‎⁨الكافية❌⁩

‫الكافية‬
‫يف عملي‬
‫اجلراحة‬
‫‪ 4114‬ه‬
‫‪ 1049‬م‬
‫بسم اهلل الرمحن الرحيم‬
‫يا خادِمَ اجلسمِ كمِ تسعى خلدمتهِ ‪ ........‬أتطلبُ الربحَ مبا فوهِ خُسرانُ‬
‫س ال باجلسمِ انسانُ‬
‫أقبلِ على النفسِ وأستَك ِملِ فضائلها ‪ .......‬فانكَ بالنف ِ‬
Table of content
Chapter one: history

Appendicitis 2
Epigastric pain 4
Hernia 6
Anal condition ( PNS , hemorrhoid ) 8
Breast cases 10
Thyroid 12
Trauma ( head injury , fracture ) 14
Swellings ( lipoma , ganglion , cyst ) 15
Urology ( hematuria , loin pain ) 16

Chapter Two : examination
General examination 19
Abdominal examination 26
Rectal examination 32
Hernia examination 36
Thyroid examination 41
Breast examination 47
Fracture examination 52
Urological examination 55
Vascular examination 56
Chapter three : Mind maps
General surgery
Acute sialoadenitis 65
Ganglion 66
Anatomy of breast 67
Triple assessment 68
Acute bacterial mastitis 69
Duct ectasia 70
CA breast 71
Anatomy of thyroid 72
Goiter 73
Simple nodular goiter 74
Graves disease 75
GIT surgery
Hernia 77
Management of hernia 78
Anatomy of inguinal region 79
Inguinal hernia 80
Anatomy of appendix 81
Acute appendicitis 82
Sign of acute appendicitis 83
Appendecetomy 84
Anatomy of gallbladder 85
Gall stone 86
Peptic ulcer 87
Management of peptic ulcer 88

GERD 89
CHPS 90
Hematemesis 91
Rupture spleen 92
Intestinal obstruction 93
Intussusception 94
Mickles diverticulum 95
Anatomy of anal canal 96
Hemorrhoid 97
Pilonidal sinus 98
Special surgery
Acute ischemia 100
Management of ischemia 101

Varicose vein 102
Pneumothorax 103
Complications of fracture 104
Treatment of fracture 105
Colles fracture 106
How to manage open fracture 107
Difference between EDH and SDH 108
Burn 109
Cleft lip and cleft palate 110
Urinary stone 111
Chapter four :Surgical skills

Chest Tube 113
NG Tube 116
Colostomy 118
Catheter 120
Cannula 122
Suture 123
Blood transfusion 126
IV fluid 127
Drugs ( antibiotic , oral hypoglycemic agent ) 133
Chapter five : Differential diagnosis

RIF pain 137
RIF mass 137
Left iliac fossa mass 137
Epigastric swelling 138
Suprapubic swelling 138
Right hypochondrial pain 139
Right hypochondrial mass 139

Epigastric pain 139
Hematuria 140
Urinary retention 140
Red color urine 140
Hepatomegaly 141
Splenomegaly 141
Kidney enlargement 141
Bleeding per rectum 142
Painful anus 142
Mass per rectum 142
Chapter six : OSCE pretest

Stations 144
1
Chapter one
How to take history in common surgery cases
Content of this chapter

Appendicitis 2
Epigastric pain 4
Hernia 6
Anal condition ( PNS , hemorrhoid ) 8
Breast cases 10
Thyroid 12
Trauma ( head injury , fracture ) 14
Swellings ( lipoma , ganglion , cyst ) 15
Urology ( hematuria , loin pain ) 16

2 Appendicitis history
ID :
 Age ( appendicitis can commonly occur in young age 20 – 30 but can occur in other age
group )
 Sex ( if female its very important to exclude pregnancy because ectopic pregnancy is very
important DDx of RIF in female )
Chief complaint :
RIF pain for ( ….. ) duration
History of present illness :

1- Pain : (Socrates )
Typical appendicitis :
 S : start around umbilicus and shift to RIF
 Onset : start suddenly
 C : felt like something constrict abdomen
 R : shift to RIF
 A : associate by nausea and vomiting in most of cases
 T : progressive and intermittent
 E: excacerbate by movement and decrease by rest
 S : may affect daily activity as it progress in severity
2- Swelling :
May be noticed by patient if the condition complicated by appendicular mass
3- Disturbance of function of GIT :
 Vomiting : amount , color , frequency , preceded by nausea or no ?
 Stool : change in frequency and consistency
4- Fever :
 Onset , course , duration
 Associated with shivering and rigor ?
 Associated with sweating or no ?
Appendicitis usually associated with increase body temp
5- History of trauma to abdomen
6- Ask about jaundice to exclude pancreatitis which may mimic appendicitis
7- Ask about urine : frequency , dysuria , color change
3 history
(And mention them here because they are important negative )

8- Pre operation :
Investigations
Any fluid or blood transfusion ( if he is anemic and he require urgent operation its better to
correct the anemia for example if his HB is 8 g / dl and you want to do operation for him its
important to decide weather he need blood transfusion or he can stand operation without
blood transfusion )
9- Operation :
 Time ?
 Result ?
 Any complications during operation ?
 Blood transfusion ?
10- Post operation :
Day zero , day one , day two …. Etc
 Time of Return to consciousness ?
 Walking? ( very important to prevent DVT and psychological support for pt )
 Pass urine ?
 Pass flatus ( very important )
 Medication
 Fluid ?
 Vomiting ?
 Fever ?
Systemic review :
Past medical :
Past surgical :
Drug and allergy :
Family history : Positive family history increase risk of appendicitis
Social history :
4 Epigastric pain history
ID :
Age :
 cholecystitis more common in age 40
 Duodenal ulcer is more common in 20-30 age
Sex :
Gallstone more common in female
DU more common in male
Chief complaint:
 Epigastric pain for ( ……. ) day duration
 Right hypochondrial pain for ( …… ) duration

1- Pain ( Socrates )
 Very important here to ask about relation of pain to eating ( for peptic ulcer )
 Very important to ask about relation of pain to vomiting is it relived by vomiting or no ( for
PU )
 Patient with pancreatitis tend to lean forward from severity of pain
 Pain of pancreatitis my radiate to back
2- Stool :
 amount ,
 color( very important , if its malena suggest upper GIT including PU
 change in frequency
 consistency
3- increase body temp ( fever )
occur usually in pt with cholecystitis , cholangitis
4- jaundice ( very important )
 onset
 duration
 progression
5- urinary symptoms ( for DDX and for jaundice )
frequency
color ( very important especially if the condition associated with jaundice )
dysuria ( for pyelonephritis which is one of ddx of cholecysititis )
6- ask about loss of appetite and change of wt ( for peptic ulcer )
7- ask about chronic use of drug especially NSAID and mention it here ( for peptic ulcer )
8- drink alcohol or no ( for pancreatitis ) mention it here
9- other symptoms like vomiting
10- pre operation , operation , post operation ( as appendix sheet )
5 history
systemic review :
past medical :
recurrent attack is very important
past surgical :
important especially if it was abdominal surgery near biliary tract area
drug and allergy :
very important but its better to mention it in history of present illness in such case
most important being NSAID
family history :
PU risk increase if he has positive family history
Social :
Alcohol most important especially for suspected pancreatitis
If he is alcoholic you should ask about :
 Duration
 Frequency
 Amount at each time ( most important )
6 Hernia history
ID :
Age : congenital inguinal hernia occur in infant and toddler
Sex : femoral hernia more common in female
Occupation : more common in people who left heavy weight ‫ العُما ْل‬, ‫الحَ مال‬
Chief complaint :
 Swelling in left groin for 2 years duration
N.B : Hernia is usually painless swelling
 Swelling in rt femoral region for 5 years duration
 Swelling at site of scar for 3 month Pain suggest complication

1- Swelling :
 Site
 Size ( ‫( اشكد حجمه تقرٌبا مثل حجم بٌضة او رمان او اكبر‬
 Shape
 Onset ‫ اٌمتى الحظته ؟‬, ‫اٌمتى بدا‬
 Course ‫ٌزداد حجمه مع مرور الوقت ؟‬
 Duration
 What increase ) hernia swelling increase by straining or coughing ‫من تعصر بالحمام ٌزداد حجمه ؟‬
)
 What decrease ) rest and lying on bed decrease the swelling )
 Pain ( if present my suggest complication like strangulation or
 Other swelling in body
 History of trauma to area
 Apparent cause for pt ? ‫المرٌض ٌكول انً شلت شً ثقٌل قبل اشهر وبعدٌن بدا الحالة‬
2- Feature of complication : ( infection , complication )
 Vomiting
 Abdominal pain
 Fever
 Change color of skin in area of swelling
3- Effect of hernia on urination :
 Double micturition ?
 Frequent micturition ?
( hernia if large it may press on urethra or bladder )
4- Pre operation , operation , post operation … same as appendix sheet
7 history
Systemic review :
Past medical :
Chronic constipation is risk factor
Chronic cough is risk factor
Past surgical :
 Prior surgery of appendicitis is risk for hernia why ?
During appendicitis we use grid iron incision
When you do grid iron incision , there is risk of injury to ilioinguinal nerve
Ilioinguinal nerve supply the conjoint tendon ,
So if you injury this nerve during doing appendicitis this can cause paralysis of conjoint
tendon which is risk of hernia due to weakness result from paralysis
 Any other surgery is risk for incisional hernia
Drug and allergy :

Social history :
Smoking is risk factor because smoking leaqd to chronic cough and chronic cough increase intraabdominal
pressure this increase risk of hernia
Family history :
May be of benefit because some hereditary collagen weakness condition like marfan and other have strong
family relation
Anal condition
8 history
( PNS , hemorrhoid )
Id :
Sex : PNS more common in male
chief complain :
 mass per rectum for …… duration
 bleeding per rectum for ….. duration
 pain in anal region for ….. duration
history of present illness :

1- Pain if present SOCRATES
2- Bleeding :
 Ask about color of stool ( brown , black terry , green )
 Ask about color of blood ( dark red , bright red )
 Bleeding occur spontaeusly or during defecation only ?
 Blood is part of stool or separated from stool ? ‫الدم النازل ممزوج وٌا الخروج ام انه منفصل عنه‬
 Amount of blood ( drop of blood , small amount , large amount ) ‫الدم عبارة عن نقاط صغٌرة ام كمٌة‬
‫قلٌلة ام كمٌة كثٌرة ؟‬
 Painful bleeding or painless ?
 Ask about straining during defecation ? ( may give you clue to cause of bleeding )
3- Pruritus
Onset
Frequency
Itching any other site in body ?
4- Discharge from rectum ( other than bleeding )
5- Mass ( prolapse )
 Site , size , shape
 Onset , course , duration
 What increase , what decrease
 Relation to defecation ( occur spontaneously or during straining and defecation only )
6- Ask about incontinence
Involuntary passage of stool
7- Tenesmus :
Urgent , painful , desire to defecate which is unproductive
‫ وٌنتظر طوٌال فً الحمام وال ٌخرج شًء هذا ٌسمى‬, ‫ فٌدخل‬, ‫ المرٌض تأتٌه رغبة شدٌدة وقوٌة لدخول الحمام‬tenesmus
8- Effect on general condition :
FAHM for infection ( fever ,anorexia , headache , malaise )
Wt loss for malignancy
9 history
Systemic review :
 Hematological system to search for generalized bleeding tendency
 Urinary system
Past medical :
Past surgical :
Drug and allergy :
Taking iron therapy may confuse with bleeding per rectum because iron supply change the color of
stool to black
Social and family history :
10 Breast cases history
ID :
Age : very important for ddx
 If young age female with breast lump your first ddx will be fibroadenoma
 While female above 50 with breast lump your first ddx should be ca
Marriage and number of children :
 OCP and nullioarity increase risk of ca

 Breastfeeding decrease risk
 Breast pain after breastfeeding newborn think of acute bacterial mastitis
Chief complain :
 Mass in right breast for …… duration
 Pain in left breast for …… days
 Abnormal discharge from nipple for …. Week

1- Pain ( Socrates )
 Important to mention relation of pain to menses
 Dull ache pain suggest chronic condition
 Throbing pain suggest breast abscess
2- Swelling :
 Site , size , shape ?
 Onset ? ‫متى بدأت الحالة‬
 Course ? ‫حجمه ٌزاد مع الوقت لو ٌقل لو ثابت لو متغٌر‬
 Duration ?
 What increase , what decrease ?
3- effect of swelling ( mass ) on general condition FAHM ( fever , anorexia , headache , malaise )
4- history of trauma to breast ( even simple trauma ) very important
5- discharge if present :
 onset
 duration
 amount
 color
 occur spontaneously or after squezzing ??
6- ask about specific feature of ca :
11 history
loss of wt
skin change in breast ( dimpling , eczema of paget disease )
7- pre operation , operation , post operation as appendix sheet
systemic review :
important especially if you suspect ca to see if there is feature of cancer metastasis
like jaundice if metastasize to liver or cough if to lung or bone pain if to bone \
past medical :
past surgical :
drug and allergy :
 OCP increase risk of breast ca
 allergy may be associated with paget disease
family history :
very important to ask about it
social :
 smoking increase risk of ca
 marital statue
gynecological history :
very important to ask about it in detail
12 Thyroid history
Id :
Age :
 Primary thyroitoxicosis ( graves ) occur commonly between 20 – 30 year

 Papillary ca of thyroid occur commonly between 20 – 40
 Other type of thyroid ca occur in old age usually
Sex : thyroid disease is a disease of female
Chief complaint :
 Painless swelling in neck for 2 years duration
 Irritable and nervous for few month
 Palpitation for 3 month

1- Swelling :
 Site , size , shape , skin change
 Onset
 course ( it may progressive or regressive or flactuating , stationary )
‫المرٌضة قد تاخذ عالج فٌقل حجم الغدة ثم بعد فترة ٌبدا الحجم فً الزٌادة‬
‫من جدٌد‬
 duration
 Other swelling in body
 What increase , what decrease the swelling
 Pressure manifestation caused by swelling ( very important ) like dyspnea , dysphagia ,
hoarsness of voice )
2- Painful or painless ( thyroid swelling is painless usually , pain suggest complication )
3- Effect of swelling in general condition FAHM ( fever , anorexia , headache, malaise ) suggest
inflammatory swelling
4- Loss of wt ( for ca )
5- Disturbance of function ( feature of hyperthyroidism )
CNS : irritability
Insomnia
Night mares
Tremor
Cardiac : ask about palpitation
Metabolic : ask about heat intolerance , , thyroid paradox ( increase appetite with decrease in wt )
13 history
GIT : diarrhea is common

Eye : ask about diplopia
Urinary : ask about polyuria
Muscle : ask about muscle fatigability
6- Any drug taken by her and response of treatment
( , ‫ حتى اذا لم ٌنجح العالج باالدوٌة‬, ‫غالبٌة المرضى قبل العملٌة لمدة طوٌلة غالبا حاولوا استعمال االدوٌة المضادة للغدة الدرقٌة‬
) ‫حٌنها تاتً الى العلمٌة‬
7- Pre operation , operation , post operation like appendix sheet
( thyroid operation done usually after preparation so its important to know how to prepare thyroid
pt to operation and ask her about like lugols iodine for 2 week prior surgery and others )
Systemic review :
Very important to ask about each system in detail because thyroid gland control the other hormone
in body
Past medical :
Past surgical :
Drug and allergy :
Family history :
Important here because its graves disease is autoimmune and its related to family history
Social history :
Vital sign :
Pulse :
Hypothyroid pt has bradycardia
Hyperthyroid pt has tachycardia
Hyperthryod pt undertreatment may come with normal or bradycardia
BP :
Medullary Ca is part of MEN type II
Which include pheochromocytoma which cause HTN
So thyroid may present with HTN in case of MEN type 2
Trauma
14 history
)head injury , fracture )
ID :
Chief complain :
 Pain in leg since 3 hour ( fracture )
 Bleeding from head since 2 hour ( head injury )
 Loss of consciousness for …. Minute ( head injury or fracture )

1- Introduction :
 Time of trauma
 Mechanism of trauma
Eg / If fall from height
‫االرتفاع الذي سقط منه؟‬: 
‫هل ارتطم بشًء اثناء السقوط؟‬ 
‫هل سقط على حدٌد ام تراب ام ارض صلبة او ناعمة؟‬ 
‫وضعٌة الجسم اثناء السقوط ؟‬ 
2- At site of trauma :
 Loss of consciousness , if yes for how long ?
 Bleeding , if yes ask about site , amount , duration , any first aid ?
 Pain if yes then ( Socrates )?
 Walking after accident ?
 Vomiting in this period ?
 Any first aid done for him at site of trauma ?
3- Transportation :
Transported by car or ambulance ? ‫سٌارة خاصة ام اسعاف‬
How much time till he reach hospital ?
Condition of pt during transport ( ill , unconscious , in pain etc )
4- At hospital :
What done for him when he came to hospital
5- Pre operation
Operation
Post operation
Systemic review
Past medical
Past surgical
Drug and allergy
Social and Family
Any swelling in body
15 history
Lipoma , ganglion , cyst
ID :
Chief complain :
 Swelling in chest for …. Duration
 Swelling in forearm for …… duration

1- Swelling :
 Site , size , shape
 Onset ?
 Course ?
 Duration ?
 What increase ?
 What decrease ?
 Other swelling in body ?
2- Pain (if yes then SOCRATES )
3- Effect of swelling on general condition FAHM :
Fever , anorexia , headache , malaise
4- Wt loss for malignancy
5- History of trauma to the area of swelling
Because the cause of swelling could be due to trauma
6- Disturbance of function at site of swelling :
 If swelling in chest it may affect the breathing (SOB ) or press on esophagus cause (
dysphagia )
 Swelling at arm my limit join movement
 Swelling in groin may affect urination , sexual function
So according to site of swelling you should ask about the effect
7- Preoperation , operation , operation
Systemic review
Past medical
Past surgical
Drug and allergy
Social and family
16 Urology history
Chief complain :
Red color urine for 2 day
Left loin pain for 4 days

1. Hematuria :
 Color
 Amount
 Timing of hematuria ( at beginning of urine , at middle , at end , all along the course of
urination )
2. Frequency of urination
3. Dysuria
4. Abdominal pain “ renal colic “ ( if yes then do Socrates )
5. Swelling in body ( periorbital swelling , leg swelling )
6. Other urological symptoms :
 Urgency
 Nocturia
 Hesitancy
 Feel of incomplete empty
 Stream
 Straining during urination
7. Nausea and vomiting ( important in urology )

8. Investigation done and its result
9. Treatment given and its result
Systemic review :
Gynecological history :
Very important if the patient female
Past medical :
HTN, DM are important
Past surgical :
17 history
Family history :
Social history :
Drug history :
Very important because a lot of drug are nephrotoxic like gentamicin which is strong antibiotic used
commonly in Iraq and its nephrotoxic
18
Chapter Two
Important note in examination of surgical condition

General examination 19
Abdominal examination 26
Rectal examination 32
Hernia examination 36
Thyroid examination 41
Breast examination 47
Fracture examination 52
Urological examination 55
Vascular examination 56
19 General examination general examination
( before starting , introduction , head & neck , hand and leg )
1- Before starting :
 Stand on right side of pt
 Introduce yourself
 Take permission
 Explain what you will do to the patient
 Say “ ‫ “ بسم هللا‬and then start
2- Introduction :
Describe the following point :
 Age and sex ( child , young age , middle age , old age ….. male / female )
 Position ( sitting , semisitting , lying supine , lying on side )
 Level of consciousness ( conscious or no )
 Oriented to time/place/person or no
 How he looks ( comfortable , in pain , nervous , anxious )
 Built ( normal wt or looks cachexic )
 Dyspnea present or no ?
 Environment ( cannula , oxygen, catheter , NG tube….etc )
3- Head and neck :
In face :
a-eye : conjuctival pallor , yellow discoloration of sclera
b- mouth : contour of mouth , any ulcer , any bleeding , dental caries , tonsil , uvula,
tongue abnormality )
c- lip : cyanosis
neck :
 swelling
 scar
 fistula
in both head and neck :
lymph node examination
( submental , submandibular , preauricular , post auricular , occipital
Anterior cervical , posterior cervical , supraclavicular )
20 general examination
Lymph node :
4- hand :
5- leg
Common question in exam
Q / where you look for pallor :
 Conjunctiva in eye
 Palm of hand
 Inner aspect of lip
 Skin of face
 Nail of hand
Q / cause of pallor ??
1. Anemia
2. Shock ( due to decrease cardiac output
3. Anxiety and fear
Q / cause of pallor with normal CBC ( without anemia )?
1. Shock
2. Fear and anxiety
Q / cause of yellow discoloration of sclera other than jaundice ?
1. Hypercarotenemia
2. Uremia
3. Xanthomatosis
Q / cause of jaundice ??
1. Prehepatic : hemolytic disease of blood , gilbert syndrome

2. Heaptic : hepatitis
3. Post hepatic : stone in bile duct
Q / cause of clubbing ?
1. Heart : cyanotic CHD , infective endocarditis

2. In lung : lung cancer , broncectasis , lung abscess
3. GIT : liver cirrhosis
Q / why you look for cyanosis In tongue ?
Has no autonomic fiber , and its highly vascular

Q / difference between central and peripheral Cyanosis ?

26 Abdominal examination
Inspection Palpation Auscultation Percussion
 Symetrical  Superficial : 1. Bowel sound: medial to Shifting dullness

umbilicus
 Distension Tenderness Fluid thrill
2. Renal bruit :
 Umbilicus shape and Mass, rigidity
position  2 cm above and
Guarding lateral to
 Scar umbilicus
 Deep palpation :
 In renal artery
 Pigmentation
Tenderness stenosis
 Dilated vein ( caput 3. rare : hepatic hump
Mass
medua )
 Palpation for organ :
 Visible peristalsis
Liver
 Visible pulsation
Spleen
Complete abdominal examination by examining hernia orifice , genitalia and doing per rectal examination
27 abdominal examination
Q / what are abdominal cause of clubbing ?

 Inflammatory bowel disease
hepatoma
 Malabsorption syndrome
 Primary biliary cirrhosis
Q / area of exposure of abdomen ??

From nipple to mid thigh ( 4th intercostal space to mid thigh )
Why to level of nipple ?? because maximum respiration will raise the diaphragm to level
of 5th intercostal abdominal organ will also be raised
For example in deep palpation we ask him to take deep breath and palpate the abdomen
, if we did not expose to level of 5th intercostal we may miss pathology and not palpate
well
Why to mid thigh ?? because the fascia of abdomen is contious with that of thigh , and
also not to miss hernia or undescended tests ( ectopic testes in femoral region
Q / what are weak area of abdomen ??

 Linea alba
 Groin ( groin is area 2 inch above and 2 inch below inguinal ligament )
 At site of scar
Q / cause of visible peristalsis ?

 Pyloric obstruction
 Intestinal obstruction
Q / cause of visible pulsation ??

 Aneurism ( aortic aneurism )
 Right ventricular hypertrophy
 Very thin patient
 Pulsating mass
Q / difference between guarding and rigidity ?
Q / how to palpate for spleen ?

Start from right iliac fossa , why ?
Because enlargement of spleen is oblique toward right iliac fossa
Q / how to examine for gallbladder ??

Ask patient to breath deeply while you apply pressure over the surface anatomy of GB ( junction between
right costal margin and linea semilunaris )
Sudden catch of breath with gasp is positive morphy sign

Q / What are abdominal plane
What are surface anatomy of abdominal region ?

2Vertical plane :
each one from midclavicular line down to midway between anterior superior iliac spine and
symphysis pubis
2 horizontal line :
1. Transpyloric plane : passes through tip of 9th costal cartilage on each side , that is area
where lateral edge of rectus abdomius ( linea semilunaris) cross the costal margin
It lies opposite 1 lumbar vertebrae
2. Intertubercler plane : line join the tubercle of iliac crest on each side
Q / what is surface anatomy of liver , spleen , kidney ?

Liver :
Upper border at level of 5th intercostal space in midclavicular line
Lower border at level of right costal margin
Spleen :
Upper border of 9th rip till lower border of 11th rip

Kidney :
32 PR examination
rectal examination
( position , inspection , palpation )
1- Position : there is three position for doing PR chose one and perform the examination
 Left lateral position
 Knee chest position
 Lithiotomy position
2- Inspection :
Inspect the area of anal canal and perineum look for :
 Sinus : like in case of PNS
 Fistula : in case of anal fistula
33 PR examination
 Fissure : anal fissure

 Ulcer :
 Perineal inflammation ( redness , swelling )
 Any mass or prolapse ( like in hemorrhoid )
 Visible bleeding or discharge
34 PR examination
3- Palpation :
 Using gloves and after applying lubricant and local analgesia , insert your finger into anal canal
 Direction : first insert into directed toward umbilicus then direct it posteriorly toward ischium
 average finger length is 6 – 10 cm , thus you can examine whole anal canal and more than half of rectum
as the length of anal canal is 4 cm , and rectum is about 12 cm
search for :
 tenderness : if there is deep tenderness suggest salpingitis , acute appendicitis ,
peritonitis
 mass : as in case of internal pile , impacted feces
 in male only : examine prostate gland
 in female : if ovarian tumor
 after taking hand out of anal canal look for blood in your gloves
35 PR examination
Hernia examination
36 hernia examination
( inspection , palpation , special test , other )
1- Inspection : ( patient on standing position )

 Exposure from nipple to knee to see all type of hernia
 Look from two different plane ( from front and from side )
 Ask patient to cough : small swelling will bulge with cough
2- Palpation ( on standing position )

 Stand on side of patient , put one hand behind patient to support him , examine by your
other hand
 Can you get above swelling or no ??

Put the thumb and index and feel upper edge of swelling
If you can get above it this is mostly scrotal swelling
If you cant get above it , this is mostly hernia
its very important in inguinal hernia examination to exclude scrotal swelling
 For the swelling examine the following : ( 7 S , TT , E C )

 Single or multiple
 Site , size , shape
 Surface , skin , surrounding skin
 Tenderness , Temperature
 Edge : well defined or ill defined
 Consistency : hard or soft
3- Special test :
a- Cough impulse :
Put your hand over the swelling
Ask the patient to cough
Feel the swelling as it become tense and expand in all direction , if yes this mean positive
expansile cough impulse
( expansile cough impulse mean increase in size in all direction )
b- Reducibility :
Reduce the swelling by your hand to see its reducible or no
N.B Irreducible hernia suggest strangulation
c- After reduction :
Watch the swelling appear from where
1- Reappear direct forward this is direct inguinal hernia
2- Reappear oblique and downward this is indirect inguinal hernia
d- Pubic tubercle test :
Locate pubic tubercle
After locating the pubic tubercle :
 If hernia is above and medial to pubic tubercle this is inguinal hernia

 If hernia is below and lateral to pubic tubercle this is femoral hernia
e- Internal ring test :
 While patient is lying , Reduce the hernia
 Locate deep inguinal ring ( 1-3 cm above mid point of inguinal ligament )
 Put your finger and press over the deep inguinal ring
 Ask patient to stand , then to cough
 Watch the result :
1. If hernia reappear this is direct inguinal hernia ( because direct not pass
in deep inguinal ring so it not be affected by your finger closing the deep
ring )
2. If hernia did not appear , then open the deep ring by taking your hand
away , if hernia appear this is indirect inguinal hernia
f- Three finger test ( zeimen test ):

 Patient on lying position
 After that , ask patient to stand and then to cough , then watch the cough impulse
affect which finger :
4- Other :
 Auscultation : positive bowel sound
 Percussion : dull
 Examine the lymph node
N.B
Percussion and auscultation only if the content of hernia was intestine
Percussion and auscultation is not commonly used test in hernia

thyroid examination
41 thyroid examination
( general , Eye , hand , neck )
1. General :
 Irritable , nervous , anxious
 dull face ( hypothyroid )
 body wt
 jaundice ( side effect of antithyroid drugs )
2. eye : 8 sign
1. exophthalmos :
 eye protrude outward
 the sclera below lower limbus is visible
how to examine for exophthalmos ??
 look from above patient head

 look from front to see visible sclera below lower limbus
 use ruler to measure the protrusion ( usually its 15 -17 if above this range its exopthalmus )
‫‪42‬‬ ‫‪thyroid examination‬‬
‫‪2. Lid retraction :‬‬
‫) يعني بطئ او متأخر ‪3. Lid lag : ( lag‬‬
‫‪The upper eye lid does not keep pace with eyeball as it follow your finger‬‬
‫قم بتحريك اصبعك من االعلى الى االسفل طالبا من المريضة ( ُ‬

‫قلت مريضة وليس مريض ألن اغلب حاالت الغدة الدرقية هن نساء‬
‫فالمرض شائع اكثر في النساء ) ان تتبع حركة اصبعك بعينها‬
‫في االنسان الطبيعي ‪ upper lid‬ينزل مع حركة العين‬
‫اما في هذا ال ‪ sign‬فان ‪ upper lid‬تتاخر او التنزل مع حركة العين التي تتبع اصبعك التي تحركها انت‬
N.B
Lid lag also called von graefe sign
4. Lack of convergence :
If you move finger from away toward nose side of eye , there will be convergence , this is in normal
human
In thyroid disease there may be lack of convergence

5. Corneal ulceration :
Occur due to difficulty closing eye due to exophthalmos
( its one of consequence of exophthalmos )
6. Opthalmoplagia :
Occur due to myopathy of ocular muscle
7. Lack of forehead wrinkle :

8. Chemosis :
Edema of conjunctiva
3. Hand :
a) Pulse :
 Bradycardia in hypothyroid
 Tachycardia in hyperthyroid ( thyrotoxicosis )
 Normal pulse in hyperthyroid ( due to side effect of beta blocker used in
treatment of thyrotoxicosis , so you may see hyperthyroid patient with
normal pulse if he is under treatment
b) Tremor :
 Fine fast tremor
c) Look in palm of hand
 Sweaty hand in hyperthyroid
4. Neck
( inspection , palpation , auscultation percussion, lymph node )
a) Inspection :
 Symmetry , swelling , scar ,
 Ask her to swallow water
 Ask her to protrude tongue
b) Palpation :
From behind :
 Palpate from behind using both hand

 Press from one side by one hand , palpate by the other hand
 Repeat the step to palpate the other side
 If there is swelling :
Describe it ( site , size, shape , skin , surrounding skin , tenderness , temperature , edge , consistency )
Surface is very important for ddx
From front of patient:

 feel the trachea ( goiter can cause tracheal deviation )
c) Auscultation :
For systolic bruit which occur in thyrotoxicosis , vascular lump
d) Percussion :
 Percuss along clavicle
 Percuss upper chest
 Percuss over sternum
What is benefit of percussion ? used to detect lower extent of swelling
e) Lymph node :
For evidence of metastasis of malignancy if present

Breast examination
47 breast examination
( inspection , palpation )
1. Inspection :
Position : 4 position
a. Hand rest on thigh

Look from 2 different plane of view
Look to undersurface of breast
b. Press by hand on hip :to contract the pectoralis major muscle
c. Rise hand above head : to make mass more prominent

d. Lean forward : to see if one of breast are pendulus and other not
What you look for in inspection ?
1- Both breast are symmetrical or no ; you know this from level of nipple
2- Look to this nipple :
 Direction should be downward , forward and to the left
 Retraction : nipple retraction may be congenital or acquired , acquired may
be caused by cancer
3- Look to areola :
 Eczema of paget disease which is malignant condition
4- Skin of whole breast :
 Any sign of inflammation like redness of edema
 Dilated vein ( disease of vein of breast called mandors disease )
 Ulcer
 Nodule
 Dimple ( ‫) نقطة صغيرة من الجلد متهة الى داخل‬
 Bunkering ( ‫) مجموعة من النقاط متجهة الى الداخل‬
 Peu de orange ( ‫ هذه واحدة من عالمات السرطان‬, ‫) شكل الجلد يشبه شكل قشرة البرتقال‬
5- Ask her to squeeze the breast to see if there is discharge
6- Look to infra mammary area for any skin abnormality
2. Palpation :
Position
 Best position is patient lying on bed
 You can do also while she is setting
how to palpate ?
You should palpate 7 area ( by flat of your hand )
 Nipple and areola

 4 quadrant of breast
 Axilla
 Infra mammary area
if there is swelling or mass you should comment on the following :

How to examine axillary LN ?
Common question regarding breast :
 What is artery supply of breast ?

 What is surface marking of breast ?
 What are type of breast ca?
 What are surgical treatment of breast cancer ?
 Type of operation and indication of each one ?
 Indication of conservative mastectomy ?
52 Fracture
Neurovascular
Before starting Assess gait Look , feel , move Special test examination
 Stand at right  Antalgic gait :  Like testing for 1. Exam the distal
side of patient occur in hip union artery to
 Introduce joint arthritis involved area
yourself  Trendelberg 2. Do neurological
 Take gait : in hip exam of area
permission muscle problem involved :
 Explain to  Foot drop : motor , sensory
patient what nerve injury , reflex
you will do
 Say “ ‫“ بسم هللا‬
and start
Look Feel Move
1. In skin : bruise , scar , 1. Skin : sensory loss 1. Active movement : ask the patient
ulcer , rashes , 2. Soft tissue : tenderness , to move joint in all direction of its
pigmentation effusion , mass movement
2. In soft tissue : 3. Bone : joint tenderness , joint 2. Passive movement : move the
swelling , lump , line involved joint or area In all
muscle wasting possible direction
3. Bone : deformity ,
abnormal alignment
53 fracture examination
Presentation :
On inspection of hand of this patient , there

is no scar , no ulcer or bleeding , no swelling ,
no muscle wasting
There is deformity in the area of lower

forearm and wrist , the radial side of forearm
displaced , this is dinner fork deformity
Most likely diagnosis from inspection is

fracture of distal end of radius ( colles
fracture )
And I will do x ray to confirm my diagnosis

54 fracture examination
Urological examination
55
1. Vital sign :
especially BP and pulse are extremely important in urological cases
2. General examination :
 Periorbital edema
 Leg edema , sacral edema
 Shortness of breath
 Level of consciousness
 Dehydration
3. Local examination :
Inspection :
Distension ( enlarged kidney )
Palpation :
Tenderness is most important sign for example loin tenderness in kidney problem or suprapubic
tenderness in bladder problem like cystitis
Tenderness in renal angel is very important sign in acute pyelonephritis
Auscultation :
Bruit of renal artery stenosis
Percussion
4. Digital rectal examination

In male for prostate enlargement
65 Vascular
Inspection Palpation Auscultation Pulse
1. Color : 1. Temperature : 1. Femoral artery

For bruit over artery : bruit
 Normal color according 2. Popliteal artery :
Normal ischemic leg take indicate stenosis due to
to person complexion
the temperature of turbulent blood flow How to feel the pulse of popliteal
 Blue
environment artery ?
 Pale Site of auscultation :
 Black : gangrene If environment is hot it  Leg is straight to feel the
General :
2. Vascular angel : see will be hot if environment upper part of artery
next page is cold it will be cold  Carotid artery  Leg is flexed to feel the
3. Vascular refilling : see  Femoral artery lower part of artery
next page 2. Capillary refilling :  Prone position
 Renal artery
4. Guttering vein ( Press on tip of nail or
3. Posterior tibial
groves ) Specific in ischemic limb : 4. Dorsalis pedis
press on tip of finger
5. Look to pressure zone See next page
 Along the whole
for ulcer , gangrene
course of artery , you
Pressure zone like malleulous auscultate for
and dorsum of foot stenosis
‫‪57‬‬
‫‪# Vascular angel ( burger test ) :‬‬
‫اطلب من المريض االستلقاء في السرير‬
‫الحظ لون رجل المريض‬
‫قم برفع رجل المريض وهو مستلقي بشكل مستقيم وانظر عند اي درجة يحصل تغير في لون القدم‬
‫مثال‬
‫تغير في ‪ color of leg‬عند درجة ‪ 03‬من الرفع او عند ‪ 03‬درجة من رفع القدم او عند ‪ 03‬درجة من رفع القدم‬
‫كلما حصل التغير في ‪ color‬في درجة اقل فمعناه المرض اكثر ‪sever‬‬
‫) ‪# Vascular refilling ( dependency test‬‬

‫‪Done after burger test‬‬
‫‪Hang the leg down the bed after doing burger test like in the picture‬‬
58
How to palpate popliteal pulse??

59
60
61
Chapter Three
Mind Maps of common surgical topics
General surgery
Ganglion 66
Duct ectasia 70
CA breast 71
Goiter 73
Graves disease 75
62
GIT surgery
Hernia 77
Anatomy of Inguinal region 79
Inguinal hernia 80
Appendicectomy 84
Gallstone 86
Peptic ulcer 87
GERD 89
C.H.P.S 90
Hematemesis ( Upper GIT bleeding ) 91
Rupture spleen 92
intussusception 94
Mickle diverticulum 95
Hemorrhoid 97
Pilonidal sinus ( PNS ) 98
Special surgery
Acute ischemia 100

Management of ischemia 101
Varicose vein 102
Pneumothorax 103
Complications of fracture 104
Treatment of fracture 105
63
Colles fracture 106

How to manage open fracture 107
Difference between EDH and SDH 108
Burn 109
Cleft lip and cleft palate 110
Urinary stone 111
64 Mind Maps
General surgery
‫الجراحة العامة‬
This include :
Ganglion 66
Duct ectasia 70
CA breast 71
Goiter 73
Graves disease 75
‫الجراحة‬
,‫ ليست مذكورة هنا‬, ‫العامة تتضمن مواضيع اخرى مثل القرحة واالكياس الدهنية وغيرها‬
‫في هذا الفصل ذكرت ولخصت اكثر الحاالت شيوعا والتي يراها الطالب في المستشفى قبل‬
.... ‫التخرج والتي يحتمل ان ُيسأل عنها في االمتحان‬
Acute sialoadenitis
65
Define c/p
Complication Investigation
Acute suppurative 1- Symptoms : 1- Chronic 1- CBC : WBC elevated

inflammation of sialoadenitis 2- ESR : elevated
salivary gland General : FAHM 2- Abscess : 3- CRP :elevated
Local : need surgery 4- Plain x ray : to detect stone in
3- Spread of the duct
 pain in face infection to
 Swelling inside mouth other body
 Pain increase by eating system
acidic food like lemon
2- Sign :
General :fever ,
tachycardia Mx
Local :
Salivary gland diffusely

Medical : 3 A
enlraged
Analgesia
Antibiotic
Etiology
Antipyretic
Surgery :
Organism : staph aureus
Hilton operation
Predisposing factor :
 Poor oral hygiene

 Bad general condition like DM , immuncompromised person
66 Ganglion
Define c/p
Symptoms :
Chronic cyst X ray
contain mucoid Painless swelling at dorsum 1. Infection
material related of hand or around ankle 2. Rupture of cyst
to tendon 3. Hemorrhage
4. Calcification
Usually seen at
Sign :
dorsum of hand
or around ankle  The swelling could
be tense
 Cystic swelling
Mx
Etiology
Indication of surgery :
Degeneration of fibrous tissue of tendon  Patient will

sheath  Presence of complication
Option of surgery :
 Aspiration
 Complete excision of cyst
67 Anatomy of breast
Notes Venous
Lymph node
 Breast is modified Superficial vein cross 1. 15 % drain to internal mammary LN

sebaceous gland the midline 2. 85 % drain to axillary LN
 Formed of fibrofatty
Deep vein accompany Group of axillary LN :
tissue
the arteries
 It lies in superficial 5 group of axillary LN which are apical , medial , lateral , posterior ,
fascia so its Intercostal vein : central
superficial gland
 Breast fixed to  Drain to azygous Another classification of axillary LN :
overlying skin and to vein on Rt side
 Drain to  According to relation with pectoralis minor
pectoralis fasica by
hemiazygous vein  Level I : lateral to PM
copper ligament
on Lt side  Level II : posterior to PM
 Breast lies over :
1. Pectoralis major  Level III : medial to PM
muscle
2. Seratous anterior
muscle
Surface
anatomy
Blood supply
Vertically extend from 2nd to 6th rip

1. Lateral thoracic artery which is branch of 2nd part of axillary
artery Horizontally extend from sternum to midaxillary line if axillary
2. Perforating cutaneous branch of internal mammary artery tail counted
3. Branches comes from intercostal artery
Horizontally from sternum to anterior axillary line if axillary tail
not counted
68 Triple assessment
Clinical Imaging Pathology
History ( see Three option :

chapter1 )
FNAC :
Examination ( see
chapter 2 )  most commonly used
because its easy to perform
and simple
 Give accurate result
Core cut :
Mammography MRI  More difficult and more

U/S aggressive method
 Give accurate result
 Put the breast on table and take x
To detect the mass is Open biopsy :
ray film Not commonly used because
cystic or solid
 Used to detect non palpable its expensive and not  Incisional bx
breast lump  If cystic aspirate practical  Excisional biopsy
 Normal mammography doesnot  If solid take
exclude malignancy that is why it Used in implantable breast
biopsy
should be combined with u/s because silicon used in
implantation increase size of
 Young female BREAST is high
brease that why MRI in this
density ,old age female breast is
patient are more accurate
low density , high density breast
not well visualized in xray wjile
low density lump is well
visualized
 That is why in young age female N.B : triple assessment give 99 % accuracy of detecting breast mass , and to know its type of benign OR
mammography is less accurate MALIGNANT
69 Acute bacterial mastitis
Define c/p
DDX Investigation
4 stage : Mainly dx clinically from hx

Its acute  Retromammary abscess
and examination
inflammation of  Stage of engogement :  Mastitis carcinomatosis
breast , its either CRP and ESR will be elevated
lactational or not Dulla ache pain + mild fever + no
related to lactation sign of inflammation
Majority of cases  Stage of cellulitis : Mx

are acute bacterial
Pain worsen + increase fever
lactation mastitis
Sign of inflammation like redness
‫انطفم في اول اياو انوالدة‬
hotness swelling etc Advice :
‫يكوٌ فًه يًهوء بال‬
staph bacterial  Stage of abscess : thropping Tell her to stop breastfeed from the affected breast and use the
‫ففي اثناء انرضاعت ينتقم‬ pain + pus discharge + hectic other breast or bottle feeding
fever
breast ‫يٍ فى انطفم انى‬
 Stage of chronicity Medical : ( stage 1 and 2 only )
 Antibiotic against staph aureus like fluxcacillin

 Analgesic
 Antipyritic like paracetamol
Etiology
Surgical : ( stage of abscess )
Bacteria : staph aureus  Either by making incision in skin and drainage of abscess
 Or by u/s guide aspiration of abscess
Route of infection : mouth of baby
Presentation :
‫ وهي ترضع انطفم رضاعت‬, ‫ايرأة وندث قبم فترة قصيرة‬
breast ‫ بداث تشتكي يٍ انى في‬, ‫طبيعيت‬
70 Duct ectasia
Define c/p
Investigation
1. Nipple discharge which is

Its dilatation of most important and  Cytology to exclude tumor
milk duct which is common presentation  Triple assessment for mass if suspected
usually associated 2. Subareolar mass  Benzidine test for blood
with periductal 3. Abscess may develop
inflammation 4. Fistula
5. Nipple retraction may
occur
Mx
 Exclude ca this is very important step

 Early and mild case can be treated by antibiotic and
follow up
 Surgery : mx of choice
Name of operation ( hadfield operation )
In hadfield operation the surgeon do excision of all major

dilated duct
Incidence
‫اىعمييت ال تؤثز مثيزا عيى اىمزأة فهي تستطيع ان تنمو ارضاع طفيها مه اىطزف‬
‫االخز‬
ً‫ وباىتاىي قد ينىن عدد قييو فيه اىمزض فنقى‬duct 20-15 ‫ومذىل يىجد هناك‬
Most common cause of nipple breast ‫باستصاه اىقنىاث اىمصابت فقط دون ضزر بباقي اه‬
discharge
More common in smoker women

71 Breast cancer
Incidence Classification
Investigation C/P
1. Ductal ca :
 Very common  Ductal ca in situ ( DCIS ) 1. For diagnosis : Symptoms :
condition  Infiltrative ductal ca  Triple assessment
 Most common 2. For staging :  Painless swelling In breast , the
2. Lobular ca :
cause of death in  CT scan commonest presentation
 lobular ca In situ ( LCIS )
middle age female 3. Investigation for  Discharge
 Infiltrative ca
 Most common site metastasis like CBC ,  Symptoms of metastasis like bone
3. Paget disease of breast
of ca is in upper cxr , RFT , LFT pain , chest pain
lateral quadrant (
Sign :
60 % )
 Extremely rare See breast examination page
below age of 20 ,
very common after
60 years old
 Strongly related to ‫ وهي نم جحسوج ونم جرضع او جسوجث ونم‬, ‫ ونديها حانة سرطان في اقرباءها‬breast ‫ ) في ال‬mass ( ‫امرأة في انسحيىات مه انعمر جشحكي مه وجىد عقدة‬
family history , ‫ كيهى‬100 ‫ وهي جدخه ووزوها اكثر مه‬, ‫ وجسحعمم ماوع حمم بكثرة‬, ‫جرضع‬
Spread
Risk factor
1. Local spread
1. Nulipara 2. Lymphatic spread : axillary LN mainly , less common to
2. Not breastfeeding supraclavicular LN
3. Use of ocp 3. Blood spread : LBLB ( liver , brain , lung , bone )
4. + family history , old age
5. Alcohol and obesity
6. Early menarch and late menopause
Anatomy of thyroid gland
72
Notes Artery supply Venous

drainage
Thyroid is large 1- Superior thyroid 1- Superior thyroid vein :

endocrine gland artery : its branch of drain into internal jugular
external carotid vein
Located In lower neck artery 2- Middle thyroid vein : drain
opposite to 5th , 6th , 7th 2- Inferior thyroid into internal jugular vein
cervical vertebrae artery is branch of 3- Inferior thyroid vein :
thyrocervical trunk drain into left
It has two capsule :
which is branch of brachiocephalic vein
1- True capsule subclavian artery
2- False capsule 3- Thyroid ima :
1-2 % of population
Thyroid consist of two have this artery, it
lobe joined by isthmus come from arch of
aorta
Thyroid secrete T3 and
T4 which control
effectiveness and
secretion of other
hormone in body Nerve
1- External laryngeal
nerve
2- Recurrent laryngeal
nerve
73 Goiter
Define Classification
Management
Its enlargement of the
thyroid gland
 Medical
 Surgical :
Thyroidectomy
Simple goiter Inflammatory Malignant

Toxic goiter goiter goiter
1- Acute bacterial thyroiditis ( 1- Tumor arise from C cell :

1. Simple  Diffuse toxic very rare ) medullary Ca
physiological goiter ( graves 2- Subacute thyroiditis ( de 2- Tumor arise from follicle :
goiter disease ) quervan thyroiditis  Follicular Ca
2. Simple endemic  Toxic nodular 3- Autoimmune thyroiditis  Papillary Ca
goiter goiter ( hashimoto thyroiditis and  Aneoplastic Ca
3. Simple nodular riedle thyroioditis )
goiter:
Require surgery
74 Simple nodular goiter
Define c/p
Investigation
Symptoms :
TSH , T3 , T 4 all are normal
Non toxic ,
1- Cosmotic disfeguerment
noninflamatory , US : confirm presence of nodule
non malignant ‫المزيضت تأتي ٌَي تعاوي مه تضخم الزقبت‬
enlargement of ‫مما يسبب لٍا مشاكل وفسيت َتزعجٍا‬ FNAC : to exclude malignant goiter
thyroid gland
ِ‫ غالبا ال تُجد اي شكُِ اخز‬, ‫عدا ٌذا‬
Its diagnosed by
exclusion of other 2- Presentation of
type complication :
 Pressure manifestation
if massive enlargement
 May change to toxic if Mx
left untreated
Sign :
Medical
On examination there is nodule
Surgical :
( nodular enlargement not
1- Partial thyroidectomy
diffuse )
Etiology 2- Subtotal thyroidectomy
3- Total thyroidectomy
Its due to flactuation in level of TSH
‫في ٌذي الحالت الٍُرمُن احياوا يزتفع َاحياوا يىخفض‬
‫وتيجت لٍذي الحالت المتغيزة تىشئ عقد بسيطت‬
ً‫غالبا سبب التغيز في الٍُرمُن ٌُ القلق َما يزتبط ب‬

75 Graves disease
Define c/p
Symptoms : ( of hyperthyroid ) Heart failure

 Also called Most cases diagnosed clinically
primary 1. CNS : nervousness ,
thyrotoxicosis  TSH : decreased
irritability , insomnia ,
 Also called  T3 , T 4 : elevated
tre,mor
autoimmune 2. CVS : palpitation  US of neck
thyrotoxicosis 3. Metabolic :
 Its most common 4. heat intolerance
type of 5. Increase appetite with
thyrotoxicosis Mx
decrease wt
 In 50 % there is 6. GIT : diarrhea
positive family 7. EYE : protrusion of eye
history of 8. Skin : increase sweating Medical :
autoimmune 9. Muscle : easy
disease ‘ fatigability Mild case : neomercazole 10 mg 3 times per day plus beta
 Occur usually in 10. Urinary : polyuria blocker like propranolol to protect the heart
20 – 30 years old
Sign : Duration for 6 month
female
See thyroid examination in Sever case : same as mild case but for 2 year
chapter two of this book
Surgical :
Etiology Total or subtotoal thyroidectomy after preparation of thyroid

by :
Its autoimmune disease  Antithyroid agent

 Lugols iodine for 10 day before operation to decrease
vascularity to make surgery easy
General rule in any autoimmune disease :
1. Its more common in female

2. There is positive family history
76 Mind Maps
GIT surgery
‫جراحة الجهاز الهضمي‬
Hernia 77
Anatomy of Inguinal region 79
Inguinal hernia 80
Appendicectomy 84
Gallstone 86
Peptic ulcer 87
GERD 89
C.H.P.S 90
Hematemesis ( Upper GIT bleeding ) 91
Rupture spleen 92
intussusception 94
Mickle diverticulum 95
Hemorrhoid 97
Pilonidal sinus ( PNS ) 98
‫جراحة‬
‫الجهاز الهضمي تتضمن مواضيع تبدا من الفم وثم المرئ ثم المعدة واالمعاء الدقيقة والغليظة‬
, ‫انتها ًء بالمستقيم والقناة الشرجية‬
‫قمت في هذا الفصل بتلخيص بعض المواضيع الشائعة والمهمة للطالب في اخر سنة من الكلية‬
...... ‫ وهذه هي المواضيع التي قد يراها الطالب في المستشفى و ُيسأل عنها في االمتحان‬,
77 Hernia
Part of
Define c/p Complication Investigation
hernia
Hernia consist of 3 part :

Hernia is 1- Painless swelling 1- Irreducibility
protrusion of 1- Sac ( neck , body , 2- Obstruction Hernia mainly
viscus or part of fundus ) The feature of hernia 3- Strangulation diagnosed clinically
viscus through 2- Content of sac : could swelling : 4- Inflammation
be Investigation not
normal or 5- Hydrocele of
 Reducibility done usually
abnormal opening  Omentum , sac
 Give
in body intestine , fat , 6- Rupture of sac
expansile
meckle 7- Recurrence
 Normal impulse on
diverticulum
opening like cough
3- Covering of sac
umbilicus 2- Presentation of
 Abnormal complication
opening like
incision
Etiology
Types of
(Weakness in wall) hernia
Mx
Congenital : like in congenital inguinal hernia 1- According to site :
 internal hernia like hiatus hernia
Acquired :
 External hernia like incisional hernia
1- Mx predisposing factor
 Incision of operation 2- According to incidence :
2- Truss ( ‫) حزام الفتق‬
 Increase intra abdominal pressure like in  Common hernia : inguinal , incisional ,
3- Surgery :
chronic cough or constipation femoral , umblical
 Herniotomy
 Weak anterior wall : repeated pregnancy ,  Rare hernia : obturator , lumbar , spigilian
 Herniorraphy
obesity hernia
 Hernioplasty
3- Special type :
 Other casue : collagen weakness like in
marfan synbdrome Littre H , richter H , sliding H , pantalon H
78 Mx of hernia
Mx of predisposing Truss
factor Surgery
This is very important ‫حزام الفتق‬
If you do surgery and not mx  Its just support

predisposing factor , the hernia  It will not treat hernia
will recur  It increase risk of
strangulation
Mx :
 Used in patient not set
 Chronic cough for operation
 Smoking as it cause
chronic cough
 Constipation
Hernioplas
Hernitomy
Herniorraphy ty
done in congenital inguinal hernia and hernia in children Its operation done in adult especially if there :
and infant Done in adult and elderly
 Large defect
principle : Principle :  Significant weakness in wall
 open fundus of hernia  Recurrent hernia
 reduction of content of sac  Do first herniotomy
 excision of sac  Then repair the weakness by Principle :
herniorraphy
we do it in congenital inguinal hernia because there is no  First do herniotomy then do
weakness herniorrhaphy , then put the mesh
if there is weakness like in adult you cant do herniotomy ‫ الف‬60 ‫الشبكة سعرها تقريبا‬
alone
79 Anatomy of inguinal canal
Site Length Content Inguinal

ligament
 Present in inguinal region  4 cm in adult In male :

Extend from ASIS to pubic
 Extend from deep  Shorter in children
 Spermatic cord tubercle
inguinal ring to
superficial inguinal rign  Ilioinguinal nerve
 Midinguinal point :
 Deep inguinal ring is In female :
opening fascia Midway between ASIS to
transversalis  Round ligament of uterus symphysis pubis
 Superficial inguinal ring is  Ilioinguinal nerve
 Mid point of
opening in external
inguinal ligament :
oblique aponeurosis
 Direction of canal is Midway between ASIS to
downward and medially pubic tubercle
Posterior wall :
Inferior wall :
 Fascia transversalis Hassel bach
 Conjoint tendon Inguinal ligament
triangle
Roof :
Etiology Its part of posterior wall of inguinal canal
 Arching fiber
of internal Boundaries :
Anterior wall :
oblique
 Lateral by inferior epigastric vessel
 External  Transverse
 Medially by lateral border of rectus
oblique abdominus
sheath
 Fiber of  Inferiorly by inguinal ligament
internal oblique
 Transverse Surgical importance : its triangle by which direct
abdominus inguinal hernia passes
80 Inguinal hernia
Types c/p Complication of

Surgery
hernia surgery
1. Direct inguinal Painless swelling in

1. If congenital indirect hernia : Immediate complication :
hernia inguinal region which give
2. Indirect inguinal expansile impulse on Do herniotomy alone :  Bleeding due to injury to
hernia cough inferior epigastric vessel or
 Open fundus of sac iliac vessel
 Reduction of content  Urinary retention
Direct inguinal hernia Indirect inguinal  Excision of sac , then suture the skin
hernia 2. If direct or indirect hernia in adult : Next week :
Less common More common
First do herniotomy then do herniorraphy  Wound infection
Rare in children and Found in all age group operation called  Hernia recurrence
young including children  Chronic pain
Outside spermatic cord Inside spermatic cord Bassini operation
 Testicular infarction if there
Medial to inferior Lateral to IEV is damage to testicular
epigastric vessel artery
Not extend to scrotum May extend to scrotum 3. Some patient require to do mesh also :
Not enter in deep ring , Enter deep ring Herniotomyt + herniorrhaphy +

pass in hasselbach hernioplasty
triangle
Reduce upward and Reduce upward then 4. Person unfit for surgery for any reason :
straight downward laterally then
backward Truss used alone
Not controlled after Controlled after
reduction reduction
81 Anatomy of appendix
Layer
Notes Artery supply Venous
( histology ) drainage
 Its called tonsil of 1. Mucosa Appendicular artery Appendicular vein

GIT because its 2. Submucosa which is branch of drain into superior
rich in lymphoid 3. Muscularis ilieocecal artery mesenteric vein which
tissue 4. Serosa which is branch of join splenic vein to
 Its superior mesenteric form portal vein
intraperitoneal artery which is
organ branch of abdominal
 Its length
variable from
person to person
, average is 7 – 10
Surface
anatomy
Position Nerve supply Lymph node
1. Retrocecal in 74 % of people Drain to superior MCburney point :

By T 10
2. Pelvic in 21 % of people mesenteric lymph
Medial two third and lateral one third
3. Subcecal in 3 % Umbilicus also supplied node
from umbilicus to ASIS
4. Pre ilieal by T10 , that is why at
5. Post ilial first presentation , Mcburney point is same in all type
6. Subhepatic patient complian of because it represent the base of
7. Situs invertus ( appendix on right pain in around appendix
side ) umbilicus
82 Acute appendicitis
Epidemiology c/p Investigation
 Very common
condition 1. Symptoms: Appendicitis is usually diagnosed clinically
 Affect young age 2. Pain : typically start sign :
group mainly around umbilicus and However you do some Ix like :
see next page
between 20 – 30 then shift to RIF after few 1. Pregnancy test to exclude ectopic
 Rare below 5 and hours , colikly in nature , pregnancy
after 60 , however agrevated by movement 2. Urinalysis to exclude UTI
if occur , its or cough 3. U/s and CT if you in doubt about
difficult to 3. Anorexia , nausea , your Dx
diagnose vomiting , slight fever ,
 Most common constipation and
infectious agent is sometime diarhea
E.Coli
 Most common
type is obstructive Fate of appendicitis
type
What will happen if
appendicitis not treated ?
Mx
Resolve spontaneously : 1. Supportive treatment like analgesia

Complication happen : 2. Surgery is Mx of choice :
 If its non  Appendectomy
1. Gangrene and perforation
obstructive type  Mx of appendicular mass if occur
2. Appendicular mass
 At risk of 3. Appendicular abscess  Mx of appendicular abscess if occur
recurrence 4. Chronic appendicitis
5. Fistula
Sign of acute appendicitis
83
1. Tenderness in RIF
2. Rebound tenderness in RIF
3. Rovsing sign : ( also called crossed tenderness )
Pressure in left iliac fossa cause pain in RIF due to movement of gas from pelvic colon to caecum
4. Blumberg sign ( also called crossed rebound tenderness )

Lifting hand from LIF cause pain
5. Cough sign :
Pain increase if you ask patient to cough
6. Pointing sign :
Pt point by his finger to area around umbilicus then to area of mc burney point
7. Obturator sign :
Internal rotation of flexed right thigh cause pain in Rif due to irritation to obturator internus
muscle
This sign most obvious in pelvic appendix
8. Psoas sign :
Extension of right thigh cause pain in Rif due to irritation of psoas muscle
9. Hyperasthesia in triangle of sheren :

This triangle is between ASIS , symphysis pubis and umbilicus
10. Baldwing sign :

Rising lower limb from bed cause pain in RIF
11. Aaron sign :

Continuous pressure on RIF cause pain in Epi-gastric region
84 Appendicectomy
Type of Complication
surgery of surgery
1. Post operative wound infection

which is most common
complication of appendicectomy
Laparoscopic Open surgery and occur in 5 -10 % of cases
2. Other complications are not
Advantage : Type of incision :
common like :
1. Rapid recovery 1. Grid iron incision ( most  Respiratory complication DVT
2. Early return to work commonly used ) and PE
3. Minimal incision 2. Lanz incision  Ileus
4. Less risk of surgical 3. Midline incision  Fecal fistula
site wound infection 4. Pfensteal incision  Intestinal adhesion which in
5. Less post operative 5. Rutterfeild incision future can cause intestinal
pain 6. Right lower paramedian obstruction
incision  Hernia either due to damage to
ilieoinguinal nerve or incisional
hernia
85 Anatomy of gall bladder
Arterial
Notes supply Vein Lymph node
 GB is pyriform Cystic artery which is Cystic vein which Cystic lymph node of lund
shape ‫كمثري الشكل‬ branch of RT hepatic artery drain into right
 Capacity is 30-50 which is branch of common branch of portal
ml hepatic artery which is vein
 It has three part : branch of celeiac trunk at
 Fundus , body, level of T12 which is branch
neck of abdominal aorta
 Fundus is the
part that seen
below the
inferior surface of
liver
 GB located in Triangle of
Nerve supply
posterior surface calot
of liver Surface anatomy
 Function : store of GB
bile Very important anatomical Autonomic : sympathetic and
region in surgery of GB parasympathetic
At junction of right semilunar and right
costal cartilage This triangle is between : Sensory :
( tip of right 9th costal cartilage )  Liver By right phrenic nerve

 CHD C3,C4,C5
 Cystic duct
This is same segment as
supraclavicular nerve that is
why pain refered to right
shoulder
86 Gallstone
Types of
Define Presentation Complication
gallstone
of gallstone
( fate of gallstone )
1. Cholesterol : commonest
Presence of stone In GB :
type in usa and EU 1. Asymptomatic : the
in
2. Pigmented : commonest commonest  Biliary colic
GB
in asia oresentation more than  Acute cholecystits
Its common 70 % of case  Chronic cholycystitis
Its two type
condition 2. Biliary colic :  Empyema of GB
 Black pigmented stone  Sudden onset of colic  Mucocele of GB
Incidence increase pain in RT
 Brown pigmented stone  Perforation
with age hypochondrial region
3. mixed type  Cancer risk
Gallstone is most  Radiate to shoulder
 Increase by fatty meal In bile duct :
common biliary
condition  Decrease by
 Biliary obstruction (
antispasmodic
obstructive jaudice )
 Associated with nausea
 Acute cholangitis
and vomiting
 Acute pancreatitis
Risk factor 3. Presentation of
complication In intestine :
5F:  Gallstone ileus ( by

fistula )
1. Female
2. Fatty
3. Forty ( ‫) في االربعين من العمر‬ Investigation Mx
4. Fertile
5. Flatulent
1. U/S : 98 % accuracy Asymptomatic : no RX
2. Plain x ray : 10 % of stone can be
seen Symptomatic :
3. Other Ix like ERCP ,/MRCP , CT as cholecystiectomy
indicated
87 Peptic ulcer
Precipitating
Define factor c/p Complication Investigation
1. h.pylori 1. Pain ( commonly 1. Endoscopy ( ix of choice )

Its ulceration of 2. NSAID 1. Perforation
epigastric ) 2. Bleeding 2. Investigation for h.pylori:
mucosa 3. Cigarette smocking
2. Repeated vomiting ( hematemesis  Biopsy
4. Stress 3. Change in appetite
site of peptic or malena )  Serology
ulcer: 4. Change of weight 3. Change to  Urease breath test
5. Presentation of malignancy 3. CBC : anemia [ chronic
1. Duodenum complications bleeding ]
2. Stomach 4. CXR : perforation
3. Esophagous 5. Barium meal
4. Meckle
diverticulum
Difference
DU GU
More common then GU Less common than DU

Etiology
Usually in young age Usually in old age
Food relief pain Eating food exacerbate
pain
Peptic ulcer is due to Vomiting is not common Vomiting is very common
feature as it relief pain
1. HCL hypersecretion Appetite is good Loss of appetite and wt
2. Disturbance of mucosa Very rare to change to ca Considered ca until bx
prove otherwise
So any thing increase hcl secretion can cause ulcer
like h.pylori , food , liver disease
Also any thing disturb the mucosa cause ulcer like

NSAID
88 Mx of peptic ulcer
Surgical
Medical
Main line of treatment
Life style change : Gastrectomy

Vagotomy
 Rest
 Avoid stress
 Avoid irritating food like chocolate Its cutting the vagus nerve
 Avoid smoking and alcohol Its surgical removal of stomach
 Small frequent meal daily Vagus nerve in abdomen has three branch :
Types :
Medication : [ triple therapy ]  Celeiac branch supply stomach
 Hepatic branch branch supply the Anterectomy : removal 50 % of stomach
1. Antibiotic : clarithromycin 500 mg liver Partial gastrectomy : 65 %
1*2  Pyloric branch supply pylorus of
2. Metronidazole 500 mg 1 *3 stomach Subtotal gastrectomy : 80 %
3. PPI [ oemeprazole ] 20 or 40 mg
1*1 or 1*2 Type of vagotomy : Total gastrectomy : 100 %
AB + metronidazole for 10 day 1. Truncal vagotomy : cutting nerve

from its trunk , involve all three
PPI for 2 month and then revisit doctor After doing gastrectomy you should connect
branch of it resulting in a lot of
stomach to intestine
complication
2. Selective vagotomy : cutting only the How to do that ?
branch to pylorus
3. Highly selective vagotomy : cutting 1. Bilrtoh one : anastomosis of stomach to
just the branch supply stomach duodenum
4. Seromyomectomy : cutting only the 2. Bilroth 2 : anastomosis of stomach to
part of nerve supply the muscle of jejunum
stomach
89 GERD
Define c/p
1. Herat burn : 1. Increase risk of

Its influx of acid  Retrosternal barret esophagous  24 h abulatory PH monitor :
from stomach to  Increase by meal and 2. Ulcer and bleeding investigation of choice
espophagous lying flat in esophagous  Esophageal manometer
 Decrease by standing 3. Angina like chest  Barium swallow
up pain  Ueepr GIT endoscope
2. Unpleasant taste at 4. Pneuomonia
mouth
3. Dysphagia
4. Regurgitation : postural
5. Presentation of
complications
Mx
Etiology
1- Life style : loss of wt , stop smoking , avoid tea and coffee , avoid lying flat after meal
1. Hiatous hernia is one of the 2- Medical : first and main line of treatment
commonest cause
PPI like eomeprazole very effective in 80 % of case
2. In adult : smoking , alcohol ,
obesity increase risk of GERD 3- Surgery : if medical therapy fails :
3. Hellar operation used in
achalasia surgery Type of operation :
 Total fundoplication : nissen operation , this has complication

 New method is modified nissen operation
 Other surgery option : dor watyen operation , belsey mor operation
90 C.H.P.S
Define Complications
DDx Investigation
Its congenital  Dehydration ( ‫)اهم نقطة‬

If DDx of vomiting in neonate Gastrographin barium ,
condition in which  Metabolic alkalosis then take x ray it will
there is  Paradoxical acidosis  Gastroenteritis show :
hypertrophy of  Chest infection  Intracranial Hg
mucosa of pylorus  Not gaining wt since birth  Feeding problem  Dilated stomach
part of stomach  Doadenal atresia ( ‫) اهم نقطة‬  Delay empty of
stomach
Doudenal CHPS  String sign
Etiology is atresia
Give saline orally to Pt
unknown
Bile stained NOT bile stained and then do US it will
vomiting vomiting show
Start soon Never at birth
after birth Usually 2 – 6 week  Thickened
C/P after birth pylorus
X ray : X ray : string sign  Dilated stomach
double
bubble sign
Symptoms :
Mx
 Projectile vomiting which is NOT bile
stained
 Constipation may present
This condition not respond to anti-emetic drug
Sign :
1. Rehydration is most important initial step
 Dehydration ( most important ) 2. Surgery as soon as possible is the mx of choice :
 Upper abdomen distention
 Visible peristalsis Name of operation is : Ramsted pyloromyomectomy
 Mass in rt hypocondrium
91 Hematemesis
Important
Define Important point in Investigation
point in hx
examination
 Epigastic pain , heart

 Its vomiting of burn  Epigastric tenderness  CBC
blood which is  Vomiting analysis  Rigidity ( perforated PU )  Blood group and cross match
fresh blood or  Syncope  Sign of liver disease ‫مهم‬  RFT ,LFT
coffe ground  Hx of liver disease ‫مهم‬  Orthostatic BP ‫مهم جدا‬  Platelete count and coagulation profile
 Its emergency  Drug hx ( NSAID ) ‫مهم‬  Endoscopy should done after stabilization
condition  Bleeding disorder
Mx
Etiology
1- Monitor & resuscitation :

 Catheter , IV line , NG tube if required
In esophagus :
 Blood transfusion if required
 Esophagitis  Analgesia if there is pain
 Esophageal caner  Put on chart ‫مهم جدا‬
 Esophageal varices 2- Detect source of bleeding :
 Malori wies tear  Urgent endoscopy done after resuscitation to detect source of bleeding
3- Control source of bleeding according to cause :
In stomach :  By endoscopy
 By surgery
 Gastric ulcer
 Gastric ca
 Vascular malformation
In duodenum :
DU , duodenal tumor , aortodoudenal fistula

92 Rupture spleen
Cause c/p On
Investigation
examination
1. Trauma : Hx of trauma to abdomen ( Inspection : 1. U/S : FAST U/S

blunt , penetrating , iatrogenic ) 2. CT is investigation of choice to
Most common organ Bruise , ecchymosis detect type of injury
injuried in trauma is  Abdominal pain 3. Diagnostic peritoneal lavage
spleen then liver then Decrease abdomen movement
 Shock ( hypovolemic
kidney with respiration
shock )
 Sign and symptoms of Palpation :
2. Spontaneous
peritonitis
rupture : Tenderness , rebound
Eg/ in typhoid tenderness , guarding
Auscultation : decrease bowel

sound
Mx
Pathology
Percussion : tender to percuss
( types of spleen )
DRE :
1. ABCD at time of patient arrival to
Subcapsular hematoma ( ‫غالبا ال يحتاج الى عملية‬, ‫) نزف خفيف‬ In male fullness in rectovesical hospital
pouch 2. Resuscitation by fluid and blood as
Superficial tear ( ‫) خدش سطحي مع نزيف‬
required
In female fullness in douglas
Deep tear 3. If minor injury :
pouch
Conservative and follow up in ICU
Partial avulsion ( ‫) تمزق وتحطم اجزاء من العضو‬ 4. If major injury :
Splenectomy
Complete avulsion
5. Post operation :
Long term prophylactic antibiotic

93 Intestinal obstruction
Cause of
Define obstruction Complication
Presentation
Its arrest of 1. Something in lumen : feces , FB,
downward 1. Electrolyte disturbance due to
Gallstone
propulsion of vomiting ( can lead to death )
2. Something in wall : stricture , tumor
intestinal content 2. Strangulation ( lead to death ) 4 cardinal feature :
3. Something outside wall : adhesion ,
3. Hypovolemic shock ( lead to
volvulous
MOF which can end in death )  Pain
Classification  Vomiting
 Distension
 Constipation
According to pathological nature :
 Simple obstruction : not interfere with blood

supply
 Strangulated obstruction : interfere with
blood supply investigations Management
According to level of obstruction :
 High small bowel obstruction 1. Plain x ray : 1. General measure :

 Low small bowel obstruction Erect and supine : this  Nothing by mouth
 Large bowel obstruction usually confirm  NG tube
diagnosis  Catheter , two wide bore
According to onset of obstruction : 2. CT scan : detect the cause cannula
of obstruction  Correction of fluid loss by NS
 Acute obstruction
other like barium enema 2. After supporting patient health :
 Chronic obstruction ( ca colon )
3. Investigation for  Surgery to relive obstruction
 Acute on top of chronic
complication :
According to motility :  RFT
 Serum electrolyte
 Dynamic obstruction
 Adynamic obstruction
94 Intussusception
Define c/p
investigation
Symptoms :  Plain abdominal x ray : erect and supine position

Its invagination of
 Barium enema ( claw sign )
intestinal segment  Pain : the child cry and scream  Serum electrolyte
into lumen of  Vomiting : projectile
adjacent segment
 Bleeding per rectum
It can be classified
( any child with pain + blood stained
into :
mucos in stool or bleeding its
 Primary : in intussusception until proven
infant otherwise ) Mx
 Secondary : in
Sign :
adult
 Feature of dehydration
 Distension ( late presentation ) General measure :
 Mass may be felt
 NG tube , two wide bore cannula
 Catheter
 Replacement of fluid loss
frequent monitoring by chart especially pulse and blood pressure
Site Definitive management :
 Hydrostatic reduction ( using enema ) , 50 % success rate

The most common site is ileocecal  Operation by surgery if hydrostatic reduction failed
This mean ileum invaginate into lumen of

cecum
95 Meckel diverticulum
Define Presentation
Investigation
Majority asymptomatic and remain

Persistent ( asymptomatic 1. Barium meal follow through
unobliterated ) 2. TC 99 ( tecnitium 99 )
proximal portion 2 % symptomatic , may present as : 3. Laparoscopy confirm diagnosis
of vitello 4. X ray for complication
1. Intestinal obstruction
intestinal duct
2. Bleeding from rectum ( marron
Its antimesentric color )
3. Peptic ulcer at site of
diverticulum
Mx
4. Littre hernia ( hernia of
diverticulum )
5. Peroforation
6. Diverticulitits 1. Asymptomatic :
Leave alone without intervention
Indication of surgery in asymptomatic meckle :

Incidence
1. Very narrow
2. Length is very long
3. Child below 2 years and diverticulum discovered
Role of 2
2. Symptomatic or complicated :
2 % of people has the condition
Resection of short segment of ileum and closure of defect then end to
2 % become symptomatic end anastomosis between two remain segment
2 feet ( 60 cm ) from ileocecal junction
2 inch in length
2 times more common in male

96 Surgical
anatomy of anal
Notes Blood supply Venous

drainage Nerve supply
Its 4 cm in length
Superior rectal artery which is
Dentate line : Superior rectal vein drain into Above dentate line :
branch of inferior mesenteric
inferior mesenteric vein which
artery
Divide anal canal into drain into portal system Its involuntary ( smooth muscle ) ,
upper and lower part Middle rectal artery which is supplied by sympathetic and
Middle rectal vein which drain parasympathetic
branch of internal iliac artery
Each of this two part into internal iliac vein
made by dentate line has Inferior rectal artery which is Below dentate line :
different blood supply Inferior rectal vein
branch of internal pudendal
Voluntary ( striated muscle ) has both
and nerve and lymph
sensory and motor innervation came
and venous drainage
from inferior rectal nerve
Below dentate line there
is no mucosa of
morgagni
Dentate line alos called

pectineal line
97 Hemorrhoid
Define Etiology
C/P Investigation
Dialted tortous vein of Primary pile : Can present by one or

hemorrhoid plexus of combination of following : Pile usually diagnosed clinically
vein in anal region  Weakness in tissue
 By history and examination
 Pelvic conjestion Bleeding per rectum (
Name in Arabic :  Prolong standing bright red color )
on feet cause  Prolapse
‫البواسير‬
pressure lead to  Pruritus
Classification : pile  Discharge
 Pain ( pile is usually Mx
 Internal pile ‫الوقوف لمدة طويلت على القدم‬
painless unless
 External pile Secondary pile : complicated )
 Interio- Conservative :
external pile  Ca colon
portal  Diet modification ( eat more fiber , fluid )
hypertension  Medical : sitzth bath , analgesia for pain if
present
Non surgical :
 Banding
Grade of
hemorrhoid  Cryotherapy
 Laser therapy
Grade 1 : bleed , no prolapse Surgery ( type of operation )
Grade 2 : prolapse on defecation , then return  Open hemorrhoidectomy

spontaneously  Closed hemorrhoidectomy
 Stapled hemrohoidectomy
Grade 3 : prolapse on defecation , return
manually
Grade 4 : permanent prolapse

98 PNS
Define Epidemiology
C/ P DDx
Its condition in which Common in male 20 – 30  Pain in area involved  Perianal abscess
there is penetration of year  Discharge :  Anal fistula
hair into serosangiunous or
subceotaneus tissue Common in hairy men
purulent
through skin ‫الذين لديهم شعز كثيز في هذه‬  Tender swelling just
‫المناطق‬ above coccyx
 Nidus mean hole
 Abscess complicated
 Pilo mean hair Recurrence is common
 Sinus mean
openin to skin Mx
which its other
side is blind
Name in Arabic : Pilonidal sinus :

‫ناسور عصعصي‬ In acute phase
 Clean the track

 Remove hair
Site  Frequent washing
Surgery is definitive treatment : ( under GA )
 In jack knife position , remove all sinus track , unhealthy granulation

Sacral region between buttock is the commonest site tissue , hair
 Then do primary closure
Other site :
Pilonidal abscess : ( under GA )
 Axilla
 Umbilicus  admesion to hospital , rest antipyritc , analgesic , antibiotic
 Interdigit  Drainage of abscess
‫‪99‬‬ ‫‪Mind Maps‬‬
‫‪Special surgery‬‬
‫الجراحة التخصصٌة‬
‫‪Acute ischemia‬‬ ‫‪100‬‬
‫‪Management of ischemia‬‬ ‫‪101‬‬
‫‪Varicose vein‬‬ ‫‪102‬‬
‫‪Pneumothorax‬‬ ‫‪103‬‬
‫‪Complications of fracture‬‬ ‫‪104‬‬
‫‪Treatment of fracture‬‬ ‫‪105‬‬
‫‪Colles fracture‬‬ ‫‪106‬‬
‫‪How to manage open fracture‬‬ ‫‪107‬‬
‫‪Difference between EDH and SDH‬‬ ‫‪108‬‬
‫‪Burn‬‬ ‫‪109‬‬
‫‪Cleft lip and cleft palate‬‬ ‫‪110‬‬
‫‪Urinary stone‬‬ ‫‪111‬‬
‫الجراحة‬
‫التخصصٌة هً التً تشمل جراحة الكسور والمجاري البولٌة وجراحة االوعٌة الدموٌة والقلب‬
‫وجراحة الجمجمة والدماغ والفقرات والجراحة التجمٌلٌة والحروق‬
‫فً هذا الفصل قمتُ بتلخٌص بعض المواضٌع المهمة والشائعة فً الجراحة التخصصٌة والتً‬
‫قد ٌراها الطالب فً المستشفى و ٌُسأل عنها فً االمتحان ‪.......‬‬
100 Acute ischemia
Define c/p
6P:
Lack of blood  Gangrene For diagnosis :
flow due to  Pain  Chronic ischemia
 Paralysis  Duppler
sudden  Volkman ischemic
 Parasthesia  Duplex
occlusion of a contracture
 Pulselessness  Arteriography
previously patent
 Pallor To detect the source of emboli :
artery with no
 Progressive coldness of
time for limb ( poikilothermia )  ECG and echo
collaterals to
open
Mx
Etiology  Resuscitation and monitoring

 Analgesia for pain
1. Embolism If emboli :
2. Thrombosis
 Embolectomy using fogerty catheter
3. Pressure from outside :
If thrombous : option according to condition and time :
Like tourniquet , tumor
 Thrombolytic
 Revascularization surgery
 Ambutation
101
Chronic ischemic limb
Medical Surgical
1- General : encourage to walk ,

Intermittent
exercise , stop smocking Rest pain Gangrene
claudication
2- Diet : modification of diet for
obese and high lipid level
patient
3- Drugs :
treat HT , DM Transluminal Ambutaion may
angioplasty be needed
Drugs for treatment of
with stent
hyperlipidemia
Antiplatelet is also important

like aspirin Aortoiliac Femoropopliteal
occlusion occlusion
Aortofemoral bypass surgery Femoropopliteal bypass surgery
The material used is Dacron The material used is spahneous vein

graft
102 Varicose vein
Define c/p
 Cosmotic disfigurement
Dilated tortuous , is main complain Vein complication : Its diagnosed clinically
elongated otherwise there is mild
superficial vein of problem  Hemorrhage Investiogation done to detect the site
lower limb  Edema of limb of incompetence of vein :
 Aching and discomfort
 Mild swelling of leg  Superficial
It could be primary  Duppler U/S
thrombophlebitis
or secondary  Duplex
Skin complication :  Venography
 Ulceration
 Skin pigmentation
Etiology
and dermatitis
Primary varicose vein : (85 % )

Mx
There is no apparent cause , congenitial
valvular incompetence
Secondary : ( 15 % ) Reassurance
Advice to elevation of lower limb to prevent congestion

 DVT
 Pregnancy Definitive treatment :
 Pelvic tumor aneurism
 Burger disease 1. Injection sclerotherapy
 Av fistula 2. Surgery :
 Trendulberg operation
 Stripper of varicose vein
103 Pneumothorax
Define c/p
Investigation
 Presence of air Symptoms : Chest x ray :

within the
pleural space  Hx of trauma  jet black opacity on affected side
 The cause  Acute chest pain  Lung collapse
could be due  SOB  Tracheal deviation
to trauma or  Cyanosis
Arterial blood gasses for complication
iatrogenic or
Sign :
sponteaneuos
rupture of Inspection : ecchymosis , bruise , decrease
bullae chest movement of affected side
 Its emergency
condition Palpation : tracheal deviation
Mx
Auscultation : significant decrease in air
entry
1. ABCD
Classification 2. Resuscitation and monitoring
3. Definitive treatment :
Insertion of chest tube
According to etiology :
Traumatic , iatrogenic , spontaneous
According to pathology :
 Closed pneumothorax
 Open pneumothorax
 Tension pneumothorax ( top emergency )
104 Complication of fracture
General Local
1. Shock 1. Skin : injury , sore

2. Fat embolism 2. Muscle and tendon : myositits ossificans
3. Tetanus 3. Blood vessel : acute ischemia , compartmental
4. DVT and PE syndrome . volksman ischemic contracture ‘
5. Respiratory dysfunction 4. Nerve : injury to nerve
6. Crush syndrome ( ‫) دبابة‬ 5. Viscera : like bladder injury in pelvic fracture or
7. Infection like chest lung injury in rip fracture
infection , UTI , gas
6. Bones : non union , malunion , delay union ,
gangrene
shortening , avascular necrosis
7. Joint : hemoarthrosis , ligament injury
Early general :
Early local complication :
 Shock
 Fat embolism  Compartmental syndrome
 Respiratory dysfunction  Acute ischemia
 Hemoarthrosis
Late general :  Visceral injury ….etc
 Chest infection Late local complication :

 UTI
 DVT and Pulmonary embolism  Delay union , malunion , non union
 Crush syndrome  Myositits ossificans
105 Treatment of
fracture
For fracture
Define
Primary survey
Resuscitation
Secondary survey and Rehabilitation

Immobilization
monitoring
Method of immobilization : ‫عالج طبيعي‬

Reduction
1. POP Used to restore function
2. Traction of bone
Closed reduction : 3. External fixation
Very important step in
4. Internal fixation
 Done under local or GA management of fracture
 Used for most common fracture Type of internal fixation :
 Better than open reduction because there is no
need for making incision and no need to insertion  Screw
of different material inside body  Screw and plate
 Done by gentle manipulation or by traction  Intramedullary nail
 K wire
Open reduction :
 Done under GA
 Used if closed reduction failed
 Usually require internal fixation
106 Colles fracture
Site Displacement
c/p Investigation Complication
Distal end of In few cases there is

radius and displacement Symptoms : X ray : 1. Non union
usually 2 cm 2. Malunion
Pain . swelling AP view : lateral shift 3. Sublaxation of
above articular
of bone distal radioulnar
cartilage Inability to move the affected
Lateral view : distal joint
Incidence : area and joint
fragment shift 4. Rupture of
Sign : anterior extensor policies
Most common
longus tendon
type of fracture
Inspection : dinner fork 5. Suddeck
in old age above
deformity dystrophy
40 year indicate
6. Compression on
generalized Palpation : radial styloid is no
median nerve and
osteoporosis and longer lower than ulna
radial artery
Movement :
 Loss of active
movement
 Painful passive Mx
movement
Etiology
NVB examination :
Undisplaced : closed reduction + POP for 3
Fall on outstretched hand Allen test for radial artery week
Medial nerve injury lead to Displaced : CR+POP for 3-4 month
ape hand and sensory loss
over area supplied by median Indication of fixation :
nerve
 Young unstable pt
 Comminuted fracture
107
How to manage open wound fracture
1. First aid : ABCD

2. Antibiotic intravenously as soon as possible
3. Wound debridement and irrigation
) ‫( تنظيف وتعقيم الجرح‬
4. Leave the wound open
5. Antitetanus
6. External fixation if indicated
7. Follow up and monitoring
8. Closure of wound later
108
Diffrence EDH SDH
Etiology  Usually mild trauma  Usually require sever trauma

 Injury to middle menegeal  Damage to large cortical vein as it
artery crosses the subdural space
Clinical picture  Usually there is mild brain  Usually sever brain damage
damage  No lucid interval
 Lucid interval may present  Hematoma commonly bilateral
 The hematoma usually
unilateral
Investigation CT : biconvex CT : cresentric ( concavoconvex )
Treatment Early surgery is successful The patient has serious brain damage
with edema in addition to hematoma , so
surgery is difficult and not always
successful
Prognosis Better prognosis than SDH Worse prognosis

Mortality rate is 50 %
109
Burn
Indication of admission to Role of 9 Parkland formula

hospital
1. 2nd degree burn > 10 % in pt

< 10 years or older than 50 Its formula used to replace fluid in patient
year with burn
2. 2nd or 3rd degree burn > 20 %
in other age group 4 * % of burn * body wt in kg
3. 3rd degree burn more than 5
%
4. Chemical burn First 24 H : ( NACL or ringer )
5. Electrical burn
1st 8 h give 2 / 4 of total amount
6. Inhalation injury
calculated
7. Burn of special area like :
 Perineum 2nd 8 hour give 1 / 4
 Hand ear eye , face , foot
8. Circumferential burn 3rd 8 hour give last 1 /4
9. Pre-existing medical disease
Second 24 h : ( albumin + glucose saline )
like DM HTN
10. Burn together with trauma
like burn + fracture
110 Cleft lip and cleft palate

Chief
Incidence complaint Complication Diagnosis
Cosmotic deformity
Isolated cleft lip Psychological for the After birth diagnosed clinically
15 % mother
During pregnancy :
Isolated cleft Feeding difficulty
palate 40 % All types of cleft can be detected by U/S after 18
Articulation problem week except isolated cleft palate because fetus
Cleft lip + cleft mouth is usually closed so we cant see the cleft
palate 45 % Complication after surgery : isolated cleft palate
Poor surgery which need
secondary reconstruction
Classification
Hearing problem that is
why we need to check the
Cleft lip : hearing before 12 month of
age Timing of
1- Unilateral : surgery
 Complete unilateral
 Incomplete unilateral
Cleft lip : role of 10
2- Bilateral :
 Complete bilateral  at 10 week ( 3 – 6 month ) if delayed may cause articulation problem
 Incomplete bilateral  10 kg of weight
Cleft palate :  10 g/dl of hemoglobin
Isolated cleft palate : at 6 – 18 month

 Incomplete : only soft palate
 Complete : soft and hard palate Cleft lip + cleft palate :
 Complete bilateral
 Cleft uvula ( bifid uvula )  Do surgery for cleft lip at 3 – 6 month alone
 Then do another surgery for cleft palate
Do not do both at same time

111 Urinary stone
Epidemiology c/p
Its common and Asymptomatic in majority

present in 20 %  Hematuria 1. GUE : RBC detected in 90 % of
of population Symptomatic :  Infection cases
 Obstruction 2. Plain x ray
Bladder stone is 8  Pain 3. Us especially for bladder and
time more  Hematuria renal
common in 4. CT scan is the investigation of
Other symptoms like Frequanecy of
female choice
urination
5. IVU
Types of stone : 6. Ascending pylography
Difficult in micturition
7. Investigation for cause : like
 Oxalate
according to where is ther stone in serum ca for hyperparathyroid
 Cysteine
kidney or ureter or bladder or
 Phosphat
urethra
e
 Urate
Mx
Etiology
During acute attack :
Predisposing factor : Admission to hospital ,Analgesia ,Antibiotic
 Metabolic error like gout and Definitive treatment :

hyperparathyroid
 Infection :lead to stone through changing the  Conservative mx and wait for stone to pass by itself
pH  Instrumental removal of stone
 Other like diet and hot climate  Surgery to remove the stone
112
Chapter Four
s s
Important urgical kills and miscellaneous topics in surgery

Chest Tube 113
NG Tube 116
Colostomy 118
Catheter 120
Cannula 122
Suture 123
Blood transfusion 126
IV fluid 127
Drugs ( antibiotic , oral hypoglycemic agent ) 133

Chest tube
113
Define Indication
Complication
When to
remove
1. Pneumothorax
Its tube 2. Hemothorax 1. Bleeding :
inserted into 3. Chylothorax intercostal artery
chest to drain 1- Clinically :
4. Large plural 2. Injury to lung (
abnormal fluid There is no more discharge
effusion perforation 0
collection No more air bubble
5. Empyema 3. Local infection
Patient clinically improved
and empyema
Its connected 2- X ray :
4. Blockage of tube
to underwater Lung expand
5. Failure of
sealo to 3- If tube not functioning :
insertion
prevent return The tube is blocked and its not draining when it
of drainage should be draining
back into body
Site
Its inserted into 2nd intercostal space in midaxillary line
After insertion its very important to ask patient to cough

to see water elevated in underwater seal or no ?
Boundaries of triangle of safety :
 Anteriorly by posterior border of pectoralis major

 Posteriorly by anterior border of latissmus dorsi
 Inferiorly by 5th intercostal space
 Apex is at base of axilla
114
Q / how to know if the chest tube is not functioning ?

 There is no air bubble( ask patient to cough )
 There is no oscillatory movement of fluid in the underwater seal
Q / in follow up of patient with chest tube , you should each day change the container , so how you do that , what
are step ?
1. The chest tube should be below level of patient , if its above this lead to return of the contain to the lung and may lead to death
2. Its better to give prophylactic antibiotic !
3. Look daily to the bag and tube its self for :
Functioning or not
Amount of discharge
color of discharge
4. Daily change the bag : how ?
 Clump the tube by artery forcep and gauze
 Remove the bag from below
 Clean and connect it again
 Open the clump
 Ask patient to breath and cough to see if the tube functioning
Q / what are step of insertion of chest tube ?
Procedure :
Never do it in front of relative , check the drain and underwater seal is functioning ( appearance of gas bubble in the underwater seal is sign of functioning )
1- Locate the area ( fifth intercostal space midaxillary line )

2- Clean area with antiseptic ( iodine for example )
3- Local anesthesia
4- Make incision in the area mentioned separating the skin , subcutaneous tissue and intercostal muscle
5- Insert finger to confirm that you in pleura
6- Insert the drain
115
7- Suture the skin
Q / after inserting chest tube , you do suturing , what is the name of this suturing , what is its benefit ?
Purse string suture
1- This allow good fixation of drain and make it difficult to slip

2- Allow easy closure when the drain is removed
Q / how to remove chest tube ?

1- Clump the tube for 24 hour
2- Takes x ray and see the finding
3- Look to the condition of the patient in this period for sign of re -accumulation
4- Ask the patient to take deep breath and hold it then you remove the drain and suture close easily by the purse string suture you may during insertion
116 NG tube
Note Indications
Complications
Its tube inserted 1. Diagnostic indication:

from nose down to  Aspiration of gastric content for studies like in case
stomach after vagotomy , this is called Hollander test 1. Complications during insertion :
 To k now degree of bleeding in stomach and the  Injury to URT lead to bleeding
Types of NG tube :
response to treatment  Insertion of tube into trachea instead of stomach
1. Ryle 2. Therapeutic indications : this lead to aspirations pneumonia
2. Levin tube  For feeding  Vomiting
3. Polyethelen  Gastric decompression  Esophageal perforation
e  In intestinal obstruction to relieve distention  Epistaxis
 Post operation of bowel surgery to avoid gastric 2. Complications after insertion :
dilatation  Obstruction of tube
 Water and electrolyte imbalance
 Damage to ,mucosa of organ if stay for long time
 Dryness of mouth ( because feeding by tube not
mouth )
 Increase risk of GERD
After insertion , how you confirm

its in the stomach ??
1. Aspiration : gastric juice aspirated this

confirm the tube in the stomach
2. Take x ray and see the tube
3. Inject few cc of air and auscultate the
epigasdtric region for gurgling sound
117
118 Colostomy
Define Indication
Creation of an Temporary :
opening and Complication
diverting colon 1. Ca colon to remove obstruction
content ( feces ) until patient become fit for surgery
outside body 2. Trauma : bullet injury to rectum
1. Prolapse of mucosa of intestine
instead of rectum 3. After operation of fistula of anus till
through opening of colostomy
and anal canal wound heal
2. Bleeding from edge
4. Imperforated anus till operation
3. Gangrene at colostomy site
Permanent colostomy : 4. Peritonitis
5. Stenosis of colostomy orifices
Types 1. Excision of rectum 6. Complication after closure :
2. Crush injury to pelvis  Adhesion and intestinal
3. Toxic mega colon obstruction
 Failure of closure
According to time :
 Incisional hernia
1. Temporary colostomy
2. Permanent colostomy
According to site of insertion :
1. Ileostomy
2. Transverse colon colostomy
3. Sigmoidostomy
4. Colostomy of cecum
119
120 Catheter
Define Indication
Contraindication
Complications
Diagnostic indication :
Its type of closed 1. Urethral in jury
drain 1. Monitor urine output 2. Acute prostatitis 1. Traumatic insertion
2. Take urine for GUE 3. Prostatic abscess which can lead to
Type of catheter : 3. Urethrogram and cystorgram : 4. History of failure of insertion injury of urethra ,
of catheter bleeding
1. Foley In this investigation you insert catheter 2. UTI
catheter 5. UTI
then you inject dye and take imagine 3. Failure of deflation
2. Wing when want to remove
catheter Therapeutic indication :
it
3. Jj catheter 4. Late complication :
1. Urinary retention
 Size of catheter induce stone
2. Irrigation of bladder( by 3 way
measured by formation
valve )
French
3. Relieve obstruction by clot
 Each size has
4. Intravesical chemotherapy ( for
different color
bladder Ca )
Types of foley
catheter
1. According to material made of : silicon , rub ber , mixed silicon and

rubber type
2. According to valve :
 2 way vlave : one for drainage and other for inflation of balloon
 3 way valve : one for drainage , one for inflation of balloon and way
for irrigation
121
Foley catheter
122 Cannula
Indications Size If you cant find vein

what is the cause ??
1- Diagnostic : Cannula size by gauge 1- Shock

 Taking blood sample 2- Lymphedema
Each size has different color : 3- Burn
 Injecting dye for
imaging 14 gauge = ‫برتقالي‬ 4- In neonate
2- Therapeutic : 5- Dehydrated person
 Administration of 16 gauge = ‫رمادي‬
What is alternative in these
fluid , blood ,
18 G = ‫اخضر‬ situation ??
medication ,
chemotherapy 20G = ‫وردي‬  In foot
 In neck subclavian vein
22 G = ‫ازرق‬
Complication
24 G = ‫اصفر‬
Where to put
26 G = ‫بنفسجي‬
cannula ??
1- Pain
2- Bleeding
 Visible , large vein 3- Thrombophlebitis
 Non dominant hand of patient 4- Nerve , tendon , muscle
damage
 Away from joint
5- Obstrcution by clot
 Not at site of previous cannula
 Area where you can support cannula well
 Area which patient not move it a lot
123 suture
Type of suture :
Commonly used suture
Prolene Synthetic Monofilament Non-absorbable

Nilon Synthetic Monofilament Non-absorbable
Vicryl Synthetic Polyfilament Absorbable
catgut Natural Polyfilament Absorbable
Size :
Vary from 0-10 according to use
Time of removal of suture :
Suture Time of removal after suture Size of suture

Scalp After 7 days 2.0 , 3.0 non absorbable
Trunk After 10 days 3.0 non absorbable
Limps After 10 days 4.0 non absorbable
Hand After10 days 5.0 non absorbable
Lip , tongue , mouth 3-7 days 6.0 absorbable like vicryl
Type of needle used :

124
Example of suture in package :
Method of suturing :
1. Simple interrupted
2. Simple continuos
3. Vertical matress
4. Horizontal matress
5. Subcuticlar
6. Purse string suture
125
126 Blood transfusion
Preparation Types of
Complication
blood
Screening the blood of donor 1. Red cell  Whole blood

for : HIV , HBV,HCV ,syphilis incompatibitity  Packed red cell
2. Transmission of  Fresh frozen plasma
The patient : infection like  Cryoprecipitate
HBV.HIV  Platelet
 Blood group
3. Fever and allergy  Autologous blood :
 RH cross matching
4. Anaphylactic
reaction ‫ ويوضع ىزا الذم في الخزاى‬, ‫الوريض اسبوع قبل العولية يعطي دم‬
5. Direct death
‫ فسيتن تزويذه بذهو ىو الزي حضره قبل اسبوعيي‬, ‫اثناء العولية ارا احتاج الوريض لنقل الذم‬
Indication
Blood loss like in case of :
 Trauma
 GIT bleeding
127 IV fluid
Principle :
60 % of total body weight is fluid
This fluid is distributed in compartment :
Intracellular compartment and extracellular compartment
40 % of the 60 % of total body weight is in intracellular
20 % of the 60 % is extracellular
From this 20 % :
 15 % are interstitial ( between tissue )

 5 % intravascular ( inside blood vessel )
Body fluid
60 %
40 % intracellular 20 % extracellular ( outside cell ) :
( mean inside cells )  15 % interstitial

 5 % intravascular
Example :
75 kg male , composed of 45 L fluid ( 60 % of body wt )
 30 L intracellular
 12 L interstitial
128
 3 L intravascular
Normal daily fluid loss :
Normal human replace this normal daily loss by eating and drinking
Post operation , or in repeated vomiting , he cant replace the fluid loss so we give him IV fluid
according to amount of blood loss
Normal daily loss is about 2700 ml
Types of fluid
1- Normal saline :
Name in Arabic : ‫محلول ملح‬
Composition : 9 % NACL
Uses :
imbalance electrolyte ‫ تعوٌض النقص فى السوائل فً الجسم‬-１

.‫ تخفٌف االدوٌة والمضادات الحٌوٌة التى تحقن بالورٌد‬-２
‫ وكذلك تنظٌف الحروق‬، ‫ سائل معقم لغسٌل الجروح بعد العملٌات‬-３
‫ ٌستعمل لرفع الضغط الهابط وحاالت النزف الشدٌد و حاالت التقًء الشدٌد‬-４
N.B :
You should avoid using normal saline in patient with hypertension

‫‪129‬‬
‫‪2- Dextrose 5%‬‬

‫كلوكوز ( محلول سكري ) ‪Name in Arabic :‬‬
‫‪Composition : 5 % glucose or 10 % glucose‬‬
‫‪Uses :‬‬
‫عالج حاالت النقص الشدٌد فً السكر ‪ hypoglycemia‬وال سٌما فً الحاالت التً تأتً على شكل غٌبوبة‬ ‫‪-1‬‬
‫هبوط الضغط الشدٌد واالعٌاء‬ ‫‪-2‬‬
‫بعد العلمٌات لتعوٌض المرٌض عن نقص السوائل فً الجسم‬ ‫‪-3‬‬
‫تخفٌف بعض االدوٌة والمضادات الحٌوٌة مثل البوتساٌوم والهٌدروكورتٌزون‬ ‫‪-4‬‬
‫‪3- Ringer solution :‬‬
‫محلول رنجر ‪Name in Arabic :‬‬
‫‪Composition :‬‬
‫هو محلول متعادل ‪ٌ solution isotonic‬حتوى على‬

‫صودٌوم كلورٌد ‪ ٥٫٦‬جم ‪NaCl g 5.6‬‬
‫بوتاسٌوم كلورٌد ‪ ٢٤٠‬جم ‪KCl g 42.0‬‬
‫كالسٌوم كلورٌد ‪ ٢٫٠٦‬جم ‪CaCl2 g 25.0‬‬
‫‪ ١‬مول صودٌوم بٌكربونات ‪mole 1 and‬‬
‫‪of sodium bicarbonate‬‬
‫وٌذاب كل هذا الخلٌط فى ‪ ١‬لتر من الماء المقطر‬
‫‪uses :‬‬
‫‪1-‬‬ ‫‪hypovolemic shock‬‬

‫‪2-‬‬ ‫‪burn‬‬
‫‪3-‬‬ ‫‪sever vomiting‬‬
‫‪4-‬‬ ‫‪after surgery‬‬
‫‪4- ringer lactate :‬‬

‫‪composition :‬‬
‫‪130 mEq of sodium ion = 130 mmol/L‬‬

‫‪109 mEq of chloride ion = 109 mmol/L‬‬
‫‪28 mEq of lactate = 28 mmol/L‬‬
130
4 mEq of potassium ion = 4 mmol/L

3 mEq of calcium ion = 1.5 mmol/L
Uses :
 Replace fluid loss like in case of sever vomiting , trauma , bleeding

 In renal failure to encourage the body to urinate
5- Glucose saline : used for all cases of ER
6- Manitol : mainly in head trauma
Q / How to calculate amount of fluid required in post operative patient ??
 First 10 kg give 100 ml /kg = 1000 ml

 Second 10 kg give 50 ml /kg = 500 ml
 Reminder kg give 20 ml /kg
If there is extra loss you should add it for example extra loss from NG tube , colostomy ,
drain , fever
Example one :
23 year old male 70 kg , appendicectomy done for him today morning , you want to give
him fluid , how to give fluid and which type of fluid you give him knowing that he has no
extra loss
Answer :
How much to give :
First 10 kg 1000 ml
Second 10 kg 500 ml
The reminder 50 kg of this patient give 20 ml/kg so this equal 1000 ml
1000 + 500 + 1000 = 2500 cc per day

131
Which type of fluid to give :
Day one glucose water
Day two : glucose water + normal saline
Day three if patient not discharged yet : add ringer lactate to correct the potassium
How to give the fluid :
Day one :
Give 2000 or 1500 ml dextrose instead of 2500 he require , why ?
Because of body response to trauma ( read chapter one of baily and love book )
Day 2 :
1000 ml of the 2500 ml give it normal saline
1500 ml of 2500 ml give it in form of glucose water
Example 2 :
30 year old male weight 70 kg had car accident and open laparotomy done for him and
NG tube + drain used for him
How to give fluid in this patient if you knew that NG tube loss is 1000 ml and that of
drain from abdomen is 500 ml ?
70 Kg daily requirement is 2500 ml ( see example one )
Extra loss :
NG tube 1000
Drain 500
So we give this patient 2500 + 1000 + 500 = 3500 ml
N.B : for extra loss we give normal saline
Day one :
Type of fluid : glucose water + NACL ( for extra loss )

132
How to give :
2000 ml glucose water
1500 ml NACL
Day 2 :
1500 dextrose
1000 NACL
If there is extra loss add nacl if there is no extra loss no need for another NACL
Day three :
Same as day 2 + replace extra loss if present
+ give potassium
1 ml /kg this equal 70 mmol of potassium in this patient , give it in the iv fluid not
directly into cannula
133 Antibiotic group
Quinolone Beta lactam Tetracycline Macrolide

Sulfonamide Aminoglycoside
Fluroquinolones
 Sufadiazine Norfluxacin Peniciline Doxycycline Erythromycin Streptomycin

 Trimethoprim
Ciprofloxacin Ampicillin Azithromycin Neomycin
 Sulfamethoxazole
Ofluxacine Amoxicillin Clindamycin Gentamycin
Levofloxacin Cephalosporin Clarithromycin kanamycin
Generation of
cephalosporin
1st generation : cefazoline , cephalexin
2nd generation : cefprole , cefoxitine
3rd generation : cefixime , cefotaxime , ceftriaxone
4th generation : cefepime

134 Oral hypoglycemic agent
Sulphonylureas Non – Alpha glucoside

sulphonylurease inhibitor
Sulphonyl is receptor found on This group bind to receptor Inhibit the enzyme in small intestine wall that
pancrease cell other than that bind by break down the oligo and disaccharide into mono
sulphonylurease saccharide
Drug belong to sulphonylureas
group act by causing exocytosis So this group shouldnot be give ‫يقلل تحْيل العام الى سكز لذلك يستعول كوساعد للسكز ّليس عالج‬
of this receptor leading to together with sulphonylurease ‫اساسي‬
secretion of insulin group
‫ُذا الدّاء هشِْر باسن شعبي ُّْ ( هساعد سكز ) في الصيدليات‬
Example of this group : Advantage : ‫ّبيي الوزضى‬
 Glibenclamide Less risk of hypoglycemia Example :

 Gliclazide
Less risk of Wt gain Meglitide
Side effect :
Example of this group :
1. Failure rate 25 % initially
Meglitinide
then become 60 % after 6
year of using this group
2. Induce continuous
secrtion of insulin this Intestine lipase
increase risk of Biguanide inhibitor
hypoglycemia
3. WT gain
Orlistate
Decrease liver glucose production and increase glucose uptake by muscle
‫دّاء هشِْر الًَ يستعول ايضا في تقليل‬
Side effect : ‫الْسى‬
WT loss ‫ُّْ ليس عالج اساسي ّحدٍ لعالج السكز‬
Lactic acidosis ( contraindicated in renal impairment ‫يسٌعول في هزضى السكز الذيي لديِن‬
‫ّسى سائد ايضا‬
Example : metformin
135
Chapter Five
Important Differential Diagnosis

RIF pain 137
RIF mass 137
Left iliac fossa mass 137
Epigastric swelling 138
Suprapubic swelling 138
Right hypochondrial pain 139
Right hypochondrial mass 139
Epigastric pain 139
Hematuria 140
Urinary retention 140

136
Red color urine 140
Hepatomegaly 141
Splenomegaly 141
Kidney enlargement 141
Bleeding per rectum 142
Painful anus 142
Mass per rectum 142

137
DDX
RIF pain
RIF mass Left iliac fossa
( other than appendicitis )
(
In child : 1. Appendicular mass 1. Diverticular
2. Appendicular abscess 2. CA colon
 Gastroenteritis 3. CA colon 3. Crohns disease
 Mesentirc adenitis 4. Psoas abscess 4. Iliac lymphadenopathy
 Meckle diverticulitis 5. Iliac lymphadenopathy 5. Kidney transplant
 Intussusception 6. Ectopic kidney 6. Ectopic kidney
 Lobar pneumonia 7. Transplanted kidney 7. Psoas abscess
8. Ovarian tumor
In adult :
9. Fibroid ( in female )
 Regional entiritis 10. Hernia ( like incisional hernia )
 Uretric colic
 Pancreatitis
 Perforated PU
Adult female :
 Ectopic pregnancy
 PID , pyelonephritis
 Mittelschmerz
Old age :
 Intestinal obstruction
 Ca colon
 Mesentirc infarction
138
ddx
Epigastric swelling Suprapubic swelling
Pancreas : Uterus :
 Pancreatic pseudocyst  Fibroid , pregnancy , malignancy
Liver : Ovary :
 CA  Ovarian cyst , ovarian tumor

 Hydatid cyst
Bladder :
Stomach :
 Urinary retention
 CA stomach  Tumor of bladder
 GOO
Sigmoid colon :
Vascular :
 Diverticulitis
 AAA  Sigmoid cancer
 Aortic lymphadenopathy
Skin : hematoma , sebaceous cyst
Skin : hematoma , sebaceous cyst
Subceutaneuos : lipoma
Subceutaneuos : lipoma
Muscle : incisional hernia
Muscle : incisional hernia
139 ddx
Right hypochondrial painn Right hypochondrial mass Epigastric pain
1. Acute cholecystits Liver : hydatid cyst , tumor 1. Acute cholecystits

2. Acute pancreatitis 2. Acute pancreatitis
3. Acute appendicitis GB : 3. Acute appendicitis
4. Perforated peptic ulcer  mucocele of GB 4. Perforated peptic ulcer
5. Acute pyelonephritis 5. Inferior wall MI
 Empyema of GB
6. RT lower lobe pneumonia 6. Ruptured aortic aneurism
 CA GB
7. Complicated hydatid cyst
RT kidney :
 Hydronephrosis
 Renal tumor
 Polycystic kidney
Pancreas:
 Pancreatic pseudocyst
RT suprarenal gland :
 Tumor
Skin : hematoma , sebasceuos cyst
Subcutaneous : lipoma
Muscle : incisonal hernia

140 DDX
Hematuria Urinary retention Red color of urine
Cause in kidney : Acute retention 1. Certain food

2. Certain drug : rifampcin
 Renal stone 1. Mechanical obstruction : 3. Hemoglobinuria
 Pylonephritis  Urethra : stone , blood clot 4. Myoglobinurea
 Renal infarction  Prostate : acute prostatitis , CA 5. Menstruation ( in female )
 Renal injury  Bladder : stone , CA
 RCC , PCKD  Pelvic mass : fibroid
2. Paralytic cause :
Cause In ureter :  Spinal cord injury
 Stone  Surgical denervation of bladder
3. Hysterical cause
In bladder : 4. Reflix retention like after anorectal
surgery
 Stone , trauma
5. Drug like anticholinergic
 TCC
 TB , bilharzia Chronic retention :
Urethra :  Urethra : stricture

 Bladder : CA
 Urethritis
 Prostate : BPH ,CA
 Stone
 Pelvic mass : fibroid
 CA , trauma
In male only :
 Ca prostate
 BPH
 Prostatitis
141 ddx
Hepatomegaly Splenomegaly Kidney
Hepatomegaly without jaundice : Infection : 1. Hydronephrosis

2. Pyonephrosis
 Liver cirrhosis  Bacterial like typhoid , TB 3. Malignancy :
 Lymphoma  Virus like glandular fever  CA of kidney
 Hepatic vein obstruction ( budd  Protozoa like malaria , kala- 4. Solitary cyst of kidney
chiary ) azar 5. Polycystic kidney disease
 Kala azar 6. Hypertrophy of kidney
Cellular proliferation :
Hepatomegaly with jaundice :
 Myloid , lymphoid leukemia
 Infective hepatitis  Pernicious anemia
 Bile duct obstruction for any reasone  Spherocystosis
like gall stone…. etc  TTP
 Cholangitis
Congestion :
 Portal pyemia
 Portal HTN
Other cause :
 Hepatic vein occlusion (
 CA of liver buddchairy )
Infarction and injury of spleen
Collagen disease like felty syndrome in

RA patient
142 DDX
Bleeding per Painful anus Mass per rectum

rectum
Also called hematochezia Pain alone : 1. Hemorrhoid

2. Perianal hematoma
Cause from anal region :  Fissure ( pain after defecation ) 3. Prolapsed rectum
 Proctalgia fugax 4. CA of anal canal
 Hemorrhoid
 Anorectal abscess anorectal abscess
 Anal fissure
5. Prolapsed rectal polyp
 Rectal ca Pain and bleeding :
 Trauma
 Fissure
Cause from intestine :
Pain and lump :
 Intussusception in child
 Perianal hematoma
 Angiodysplasia in old age
 Anorectal abscess
 IBD
 Meckle diverticulum ( mainly in Pain and lump and bleeding :
child )
 CA colon Prolapsed hemorrhoid
Esophageal , stomach cause :  CA of anal canal

 Prolapsed rectal polyp
 Peptic ulcer  Prolapsed rectum
 Esophageal varices
general cause :
 bleeding disorder
 side effect of drug like
anticoagulant
‫‪341‬‬
‫‪Chapter six‬‬
‫‪Several common and important picture with its possible question‬‬
‫امتحان ال ‪OSCE‬‬
‫هو عبارة عن مجموعة محطات ( ‪ ) stations‬فً ٍ‬
‫كل منها ٌوجد اما صورة مع اسئلتها‬
‫او حالة مرٌض امامك وعلٌه مجموعة اسئلة ‪,‬‬
‫كل ‪ station‬لها وقت واحد غالبا ‪ 5-2‬دقائق ثم ٌنتقل الطالب الى ال ‪ station‬الذي ٌلٌه ‪......‬‬
‫فً هذا الفصل محاكاةٌ لهذا االمتحان من خالل صور من المواضٌع الشائعة والتً ٌتوقع مجٌئها فً االمتحان مع‬
‫اسئلتها المحتملة وحتى ال ٌتفاجأ الطالب وٌنصدم اثناء االمتحان بطبٌعة ال ‪ stations‬واسئلتها ‪........‬‬
144
Station 1
1. What procedure used in this patient ?

2. Give 3 indication ?
3. Give one indication for permenant usage of this procedure ?
4. Give 2 complication
145
Station 2
1. What is the procedure ?

3. Give two complication ?
4. When to remove this device ? Mention one point ?
146
Station 3
1. Give 4 differential diagnosis of this ?

2. In which neck triangle this swelling found ? Only give the name of
the triangle ?
3. Give name of one incision used in the neck during operation ?
147
Station 4
1. What is most likely diagnosis ?

2. Mention three possible complication of this condition ?
3. What is the treatment of this condition ?
148
Station 5
1. What is your diagnosis ?

2. Give two other sign you expect to find on examiantion of this
patient ?
3. Give 2 investigation you send this patient for ?
4. Outline the medical management for this patient with the dose of
each drug ?
149
Station 6
1. What is the diagnosis ?

2. Enumerate 3 complication ?
3. Enumerate one emergency complication require urgent operation
?
4. Outline the management of your diagnosis ?
150
Station 7
1. What is your diagnosis ?

2. Give one differential diagnosis ?
3. Mention 2 complication ?
4. Outline the management ?
151
Station 8
1. What is most likely diagnosis ?

2. What name of sign or appearance seen in right picture ?
3. Give 2 complications ?
4. What is the management ?
152
Station 9
1. What is the type of fracture ?

2. What is name of classification used to classify this type of fracture
?
3. How to manage this condition at ER ? Just outline in step
153
Station 10
1. What is name of this condition ?

2. Give two precipitating factor ?
3. Give one most important investigation to send ?
4. Outline the treatment ?
5. What is name of surgical operation used ion treatment ?
154
Station 11
1. What is the name of this congenital anomaly seen in picture ?

2. Can this patient do circumcision before managing the anomaly ?
Why ?
3. what is the time of surgery ?
155
Station 12
1. What is the most important DDX ?

2. Which investigation you send this patient ? Mention 3
3. Outline the treatment ?
156
Station 13

2. Which vein involved in this patient ? Just give the name ?
3. Give 2 complication ?
4. What is the surgical treatment ?
5. What is the treatment for patient not fit for surgery ?
157
Station 14
1. Describe your finding ?

2. How to give fluid to this patient in the first 24 hour ?
3. Enumerate 4 indication of admission to hospital ?
158
Station 15

2. Give 2 other investigation you want to send this patient for ?
3. Outline the management ?
159
Station 16
1.Name of this instrument ?

2.Mention 3 indication ?
3.Give 2 complication ?
160
Station 17
1. What is composition of this fluid ?

3. Give one complication ?
4. Give one contraindication ?
161
Station 18
162
Station 19
163
Station 20
164
Station 21

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‫الكافية‬

Chapter one: history

Anal condition ( PNS , hemorrhoid ) 8

Trauma ( head injury , fracture ) 14

Swellings ( lipoma , ganglion , cyst ) 15

Urology ( hematuria , loin pain ) 16

Acute bacterial mastitis 69

Simple nodular goiter 74

Anatomy of inguinal region 79

Sign of acute appendicitis 83

Management of peptic ulcer 88

Anatomy of anal canal 96

Management of ischemia 101

Complications of fracture 104

Treatment of fracture 105

Colles fracture 106

How to manage open fracture 107

Difference between EDH and SDH 108

Cleft lip and cleft palate 110

Urinary stone 111

Chapter four :Surgical skills

Blood transfusion 126

Drugs ( antibiotic , oral hypoglycemic agent ) 133

Chapter five : Differential diagnosis

RIF mass 137

Left iliac fossa mass 137

Epigastric swelling 138

Suprapubic swelling 138

Right hypochondrial pain 139

Right hypochondrial mass 139

Urinary retention 140

Red color urine 140

Kidney enlargement 141

Bleeding per rectum 142

Painful anus 142

Mass per rectum 142

Chapter six : OSCE pretest

Content of this chapter

Anal condition ( PNS , hemorrhoid ) 8

Trauma ( head injury , fracture ) 14

Swellings ( lipoma , ganglion , cyst ) 15

Urology ( hematuria , loin pain ) 16

History of present illness :

(And mention them here because they are important negative )

History of present illness :

Sex : femoral hernia more common in female

History of present illness :

Drug and allergy :

history of present illness :

Marriage and number of children :

 OCP and nullioarity increase risk of ca

History of present illness :

 Primary thyroitoxicosis ( graves ) occur commonly between 20 – 30 year

Sex : thyroid disease is a disease of female

History of present illness :

GIT : diarrhea is common

History of present illness :

History of present illness :

Left loin pain for 4 days

History of present illness :