■ Surgical Drains || *Important Topic
#Surgery_rotation

💢Under water sealed

▪︎Is a Chest drain inserted to allow draining of the pleural spaces of air, blood or fluid, allowing expansion of the lungs and restoration of negative pressure in the thoracic cavity.

▪︎Active Close System

▪︎The water in the water seal chamber will rise and fall (swing) with respirations. This will diminish as the pneumothorax resolves.

▪︎Watch for unexpected cessation of swing as this may indicate the tube is blocked or kinked


🔹Indications for Insertion of a Chest Drains:
▪︎Post operatively e.g. cardiac surgery, thoracotomy

▪︎Pneumothorax

▪︎Haemothorax

▪︎Chylothorax

▪︎Pleural effusions


🔹Indications for Removal of Chest Drains:
▪︎Absence of an air leak (pneumothorax)

▪︎Drainage diminishes to little or nothing

▪︎No evidence of respiratory compromise

▪︎Chest x-ray showing lung re-expansion

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❇️The 'safe triangle' for chest drain insertion

🔹bounded anteromedially by the lateral border of pectoralis major

🔹inferiorly by a horizontal line at the level of the nipples

🔹posteriorly by the anterior border of latissimus dorsi.

This area is 'safe' because it avoids damage to the chest wall muscles and breast.

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■Detailed History of Lump/Ulcer

بالإضافة لـ تحديد ⬇️ :
✅ Site
✅ Laterality ( Unilateral/ bilateral) If it is in Extremities
✅ Size e.g ( bean like ,lemon like)
✅ Number ( single or Multiple)
✅ Depth ( Is it reach to Muscle/bone)

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✅ Types of ulcer edges

▪︎Sloping edge : healing, traumatic and ischaemic venous ulcers.

▪︎Undermined edge : TB

▪︎Punched-out edge : ischaemic and syphilitic ulcers

▪︎Rolled edge : basal cell carcinoma

▪︎Everted edge : squamous cell carcinoma and the ulcerated adenocarcinoma.

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✅ Pressure sores ( bed Ulcers)

Definition : pressure sores or bedsores are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin.

•affect people confined to bed or sit in a chair for long periods of time.

#Site
#Grade
#Prevention

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Diabetic Foot (Clinical Practice)

✅ Definition: Diabetic foot is defined simply as any foot pathology that results from the long term complications of diabetes mellitus mainly neuropathy and angiopathy. The foot pathology may include foot infection, ulceration, and osteoarthropathy.

✅ Main risk factors of diabetic foot are:
➢ Poor glycemic control.
➢ Duration of D.M more than 10 yrs.
➢ Age, Smoking and Male gender.
➢ Obesity.
➢ Peripheral vascular disease.
➢ Peripheral neuropathy.
➢ Diabetic nephropathy and retinopathy.
➢ Foot deformity (abnormal foot structure).
➢ Previous history of foot ulceration/ gangrene.

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Grades of diabetic foot ulcer :-

✅ Wagner classification:-

➢ Grade 0: intact skin in high risk patients (no ulcer).
➢ Grade 1: superficial ulcer involving the skin and subcutaneous tissues.
➢ Grade 2: deep ulcer involving muscles, tendons & joint capsule without bony
involvement.
➢ Grade 3: bony involvement (osteomyelitis).
➢ Grade 4: localized gangrene as gangrene of a toe or heel only.
➢ Grade 5: extensive gangrene involving most of the foot.

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The important points in history of a diabetic patient with foot ulceration

✅ Regarding ulcer:
➢ Onset.
➢ Duration.
➢ Pain.
➢ Discharge (color, amount, odor)
➢ Bleeding.
➢ Progression of ulcer over time.
➢ Preceding trauma.
➢ Previous foot ulceration

✅ Regarding diabetes:
➢ Duration of DM.
➢ Glycemic control (dietary modification, medications, or insulin).
➢ Compliance to treatment.
➢ History of diabetic complications as:
1. Peripheral vascular diseases : intermittent claudication (muscles cramping/ fatigue in
one or both lower extremities on walking for a certain distance and relieved by resting
for several minutes) , rest pain, and change in leg color.
2. Peripheral neuropathy: as weakness of lower extremities (motor), impaired sensation
as hyposthesia, paresthesia, and hyperesthesia (sensory) and skin dryness
(autonomic).
3. Diabetic retinopathy: any problem in vision.
4. Diabetic nephropathy: any renal problem.

✅ Foot history:
➢ Daily activities including work.
➢ Footwear: whether shoes, slippers, sandals, or different footwears, and whether the
footwear is fit, lose, or tight.
➢ Foot care: inspect foot daily, aware of foot problem, foot washing, and proper nail care and trimming.
➢ History of Callus formation and foot deformity as Charcot deformity.
➢ Previous history of foot infection, blisters, ingrown toenail, and foot surgery.

✅ Social history: including occupation, smoking, and alcoholism.
✅ Past medical/ surgical history.
✅ Drug history: including medications in current use and allergies.

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Staging of bed sores ( Ulcer)
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✅ Ischemic ulcer

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✅ #Trophic ulcer

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Trophic (Neuropathic) and ischaemic ulcers

✅ Trophic ulcers (Neuropathic ulcers)
•Weak nerve sensation of the skin
•Mostly Due to DM

✅ Ischaemic ulcers :
•inadequate Blood supply to the skin.
•Mostly Due to Atherosclerosis

🔥 When examin a patient with an ulcer on their foot you should :

1. examine the circulation (pulses).

2. examine the sensory nerves (light and deep touch and pain sensation).

3. test the urine for sugar.

▪︎Both occur in parts of the feet are subjected to repeated pressure and trauma

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✅ Causes of Ischemic & Trophic ulcers

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✅Cholecystitis 
is inflammation of the gallbladder after Blockage mostly by Stones


💢Symptoms
▪︎right upper abdominal pain
▪︎pain in the right shoulder
▪︎nausea, vomiting
▪︎fever
▪︎gallbladder attacks (biliary colic) precede acute cholecystitis.

▪︎Pain with deep inspiration leading to termination of the breath while pressing on the right upper quadrant of the abdomen usually causes severe pain (Murphy's sign).

▪︎The pain lasts longer in cholecystitis than in a typical gallbladder attack.


💢Risk Factors
▪︎Birth control pills (Estrogen)
▪︎pregnancy
▪︎family history
▪︎obesity
▪︎diabetes
▪︎liver disease
▪︎rapid weight loss
▪︎diet high in fat and cholesterol


💢Complications Of Acute Cholecystitis
▪︎Gangrene Of Gallbladder
▪︎Gallbladder rupture
▪︎Empyema
▪︎Fistula formation


💢Gallstones Complications
▪︎Acute Pancreatitis
▪︎Acute Cholecystitis
▪︎Acute Cholangitis
▪︎Obstructive Jaundice
▪︎Gallbladder Ileus

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■DDX OF NECK MASSES

❇️Multiple lumps: are invariably lymph glands.

❇️A single lump: 👇

♦️In the anterior triangle that does not move with swallowing:

▪︎Solid: Lymph gland, Carotid body tumor.
▪︎Cystic: Cold abscess, Branchial cyst.


♦️In the posterior triangle that does not move with swallowing:

▪︎Solid: Lymph gland.
▪︎Cystic: Cystic hygroma, Pharyngeal pouch, occasionally a secondary deposit of a papillary thyroid carcinoma
▪︎Pulsatile: Subclavian aneurysm.


♦️In the anterior triangle that moves with swallowing:

▪︎Solid: Thyroid gland, Thyroid isthmus lymph gland.
▪︎Cystic: Thyroglossal cyst.

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✅Notes on Neck Mass

⬇️ Ask the patient to swallow some water and observe the movement of the mass:

▪︎Thyroid gland masses (e.g. a goitre) and thyroglossal cysts typically move upwards with swallowing.

▪︎Lymph nodes will typically move very little with swallowing.

▪︎An invasive thyroid malignancy may not move with swallowing if tethered to surrounding tissue.


⬇️ Ask the patient to protrude their tongue:

▪︎Thyroglossal cysts will move upwards during tongue protrusion.

▪︎Thyroid gland masses and lymph nodes will not move during tongue protrusion.

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#How to take history in common surgery cases
#DDX
#Examination
#Instrument
#Discussion

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❇️Appendicitis
is inflammation of the Appendix Mostly by obstruction of the opening of the appendix, as a result of either a faecolith (hardened stool) or lymphoid hyperplasia

🔹Typical symptoms:
▪︎Nausea and vomiting
▪︎Low-grade fever
▪︎Migratory abdominal pain ( staring as Umbilical pain then shifting to
Right iliac fossa pain)
▪︎Diarrhoea
▪︎Anorexia & Loss Appetite

🔹Typical clinical findings:
▪︎Right iliac fossa tenderness
▪︎Shifting (Migratory) Pain
▪︎Rebound Pain
▪︎Leucocytosis

▪︎Rovsing sign: palpation of the left iliac fossa causes right iliac fossa pain

▪︎Psoas sign: extension of the right thigh, in the left lateral position, causes right iliac fossa pain

▪︎Obturator sign: internal rotation of the flexed right thigh causes pain

▪︎Hop test: hopping or jumping causes abdominal pain

🔹If there is a delay in presentation with appendicitis, complications can include:

▪︎Perforation & peritonitis
▪︎Abscess formation
▪︎Appendicular Mass

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❇️Migration of pain in appendicitis

▪︎Initial inflammation stimulates visceral afferent pain fibres which correspond to the T10 dermatome, producing umbilical pain. (Not Specific/Not Localized Pain)

▪︎As the appendix becomes more inflamed, it irritates the parietal peritoneum which activates somatic nerve fibres and produces localised pain which is most often felt in the right iliac fossa. (Localized Specific Pain)

▪︎Visceral Pain ➡️ Parietal (Somatic) Pain

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