تَكملة المَنشور السابق👆🏻 لِ الدكتور طه القحوم.

🔹Hydrocephalus : is an abnormal accumulation of excess cerebrospinal fluid (CSF) within the ventricle or subarachnoid space.The origin of the word "hydrocephalus" is Greek. Its literal translation being "water in the head" comes from the words:"hydro" meaning water and "cephalus" meaning head.

🔹Classification of Hydrocephalus:
1.communicating مُتصل( non obstructive)➡️due to Meningitis.
2.non communicating فيه تضيق (obstructive)example➡️Stenosis, tumour of the tectum, colloid cyst).
▪︎Congenital from birth {cause ➡️(intrauterine infection, Congenital anomalies, Folic acid deficiency in mothers, genetic, related to chromosome)}.
▪︎Acquired➡️(tumour: Choroid plexus papilloma ➡️ increase CSF).

🔹CSF Production:
-CSF is mostly produced by the choroid plexus in the lateral ventricles of the brain , from there it passes through the foramen of Monro on each side ➡️to reach the midline 3rd ventricle. The fluid then passes downward ➡️ to the aqueduct of Sylvius ➡️ to the fourth ventricle. The fourth ventricle has 2 lateral foramen(of Luschka) and one midline foramen(of Magendi) which transmit CSF ➡️to the subarachnoid space around the brain and spinal cord.Most of the fluid absorption occurs inside the skull through the arachnoid villi to the blood stream.

🔹Around 450-500 ml of CSF is produced each day, with around 150 ml being present in the body at any given time (75 in the brain and 75 in spine) مُهم كَرره الدكتور (10-15ml in hours ) (0.30ml in minutes).
-Hydrocephalus is a severe complication of bacterial meningitis, likely related to defective CSF resorption.

🔹Test of meningitis (Projectile vomiting, Sever fever,blurred vision, Headach,Photosensitivity):
-Kernig's sign, and Brudzinski's sign.

🔹Treatment Hydrocephalus:الذي ذكرهم الدكتور
-Diuretic ( Lasix and mannitol ).
-Acetazolamide, trade name Diamox.
-lumbar puncture that (1. Relive a large volume of CSF and 2.To diagnosis of CSF contains sugar, WBC,Turbidity,..)
-CSF diversion shunt surgery: they are of 4 main types including:
VP shunt (ventriculo-peritoneal).
VA shunt (ventriculo-atrial).
LP shunt (lumbo-peritoneal).
Ventriculo-pleural shunt.
-Endoscopic third ventriculostomy is a surgical procedure used to treat children and adults diagnosed with obstructive or non-communicating hydrocephalus تفيد بنسبة 70%.

ملخص إضافات الدكتور توفيق المخلافي.
مستشفى الكويت.

⚪️prolonged duodenal ulcer may leads to perforation
🔔How can we know if there's perforation?
-by history: stabbing pain +history of heart burn
-by Inx: 🩻 X-Ray showing air under diaphragm
💭TTT: surgery or conservative in some cases (as in small perforation leading to temporary leakage)
-Conservative is ABC, I.V Fluid and nutrition, NPO (nothing per oral)& antibiotic

⛔️ why we can't do endoscopy in this case !? because of the air used for endoscopy

🗯diverticulum occurs most commonly in esophagus and small bowel, some times in large bowel.

⚪️perforation of stomach:
caused by: trauma(whatever gun shot or accident or stabe) ulcer and malignancy

💭 in gun shot there's hemothorax , so we do chest tube to drain the blood from pleura
🔻should be observed (تحت الملاحظة) every 1 hour to detect the amount of blood, if it was more than 250 ml , it must do surgery

💭In case of empyema we also do chest tube to drain the pus
نخليه أقل شيء أسبوعين وأكثر شيء 3 أسابيع


⚪️Complications of gall bladder stone🔜septic shock:
  fistula, cholangeitis, perforations, pancreatitis, obstructive jaundice

💭 if the stone in bile duct we do
Endoscopic retrograde cholangiopancreatography (ERCP)

⚪️ Appendix rupture may lead to septic shock
🔹 pt with appendicitis may comes with epigastric pain as early symptom

💭 if there's appendix mass we treat the case by conservative ttt, we don't do surgery


⚪️ in anaphylactic shock we give hydrocortizone as first choice or chlorpheniramine as 2nd choice , or adrenaline IM or IV( if we are in the hospital and under observation)


⚪️ in Hydated cyst we give the pt albendazole (400 mg for adults)at least  2weeks prior to the surgery to avoid shock caused by the organism (larvae)

💭 complications of hydated cyst:
- anaphylactic shock
-leakage
-obstructive jaundice

⚪️ Obstructive jaundice:
  in case of biliary tumor we must do MRCB ( ERCPوليس ) before the surgery

⚪️ In case of tumor of the head of pancreas
بنسوي له دعامة بواسطة ال ERCP ونجهزه للعملية
*Whipple surgery:
remove part of pancreas and whole gall bladder and duodenum and part of stomach.

الدكتور عبد العزيز

■ DVT =itis  formation of thrombosis in deep veins
■ etiology :
"Virchow's triad "postulates the presence of three factors that predisposes a person to develop vascular thrombosis. These factors include:
1 -Hypercoagulability of blood=defect or deficiency in protein s,c as( heparine) ,antithrombin 3

2-Alteration in blood flow in the vessels(stasis) as bedridden,varicosis veins ,arrhythmia AF

3-Vessel wall injury/ Endothelial damage due to truma or smokeing ,hypertension

■ Risk factors :
- bedridden dut to accident or fracture
-contraceptive pilli
-old age
-obesity 
-shock
-blood disorders as thrombocytopenia
-operation as cholisastomy
-hypertension
-malignancy
-pregnancy
■ symptoms:
-pain and tenderness
-swelling & edematous
-skin rash
-redness &hotness
■ signs:
-Homans sign =pain  in calf muscle during examination in forced dorsiflexion of  foot with knee straight


-Moses' sign= is pain with compression of the calf against the tibia.

■  Investigation
- D-dimer
- protien s-c -anti thrombin 3
- blood test
-doppler u/s
-duplex
-  CT scan venography

■ managment :
نمشي بالترتيب
-elevated of legs
-elastic compression to reduse pain to make thrombus fixed we do bandage for 10 days to make stabilization
-heparin for 7 to 10 days then give warfarin becouse itis vit k antagonist before he go out from hospital before 3days because itis effect appear after 3 days
-analgesic
-anticoagulation for 3month to 6 month for pt who has truma or pregnancy
or for long life if Caused PE or recurrent DVT
على حسب الحالة
-thrombolysis we can do it in early conditions
-thrombotomy
-filter is indicated in recurrent thrombosis -anticoagulation insufficiency-intracranial hemorrhage.

■Examination
General inspection =pulse and BP- environmental =عكاز
- local inspection : من شعر الرأس لين القدم
- palpable : tenderness,temp ,odema ,beating.
ولو في varicose veins نعمل ال local examination تبعها أيضا

TypesCATHETERS
a. Nonself-retaining catheter: Simple red rubber catheter.
b. Self-retaining catheter: Foley’s catheter, Malecot’s cath-
eter, Gibbon’s catheter, De-Pezzer catheter.

FOLEY’S CATHETER (Adults12—16 F)(6F to 8F in Children)Types
x Two-way Foley’s.
x Three-way Foley’s—to give bladder irrigation, e.g.
following TURP.
x Silicone coated Foley’s—to reduce reaction and so as to
keep for longer period (3 months).Usesبشكل عام علئ النحوالتالي
x To pass per urethrally in retention of urine of any cause
(BPH, stricture, trauma).
x To measure the urine output in renal failure, postoperative
patients, terminally ill patients.
x Percutaneous cystostomy.
x Cholecystostomy.
x To drain fistulas. Complicationsعلئ النحوالتالي
™ Infection
™ Encrustation
™ Bleeding
™ Stone formation
™ Blockage
™ Stricture

Malecot’s catheter—
Uses
™ Suprapubic cystostomy (SPC)
– In case of urinary retention when Foley’s catheterisation fails
(after two trials)
– For diversion of urine following bladder, prostate or urethral
surgeries
™ Perinephric abscess
™ Pyonephrosis
™ Cabot’s nephrostomy
™ Subphrenic abscess
™ Cholecystostomy
™ Infected pseudocyst of the pancreas
™ Amoebic liver abscess
™ Gastrostom

HAEMATURIA
Types
x Gross (visible to unaided eye).
x Microscopic (>5 RBC’s/HPF).
™ Early (initial) haematuria: Urethral origin, distal to external
sphincter
™ Terminal haematuria: Bladder neck or prostate origin
™ Diffuse (total) haematuria: Source is in the bladder or upper
urinary tract
™ False haematuria: Discolouration of urine from pigments such as
food colouring and myoglobin.
™ Silent haematuria is due to tumours of kidney or bladder unless
proved otherwise.
يعني الاكل الشمندر والدواء مثل ميثليندوباوميتراندازول في التحليل للبول False haematuriaولاتحمل RBc

HAEMATURIA Causes; ™ Renal injury
™ Urinary stones
™ Wilm’s tumour
™ Tuberculosis
™ Renal cell carcinoma
™ Cystitis
™ Bladder tumour
™ Urinary bilharziasisركزعليهاالدكتوروتكون terminal والطورتبعها ..portal vein في جسم مجوف والانثئ تنزل lower part of وتسوي الاشكاليه
™ BPH, carcinoma prostate
™ Renal infarct
™ Glomerulonephritis
™ Blood dyscrasias

Suture Materials CLASSIFICATION I
Absorbable Suture Materialsالنوع الاول *Plain *catgut is derived from submucosa of jejunum of sheep absorbed by inflammatory reaction absorption time is 7 days. *Chromic *catgut is catgut with chromic acid salt Its absorption time is 21 day . * Vicryl *(Polyglactic acid It gets absorbed in 90 days. *PDS *(Poly Dioxanone Suture material

Non-absorbable Suture Materials Silk Polypropylene Cotton.Uses of non-absorbable suture materials
™ In herniorrhaphy for repair
™ For closure of abdomen after laparotomy
™ For vascular anastomosis (6-zero), nerve suturing, tendon
suturing
™ For tension suturing in the abdomen
™ For suturing the skin

Numbering of Suture Material
Thick. For pedicle ligation.
1-
0-zero.
1-zero.
2-zero. For bowel suturing.
3-zero.
4-zero.
5-zero. For vascular anastomosis.
6-zero. زي.حجم الشعره
7-zero.in opthalmogy

إضافات الدكتور خالد تلها 👆🏻.

💢 فهرس مُلخصات "Group C " للجراحة:
https://t.me/Surgery_Lab_37B/554
ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ

💢 فهرس مُلخصات "Group A" للجراحة 👇🏻:

- الأسبوع الثاني:
الدكتور نبيل عُثمان
https://t.me/Surgery_Lab_37B/562
الدكتور عبدالغني ناشر
https://t.me/Surgery_Lab_37B/566
الدكتور وليد غيلان
https://t.me/Surgery_Lab_37B/567
الدكتور طه القحوم
https://t.me/Surgery_Lab_37B/569
الدكتور توفيق المخلافي
https://t.me/Surgery_Lab_37B/571
الدكتور عبد العزيز الجعدي
https://t.me/Surgery_Lab_37B/572
الدكتور خالد تلها
https://t.me/Surgery_Lab_37B/573

- الأسبوع الثالث:
الدكتور علي الصباحي
https://t.me/Surgery_Lab_37B/584
الدكتور وليد المخلافي
https://t.me/Surgery_Lab_37B/585
الدكتور محمد الدوبلي
https://t.me/Surgery_Lab_37B/587
الدكتور ماجد عامر
https://t.me/Surgery_Lab_37B/589
الدكتور علي محمد صالح
https://t.me/Surgery_Lab_37B/591
الدكتور عبدالله المتوكل
https://t.me/Surgery_Lab_37B/595

- الأسبوع الرابع:
الدكتور لؤي القباطي
https://t.me/Surgery_Lab_37B/592
الدكتور زيد شيبان
https://t.me/Surgery_Lab_37B/604
الدكتور محمد الشعيبي
https://t.me/Surgery_Lab_37B/605
الدكتور عبد العزيز الجعدي
https://t.me/Surgery_Lab_37B/606
الدكتور عبدالله المتوكل
https://t.me/Surgery_Lab_37B/607

- الأسبوع الخامس:
الدكتور عبدالله المتوكل
https://t.me/Surgery_Lab_37B/619
- الدكتور خالد الكحلاني
https://t.me/Surgery_Lab_37B/627
- الدكتور محمد عيسى
https://t.me/Surgery_Lab_37B/629
-الدكتور ياسر عبدالمغني
https://t.me/Surgery_Lab_37B/632

- الأسبوع السادس:
الدكتور محمد الشهاري
https://t.me/Surgery_Lab_37B/640
الدكتور فهيم العبسي
https://t.me/Surgery_Lab_37B/642
الدكتور نشوان طشان
https://t.me/Surgery_Lab_37B/647
الدكتور محمد عيسى
https://t.me/Surgery_Lab_37B/662



💢 وسيتم إضافة روابط الملخصات الجديدة وتحديث الفهرس بشكلٍ دوري.

ملاحظات العملي
للدكتور علي الصباحي
م.الثورة
معظم كلام الدكتور موجود بالمخلص

Aim of personal hx in trauma to know if the patient is conscious or in shock

In  personal history of trauma we shoud mention Time of trauma at ( any hour ) on (day) and Time of arrival to ER and Time interval (gap time) between trauma and aarival  to ER
Pt was in shock state or no
Then :
After ER
Pt was entered urgent surgery or wait on conservative ttt (fluid replacement )

Pt in shock we have to be sure if vital organs are good or not ?
Brain : level of consciousness
Heart : vital signs
Kidney : urine output normally
30-50 ml/hour نحسبها بالساعة

Hemorrhage is divided into ?
Primary : arterial (internal)
Reactionary :  venous (external)
Secondary : capillary
For more details see doctor's summary


Classification of hemorrhage ?
موجودة بملخص الدكتور



Maintenance therapy :
Depend on body weight
1st 10kg  give 100 ml/kg = 1000
2nd 10kg give 50 ml/kg = 500
ما تبقى من من وزن الجسم نعطيه 20ml/kg
Ex. If the pt weight is 70 kg
We give him 2500 ml

Maintenance therapy is given for :

1- post-operative
2- dehydrated pt
3- pt with gastroenteritis

Basal skull fracture ?
Bruising behind the ears
Black eye
Autonorrhea
Rhinorrhea

Difference b/w semicoma and deep coma ?
Semicoma : response to painful stimuli

أهم النقاط اللي ركز عليها الدكتور وليد المخلافي...
How to deal with emegency cases ?

1st : primary survay ( ABCDEF )

It used for life threatening condition; Started with call for help then :

A : airway shoud be patent & cervical immbolization.

B : breathing and O2 therapy.

C : circulation, for shock mangement do 2 IV lines in both hands & measure pulse, if external hemorrhge do compression and do other methods to stop bleeding.

D : decubitus & disability ( do Glass coma scale and look for deformity ).

E : Exposure ( اكشف المريض كامل من رأسة الى قدمه عشان نشوف اذا في أي شئ آخر او any findings.)
and Environment ( warming the patient and room well ).

F : FAST [ focused assessment sonography for truma ] نعمل تلفزيون للبطن والحوض والقلب كامل عشان نشوف اذا في أي تجمع للسوائل أو ضرر في أي مكان ).

☆ Note : eFAST [ extended focused assessment sonography for truma ] = FAST + US to pleura spaces for looking for fluid

Then we do 3 important X- rays :
Cervical
Chest
Pelvis

☆ Note : in primary survay may take brief history [ AMPLE ]
A : allergies.
M : medication.
P : past medical history.
L : Last meal.
E : events of injury.

2nd : secondry survay :
Started from head to toes by doing complete history and examinations.

لقراءة التفاصيل أكثر حول هذا الموضوع تجدونه في التشابر الثاني [ Major truma and multiple injury patient ] من كتاب القصر العيني...

☆ Notes :
Classifications of pneumothorax
° open and closed or
° tension and simple or
° trumatic and spontanous

● Dx of pnemothorax is clinically not by chest X-ray beacuse of the short time during emergeny & pt will die while we just preparing for X- ray. معلومة مهمة جداً

● TTT of pneumothorax is needle decompression according to site of truma.

بالاضافة الى انه شرح أنواع الكانيولا والوانهن و Chest tubes ؛ سيتم ارفاق الشرح في البوست اللي تحت 👇