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GE]IERAL

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BREASI:
a a

2 g 6
7

IMUMAIOLOGY
I a I

AIUD

BAs!C GENERAT SUROERY

t5
16

I}IYROID:
I

I a

24
a
a

a
I

E]IIDOCRINE SUR,GERY:
t t a

44 45
4G

AR,IERIAL gYgIEM
I
T

SWEttIiIGS AND $AIIVARY GLANDS:

a T

:*g 'Go
. Sturg
nol,is

:*'

vx2

8lom. Sf,Eg

fieftL

VENOUS gYgIEM

btr
rc
T'
712

Gil

Urim

SURGICAL INFECIIONS . SchcmhsudbdhHnrc


.loulcdcoaes . oallfiq. EFfoob, - Ielnrs,

TYMPHATIC SYSTEM

rlt

.lumphe&r

h1 crhnnb . lrrli{l 4in Lgnirgloe rd

.lgnpJm
gut

hCrgltr* '. $rtFJ rib i*otur


gurldoc

T? 75

T'
78

llrrd frfrofus . fr1]3' f.UsloorE* Anrmr Brrt T&

&|

rMkhael '':;: .{ .lir'-:


..4,i"

:. !tt'r:t:::.!

ilRq-Twr5 1^w*Nv'J'R4W

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I I I
T

&tACrffioN
PRECIPITATING factor CLINICAL PICTURE:

DEFINITION: Acule baclerial inflammalion lhal occurs during laclalion ORGANI$M: 8IAPH.

Nipple abrasions, bad hggiene, bad general cond.

Pain Pgrexia
8'rgns

Dull achinr Mild

4
Conlinous

Throbbing Heclic fever

Attacks of remissions&
exacerbalions

l)

Enlargemenl, lenderness 2)NO sions of inflammalion

l)
2)

r) Ederna of skin Sions of inflammalion 2l D(TLARY LN8: Enlarged

lnvesl.

r . . . .

. . . .

fender swelling with gielding cenler

Tender Firrn Mobile

zfr TLC,

of abscess sile & tgpe ^EgR, ^CRP, lf no response wilhin 2 weeks U/g
:

C/8 for the choice of antibiolics

BIOP8Y

Prophglaclic irealrnenl
Al lime of deliveru: lf

lasl 2 monlhs of pregnanou

Massage of Nipple & Panlhinol Fissures are presenl) Painl {issures wilh anli-septics

{-

o o 3. F

{-

ts

Stop Laclalion:

lf infanl>9 monlhs) bg giving PARIODEI lf lnfanl<gmonlhs) Slop lactation fiorn affecled side , FeedinA from the olher

side

Evacuale breasl

* Augmenlin
(lgm/8hrs)

l)

&

analgesics

+ Hol fomenlalions

2) 3) 4)

5l

Oeneral aneslhesia Radial incision nol reaching nipple, areola Deslrog loculi bg {inger COUNTER lNClSlON if in an UNdependenl area Antibiotics & dressino

Signs of inflammalion

P
A FIBROSIS

FlmEPITHILIOSIS

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nupCR[..lE

lJg{q%l

?h l1

hlAts'
Fibrous tissue replaces lhe elastic & fattg lissue ) Obslruclion of ducl: . Unilaleral . Bilaleral . Affecting sector of breast )"Seclor Maslilis" This leads lo cgsl forrnalion: . Srnall ( Micro-cgst) . Large (macro-cgst) . lf Cgsts coalesce)Blue-dorned cast of BTOODGOOD Aberralion of
Norrnal

developrneni & lnvolution of Breast


Sorne consider il as a norrnal varianl

Atgpical epithelial
hgperplasia

. Large cgsl conlain Altered blood 1rej pr . DD: bluish. greenish discharge from Nipple

SUR+-TCr/.r5 6.\W(*NY

IJRqW

?Aqv t +

ChJNrcAt
PIC,TURE,
. AAPMT ./ 4

. Dull aching

/ V

pain; Pre-menestruallg or bg Breast rnovernenl Posl-rneneslruallg or bg breasl supporl

. . . .
a

Cornrnonlg Bilateral

$olid or cgslic
Freelg mobile Diffuse

. '.

Clear Yellow

lf retenlion

Cgsts

greenish

. . . .

Enlarged Elastic

fender
Mobile

#ltrlrilti
I
. For lhe lurnD) friple assessment . For Discharee) Cgtological \. exarninalion & Benzidine tesl , For Cgst ) Aspiration

''FE ffi #
|

S;rrrLE
I

MorcAr
I

SI,FGBY
. Biopsg
. Aspiration of cgsls

' lea, coffee l. VitaminE

. r
r

Recurrent cgsls Sclerosing Adenosis


Cancer

'. . . .

Analgesics Prim Rose Oil Parlodel Danazol Psgchotherapg

. lf cgsts are
Excision

recurrenl ,or Cgsl of Blood-good)

ilP,q=Tw.J6 hloocxr,qr

5,R(#l

Aqe I 5

oF Tl,lE
pAprur.oiA
eAhlAucr,l.{B

Docrltu

CARC'N6TA

qltrclN6tA
INrtT.rnATING

toBu[.An CAtrCJN6TA

PAGEt'S
DISEASE,

tcls
I

INHTTnANNG
r Bilaleral r Multifocal

/ / /

Comedo

Solid
Cfibriforrn

r( $chinous r( Medullarg

/ /

Maslilis Carc.
Colloid Carc.

Indian file appearance

EEhllGt{
. Benrgn . ll's lhe . Macro)single pedunculaled mass, mag ulcerale . Micro) Vascular CT core + hgperplastic epithelium
PT.

oFTl-lEffi
lumor of the breasl aff

ilR{dl-Twr5

E{9ocRlNE

IJRAW

?h I b

DOCTPAPITI.or.IA

2EnITII
Micro
I

ilirfiEIiIat
Fernale. 2O-3;O Uears

I I

[La

tIl

Fernale, 3O-5O Uears

.
NUMBER: Single SIZE: Srnall

ducls
NUMBER: Single SIZE: Largr
dsirrn

EWUtrE
ducls

Female, 3,O-4O Uears with bleeding per

Macro

nipple + Swelling +2 NO

. Bleeding, ) . Swdling)

GFrRcEt E!@E*ur[ace
CONSISTENCY: Firrn CUT SECTION:

o+rrd

SURFACE:
SriuD

urfiace o*rs,

.2

NO

>

Zonal pressure wil! reveal discharge RETENTION CYSf .. Single, Srnall, Near nipple .. NO pain, NO LNs enlargemenl

CONSISTENCY: Soft

CUI SECTION:
(Capsule

c/o
o/E
@

False cap. ) Painless lump

)True +

CAPSUTE:

Painful rapidlg growing lump


Painfu! rapidlg growing lurnp, mobile, wilh no LNs enlargemeni

pr -) For the discharge : Benzidine lesl @ iira,tl,t)For lhe Papilloma: Glaclographg

Painless Breasl lump, rnobile: wilh No LNs enlargernenl Never lurn malignanl Eneculalion (Circum-areolar incision)

..({illing defect)

Mal'rg.
TTT

Mag Turn

SARCOMA

@;r.ro)For lhe resl of the breasl: Mammographg

lf srnall :

r'

Excision with safetg rnargin, Biopsg

lf Larqe (cqstosarcoma Phqlloidesl : { Vld,lde local excision or Sirnple masleclomg

Micro-dochectomg

& histopathologg

ze l2O-9;O cm) .. probe passes

lJR+Iw.l5 A{mCFhlE flJts@l

?h l7

clrrcll.httA
. . .
Discovered accidenlallg afler rnarnrnographg) Bg Core-cut Biopsg No rnicro-calcificalions ll's a risk faclor for Cancer breasl..

DOCTAL

Bilateral

r Managernenl :

Multifocal

lndian {ile
aPPearunce

l)

2) 3)

Follow up Prophglaciic Tamoxifen lf lhere's *ve Farnilg Historg) MRM * reconslruclive surgerg

Biopsg bg self-retaining needle under mamographg

. .
row
G+RADE

Exarninalion everu 6 rnonlhs Mammographg everu 2 gears bg obligue laleral view (l gear in HRG)

lE"r-'* I

lJRq-ro}r5 696ffihlE 5,)?4W

?A

vt6
La

INFIffiNG@CAFCINoD.,IA
ti
lncidence
Pathologg

:t!{tlrts

fit

HIHHI
.
6%

it

Extensive Fibrous Tissue Macroscopicallg: Hard rnass, in{iltrating er

Most common tupe ..75yo

ffi

,l

rl,

llrvrlrl If During Lactalion

. . cut surface)@ .

Exlensive Malignant cells Macroscopicallg: SOFT like Brain

Macroscopicallg:

.
.

. SOFT rnass
'

TNVoLVES

4ESI[E]

Cul surface)

Miuoscopicallg:
Spheroidal cells producing mucoid material

areas if Hge, Necrosis Microscopicallg: Malignant rounded cells Fibrous tissues


Clinical

Microscopicallg: Mahgnanl cells, li{tle fibrous tissue,

.@

piclure

3i[":',
'
.
Dimpling..(Cooper's ligarnenr) Relracled nipple..(Milk duct)

\
Good Good .. BAD prognosis in
slornach ..

C/Oz Anorexia, Slowlg progressive pain O/E: Enlarged LNs, No siqns of inflarnrnalion

Prognosis

Bad

Bad

rlh: p@oFcANcERffi
INCIDENCE

lJFq-T1un5 nD0cFll.lv ilPhw)

?hqY t

.JYfrOFPffiFAtli

/ /

Most comrnon maligna Mosl common siie is 99% in females Age > 20 Uears

neurostt{Gr
FACIORS

.r,rrig+c , asil e*E d'Srsii+. at*ii 9 pirrfll 9 d{r.r.i , elc &c 9 . Fernale , Nulliparous, peak of age 60 gears
Sjg+c

,girilil.c

.,iiili.

. Earlg menarche,lale rnenopause . Posilive familg historg . Alcoholios, OCPs, lnactive, Obese . HIGH RtgK FACTORS: l) Pre-cancerous lesions ..Papilloma, LCIS.. 2) Previous affection with Cancer breast

Lu-Frurnini sgndrome (mutalion in gene P53) Goddwen sgndrome (Assoc. with PAPILLARY CARCINOMA OF IHYROIDI

* n , n

I (chromosome 17) BRCA 2 (chromosome 13)


BRCA

5$asag
S;rrcilNG'

Lgmphatic, blood spread, direct spread


TNM

* Manchester
+
bad indicalors ...

FRoGftlGlS

Good

. , . .

Size LNs affeclion

Invasion

Axillarg LN-ve

Melaslaiic polenlial according lo histopalhological tgpe

ilK+-TooN5 SPREAD
LYMPHATIC
. Axillaru

Y 1JPqW

ll0

.. BY EMBOLISAIION &
LNs)

PERMEATION..

Supraclavicular LNs , Rarelg lo lnternal mamrnarg LNs . lgmphalic from Lower inner quadranl pierce reclus sheath liver nodules Mag melaslasize as "SISTER JOSEPH NODULE" . Obstruction Pcau d'oranle, Melastatic nodule, Cancer en Cuirasse

DIRECT . Skin, pecloral Fascia, Pecloralis major, Serralus anierior, Chesi wall BLOOD

. Bone secondaries)OSTEOLYTIC LESIONS in . Through valveless cornrnunicalion belween Poslerior


lntercostalis Veins & Paravertebral venous plexus .. N.B. ln Proslalic cancer Bone secondaries are Osleogenic lesions TRANSCEOLOMIC ..Relrograde lgrnphatic perrneation..

. OVARIES) Krukenberg's iumor . NODULES lN DOUGLAS POUOH) Plurnmer's shelf nodules . PERIQIQNEUM) Malignant ascitis

'T *l
\-;\
q

CANCER BREAST SPREADS BY BLOOD

gPREAg) DI$TANT MICROMETA$TASI g

srAgnlq
Ta, oDg N, Mo

II(rlcgII
EARLY CANCER BREAST LOCALTY ADVANCED

BREAST CANCER

MEIASTATIC

CLn.I'CAt PIGK,FE oF EREAST CArCn


FEMALE, 50-60 YEARS WIIH PAINLESS SWELLING IN UPPER LATERAL QUADRANT OF BREASI

a&q-Toar5

E{pocxx.lE

a.Eqw

?[,q ! [

SyiimE,
PAINLESS BR,EAST LUMP
(Discovered bg routine screening)

SlCr}.lS
GENERAL:
CACHEXIA

SIGNS OF METASIASIS

DISCHARGE:
Waterg, Blood slained, pastg discharge OCCULT PR,ESENTATION: o BONE) Bone ache, pathological fraclure o Lung) Drg cough, hemoplgsis, dgspnea o Liver) Malignant jaundice o Axillarg lurnp

(LNs: Troiser sign, BONE: fender spine, LIVER: Jaundice, Hepatomegalg)

LOCAL:
EXAMINE BOTH BREASTS

AXILLA

SUPRACLAVICULAR LNs

INSPECTION..
.,ASYMETRICAL

PALPATION:

. .

BREAST"

BREAST MASS..Starl wilh lhe

Nipple & Areola: t) Nipple retraclion

l) Site) Upper laleral quadranl

norrnat sile

2)

Areola)Pagel's disease of Nipple

o o o

IATE SIAGE MASIITIS CARCI NOMAIOSIS PAGET'S DISEASE OF NIPPLE

Skin proper: l) Skin Nodules 2l Skin Ulceralion 3) Cancer en cuirasse lnfillralion o{ Cooper's ligamenl l) Skin teethering 2) Skin dimpling 3l Skin puckering
Lgmphedema: U Peau d'orange 2l Brawng ederna

2) surface) irregular 3) Edge) lll-de{ined 4) Consislencg) Hard in schirrous 5)


carcinorna. sofl in Medullarg carcinorna Mobilitg) Earlg mobilitg, fixed Iatelg.

Metaslasis:) Sisler joseph's Nodules

LYMPH NODES: Free axilla 2) Enlarged, Mobite 3) Enlarged, Fixed 4) Supraclavicular LNs enlargernent

l)

I
DUGD{oSIS

(,FffiCANCER
SrAglNG'
I I I

5R{4=Tw.t5 ElPPffhtE fl'.Ph#rl

?hqv t w

PREOP

PtLoti, OP

aSSESMertr

TRIPI.E

cxR

u/s
TCrn CT scan MR.I

ffi

TrrtvloR.
. CEA . cA l5-3

ffi
T

HORNIONAt
I I

Estrogen Progeslerone

Hisiorg

ExarninalionJ Mammographg
INDICATIONS: " Screening in high risk groirP . Delecl impalpable breasl cancer " Evaluale sound breast gICNS SUGGESTIVE OF MATIGNANCY: ' Cluslered Microcalcificalion (DUCTAL: 2O%) . Slar shaped mass

* Clinical

SonoMarnrnographg U/S
Can'l differentiale between CtS, invasive carcinoma . TruOcut needle under Local aneslhesia . Frozen Section inlraoperativelg . Excision Biopsg . Mammographg guided using Self-retaining needle

Slain wiih Her-Z antigen

(Dcls)

II ASPIRAIION

cYsTrc

sollD
FNABC

ffi-u{SruD/
I
Not affected
I

I r+ cr-rrurcAllY
rueonrnrs

Affecied
I

FOLLOW UP

IOTAL DISSECTION

(,FffiAANCER
STAGE I, !I
. Cancer breasl is a sgslernic disease . Aim is to CURE mg palient . Once il is evident) lt melaslasizes
in lhe forrn of MICROMEIASTASIS . TTT> TOCAL + SYSIEMIC TTT.
I

5uA{4-:lw.t5 a{DocxhlE f,.M{4rf}l

"Pl.d*k

I 17

STAGE

STAGE IV
HORMONAL THEMPY

Neo-adjuvanl Chernoiherapg is given) For DOWNSTAGING of Turnor (From Stage lll>ll) Surgerg is decided according lo response to Chernolherapg) MRM OR LUMPECTOMY
I

Horrnonal receplors Bone Melasiasis

*ve

CHEMOTHERAPY TTT. OF COMPLICAIIONS

Maslectomg
I I t I

Rernoval of breasl lurnp R.emoval of Breasl lissue Block dissection of axilla Reconslruclion of breasl

.- Removal of breast lump Posl-operalive Radiolherapg


5OOO RAD Local conlrol of Axilla: - Clinicallg *ve) Block disseclion - Clinicallg -ve Senlinel LN Biopsg

Cgclophosphamide

Melholrexale 5-Fluorouracil

Fernale >Togears r Free axilla I Horrnonal

*ve
g-t

t i
{ i

with Mgo-culaneous flap or proslhesis " silicon"

-,f

-HALL LNs are POSITIVE -ln MEDIAL IUMORS .... lnlernal rnammarg LNs affeclion
.-...

HIGH Grade

lumor....

Give ISOO

RAD

timi ll
li :
.

rtp

larJtr
l i

-Quadranleneclomg
-Axilla Clearance -Radiotherapg

0tle+ur !! rS\i

-..-....*....^,,

lJp.q-{1q.t5

1^w,Pli^r7

xwwl

?hqv

tw

,/

./ / / r'

TUMORg
Bilaleral ... Multi-focal Pagel's dis. ...Central lumors Tumor

PATIENT

Breast

> 4cm High grade (lll) ... clg > 20 vo

Fxed to Ms... Dislanl melaslasis

,/ / { ,/

Pregnanl Preference

'/

Small

Ptevious imadialion Conlraindicated

/ /

I o;l -Li #
ln firsl 2 gears

f aI! 51lri n
3 monlhs

Everg

Nexl2 gears ) everg 4 monlhs r'Yearlu for !ife) rnarnmographg of


the olher breasl

,D

,/ ./ ./ ,/

Complications of operations
Local recurrence

Disiant melaslasis
Carcinorna of olher breasl

ETIOLOGY:

AT{UAFEOTA
Resislant to usual

. .

lnlra-duclalcarcinoma Reirograde lgmphatic spread from schirrous carcinorna

Middle aged female glderlu female ttitsiri+,o iilur6 i', rl

TII of eczerna

. . . . . .

ln nipple )Erosion
NO itching NO oozing NO vesicles

Modified radical rnasteclomu

Well delined lesion Breasl lump

lffi
Biopsg

&

Histopathologg

Epilhelial hgperplasia, Lgmphocgtic infiltralion

9.W-TWr5

A{9tr4?[.lE

XMW

?hqv t w

MRM

+ CHEMOTHEMPY

AFTER ISI TRTMESTER

A Risk faclors : l) Prosialic cancer


2)
BRCA

f, Radiotherapg t f, Chemotherapg in ld t $ Horrnonal therapg


( -ve homonal receplors)

2 mulalion

frealrnenl )CA$IRACIION, MRM

DEFINITION: Painless Enlargernent


ETIOLOGY:

of MALE breasl due

DE-novo or on lop of sofl fibroadenorna CLINICAL PICTURE:


I

lo
Etiologg :

a) Comrnonesl cause is b) 9metabolism of eslrogen,LCF


Trealrnenl : SC masleclomg 2) Suction lipeclomg 3) Endoscopic surgerg

Spread mainlg bg Blood..( LNs spread is rare & late ) INVESIIGAIIONB: Triple assesrnent)

Large breasl mass.

l)

'

IREATMENI: Simple rnaslectorng

+ Radiotherapg

*
.:.

DEFINIIION:

Dilaled

major milk ducls

has

* * *

CLINICAL PICIURE: Fernale, middle aged, srnoker presenled bg :

l)

2)

NIPPIE DI$CHARGE ... uearng, serous, blood slained SUBAREOLAR PAINIESS SWEILING

INVE8TIGATIONS:

l)

lf Pt. presenied with sub-areolar rnass) Triple assessment 2) lI Pt. is presenled with Nipple dischaqe) Benzidine tesl, cglologg

l)

Earlg) Combination qle!!lbig!!gq

lJPq:Tw\5

XMW

?hqY I

uo

l) Reason for referra! io breast clinic ) )rnore cornrnon in srnokers 2)


3) Cause of Blood slained discharge 4) Cause of Green discharge

. .

Ducla! changes Relention cgsls of

5) Cause of Serosangious discharge ) 6) Site of breast cancer )

7) Histological tgpe of breasl cancer ) 8) Cause of bilaleral breasl cahcer )


9)
Secondarg deposil in carcinorna

of breast

)
(Nipples)

lO)MOT of breast abscess

)along

MRI breasl imaging:

. .

Dislinguishes scar from recurrence lmaging of breasl implanls Managernent of axilla in breasl cancer

& recurrenl disease CONGENITAT NIPPLE RETRACTION .. Simple nipple inversion:

. . . .

Occurs at pubertg. Unknown etiologg. Bilateral in 25%. Mag cause problerns during lactalion.

POLYMASTIA Accessorg breasl.

. . . .

Usuallg bilaleral.

Wlhout nipple.
MaU occur below pectoral region in groin or even in fhigh but with nipple.

MACROM AZIA Mild cases can be lrealed bg anti-eslrogen. TRAUMATIC FAT NECROSIS . Can occur via blunl lraurna or even indirecl violence i.e. vigorous conlraction o{ pecloral muscle. . Granuloma formalion with rnarked fibrosis. . No LN enlargernenl in axilla. . Mamrnographg is nol conclusive as il gives feaiures similar lo lhose of cancer.

x,w-Twr5
INFI.AMMATION OF BREAST r) Acule breasl abscess. 2) Chronic breast abscess

E{DocFNe

ilRqW

hqv I

s) T.B.

4l

.. Obscure igpe of thrombophlebitis affecting veins of the breasl

tr

Mammarg ducl ectasia. Sites of breasl abscess: Pre-mammarg on top of infected sebaceous cgsl.

5)

inside breasl during laclalion: can oecur al ang parl of lhe breasl. -ln slage of milk engorgement: Dull aching pain referred lo shoulder wilh persislenl fever and atlacks of shivering.

.@9I9)deeplopecioralfasciaonlopofinfecledhematoma.
lnlra-mammarv

tr tr

-!n slage of acule abscess lhere is pitting edema. CHRONIC BREAST ABSCESB: C/O) painless breasl lump and sornelimes dull aching pain wilh no sgslemic sgmploms O/E) lhe swelling is irregular.

TREATMENT) Excision under general anesthesia. TB OF BREAST usuallg occurs wilh pulmonarg TB. FIBROADENOMA Benign simple fibroadenorna is less lhan 3 cm. Gianl fibroadenoma more than 5 cm. PHYLLOIDES IUMOR) occurs usuallg in perimenopausal women in 30-50 age groups.

. . .

. . .

BREASI CANCER FNABC can't differentiale belween ClS, ln{iltralive cancer

tr
tr

(wrDE BoRE cANNULA )

tr
. . . . tr . . . tr . . . tr . , r . .

TUBUTAR CARCINOMA It is a rare bul a well diff. cancer. lt is small in size being aboul I cm in diameler hard and one seclion has radial appearance. .Histologicallg it forms lubular structures formed of single lager o{ epithelium. ll spread bg lgmphocgles and it has verg good prognosis. PAPILLARY CAR,CINOMA.. INTRACYSIIC PAPILLARY CARCINOMA Rare lgpe that is dif{icult io disfinguish from benign inlraduclal papillomafosis. Well circumsoibed and hislolo$callg demonstrale papillarg formalion it presenls bg bleeding per nipple and it is of good prognosis.

lnflarnmaiorg carcinorna can occul in all age groups. lnvasive lobular cancer indislinguishable fiom invasive ducl carcinoma. fhe second line Hormonal therapg used when famoxifen responders relapse progeslerone .. "Medroxg progeslerone acelale (provera)" . Chemotherapg is the lrealmenl of choice for melastasis Side effecls of Radiotherapg : Local burn Pulrnonarg librosis End arleriiis Axillarg surgerg in breasl carcinoma Axillaru LNs melaslasis is lhe besl marker for prognosis Trealmenl of axillarg lgmph nodes positivelg influences survival NO RADIOTHERAPY is applied if axillarg clearance is performed Lgmph obslruclion of advanced breasl cancer : Peau d'orange 9kin nodule (skin nodule + lgmphedema of breast skin) Cancer en cuirasse Edema of arm Lgmph-an$osarcoma

Sgnthetic

l'.Rq-Twr5
t- fernale in child bearing period presenled wilh a mass better felt bg tip of {ingers not lhe flat of the hand , pain and swelling are related io the cgcle ,Axillarg LNs are
enlarged, elastic, fender, mobile

hID00RINY

gMR't

?h

I tg
I

I
fbro ademma

fbruystrb dbase
2- Young Female 20 gears, presenls with well
circurnscribed painless rnass, Firrn in consisfencg, freelg mobile, Axilla is Free 3-female 4O gears old presenled with bleeding per nipple on zonal pressure

lrrtra- fuctal lafllbrt/d,


4-old female presenled with painless mass in lhe upper lateral quadranl of lhe breasl

6atcer

brast.

S-Mostlg old female presents wilh unilateral eczema like around areola (or discoloration), not ilchg and nol respond lo rnedical TIT

PaM dbase.
6-female 3O,4O gears old presented with large firm to soft palpable mass mighl reach Hulh size with NON- palpable axillarg tNS and skin ulceration might occur

6ystosarcoma

/E/bd.

8-Laclating female presented with painful breasl O/E inflarnmatorg reaction presenled in a Seclor of the breasl. Axillarg LNs are enlarged, elasic,fender,mobile

,4cilte lactatru

fi/astttb (nrk
)/as t itb

etelrgefi/etrt)

9-Lactating female presenls with bad general condition, induration of the breasl and Axillarg LNs are Hard and Fixed carc irlor/atos rb, lo-Laclating fernale presents with breast rnass, hectic fever and lhrobbing pain

Aclte brast dbscess,


ll-Female, middle aged, srnoker presented with creamg breast discharge and painless swelling (rnostlg sub-areolar)

Dtct atasn

lJRr+-rwr5 1a.liw*Nv XMWI

?hq? t q

r Earlg deteclion of cancer breast


(

r Managernenl of Acule breasl abscess


(

Ailar

f,2@7)

r Discuss Trealrnenl of Milk engorgernent r Causes of chronic breasl rnass r Breast abscess

,4ilar f' 2@7 )

( ,4y'rar F'
(

2@6 )

,4ilar

f,2M )

r Nipple discharge

,4ilar f,2CCL4' -

r4y'rar

ril' ZmO - An sfrafi/s,2@4 )


( ,4/rar
(r4drar

r Breast rnass: lnvesl'lgation


Cancer Breasl : diagnosis

f' 2fu5 )

F,2M

& ttt
( Atu

sl/aus/@5 )
Kasn

Managernenl of earlg cancer breasl


(

r Pathologu of cancer breasl

,4ilar

,1r1,

2o2,2d/

2@8

r Fibro-adenosis :etiologg , CIP & pathologg


(

( ,4/rar

)A

zma I

Alil

shafils,2m )

5,W-T0ur5 VSWW Thtqvlm

er{m@D:
DIH'SE
. CONOENITAL
. ACQUIRED:

xR4-Tw\5 1H'.{W*WXR@I

hEV

dpnen

| ?.1.

BEh[chl rilArqilA]tr
. Acuie baclerial

-Endemic -Sporadic -Colloid Goiler

FRnTAN/ SECONDAF/

' Sub-acule lhgroiditis


(DE Queruain's Thgroiditis) . Chronic (TB, $)
. Aulo-immune (Hashimoto)

.Collagen dis. ( Riedel's dis)

. . . .

Simple Toxic

lnflammation ileoplasm

. . . .

Neoplaslic ln{lammation
Toxic Simple

l)
2)

Female with neck swelling

)Goiler

3) lf Bimple )

History & Examination: Neoplaslic) inflammalorg )Toxic

Sirnple (bg exclusion)

. .

Examinalion

Smoolh surface Nodular surlace

) Simple Diffuse Goiler ) m is medical ) $imple nodular Goiter ) III is Surgerg

of

. stMP[E) EUTHYROTD t{
. NEOPLASIIC) EUIHYR.OID . Ioxtc) Ioxc . INFLAMMAIORY) VARIABTE
(HYPER then HYP0)

',

lJ(q-Taar5 n9ocPltlt ilPI#)

Thav I

L1

SMru,qptrER
. Endemic) AbsoluteVlodine uocit
llrlgll

Repeated episodes of Slress (Stress) Hge) Necrcsis)

nodule)

. PhgsioloAical) Relalive V lodine


At pubertg, pregnancg, lacialion
(VENUS NECrq Painless Mild enlargemenl of the
Gland Gland

. Nodular swelling in the neck)cosrnelic disligurernent . Pressure manifeslalions,

.
. Srnoolh, Sgrnrnetrical ) . Mobile, Nol lender . No olher manifestalions

Enlarged

EI

Firrn, Asgrnmelrical Moves with deglulilion


No loxic manifeslalions

Tracheo-malacia (Kocker's tesl MCarclid arlerg pulse (Berrg tesl)

'

l)
Same lnvesligalions as Nodular Goiter, but..

Function

2) Morphologg

3)

- U/S)Diffuse Goiler . NO FNABC


4)Exclusion of : Mal'rgnancg) FNABC

'

Treatmenl Total thgroideclomg wilh Posl-op replacemenl therapg

0.2 ngld for several monlhs lhen lapered lo 0.1 mXld for gearc

(l-thgroxin 0.1-0.2

ngd I

*Histopathological sample

lf

. m.

smal! sized in a Uoung Pf. of Complicalions

)Medical thgroideclomg

Partial lhgrcideclomg

Sublotal thgroideclomg

tr 2rg thgrolo{gggElq{glg1gus

To{al thgrcideclomg
inlernodular lissue ..257o )

tr tr tr tr

(Io avoid recurrence)


Dunhill operalion

Pressure on

lrachea)

Poslural dgspnea

Hge , lnfeclion, Cgslic degeneralion, Calci{icalion Relro-sternal exlension.

1#.14-{ooN,5 A\W*NY qu?q%l

YAQK

?4

- HYPERTIIYROIDIEM.. +Thgroxin due lo thgroid gland hgperactivitg - TIIYROTOXCOSIS.. +Thgrofn due to Thgroid gfand, drqg induced, eclopic hormone produclion.. elc

ffiffi
NEoNATAt

RAITEffi
tffi
l)
qAS+trroxtlGrS
eoEFVAtN -rrnc/RolDrrts

DRrrc-rNp(rcm

2) w

l)rHffiFACrrmA 2)ffirHffi
l) FnlciloNtNG
CAFCINortTA

sEcoNDAF$/

2) SrxrfaoVAFll 3) TSH srlenEflNg IDENortA


oF

Ptfl,rrA{/ GI.AND

1JK4-T1U\5 hleoCFN? il?4w

h{4V

| 15

I ilil

EIIOLOGY:

Aulo-immune..flEII)
Iupe V Hupersensitivitu 0n iop of Normal Gland

Osec. from

4
SNG

sec. from

0n top of long standing

0,c,D

. Sudden Onsel , Rernission & Exacerbation

. Gradual onsel . Slowlg progressive


Fernale at

CLINICAL PI )TURE:
Tgpe o{

palieni

ffi

age

subjected lo Traurna, Dre{nahcu, lacialion

clo:
,,gEE
LATER'' Dominanl manifes{alions

,foxic sgmploms
, Auloirnrnune manifeslalions

. foxic sgmptoms . M Artoirnrnune manifestalions @8 rnanifestations

Sp

rnanifeslalions

. Youngl Pl.) CNg . old Pt.) cvs

olEl

,,GLAND"

. .
.
Laboralorg

Firrn, well defined edge Non lender , Freelg mobile

Ihrill AT3,T4

INVESTIOAIIONS:

+ VISH

r
U/S
:

- ve Antibodies
Mulliple Nodules

- ve Aniibodies
Solitaru Nodule
(Low uplake of surrounding lissues )

Mild diffuse enlar[emenl (Diffuse

Thgroid scan :

Uprake)

(OVER-active inlernodular lissue)

TREATMENT:

l)

Neornercazole (10 mg x 3 /d)

Main Line is Sublolal Thgroideclomg afler Preparalion


lf
High risk Pt. (Hearl

lf Pl. < 45

Years:

lpsilateral Tolal Lobeclorng afler preparation

2)lnderal (80-l60mg/d) 3)Valium (s-15 mg/d)


N.B. IF MEDICAL ITI FAILED: . (45 Years & Large) Surgerg

failure)) ll3l

(Hemi-lhgroideclomg)

:: Medica! ITT is used ONLY


for PREPARAIION
(Lugol's iodine 2 weeks before surgerg)

'

>45

g.rr.)ll3l

No role for FNABC)As incidence of malignancg in a loxic goiter is exlremelg rare

Uo

ChJN

ff

6d

6dlb JiIe

o)

*,ri,
oi$6f

Diplopia t rl,Jt*te

J-trt t #J6xll

f ot6p j *otr J.rL SCT ederna .rtll.-irn

rls.p 1 I Jfll <; a1lu! r+tt

Jnfi

i
u'lN!)t 9 u'JJlaq$ Ihgroid paradoxl-J
6Jly't
!.

-nrlir o "i

Fine lremors t $,4too 6ie1J.rie lmitabilitg oy' ;lUts I oe*ll 6),ae,st+,h

t 6rU.f Jo ft 6ppU.ioist

f6hiL 1 ? q,Ei^ t jli *r 6i,eJ.Jrie

Polguria eJ$Jl.f

"rU"p

Jdl

ACOP

HFU

t ay' & ,r'6 6sy' Jlt> j

-o19

JL1

I 6/#t ,s, J/tl'"..,1$g

r .
tr tr

ls il lrue or false?
Nafzrger

lesl , Ruler tesl

. PULSE: (Tachgcardia, Waler Hurnmer pulse,


. B[00D PRESSURE: Asgstolic,9Diaslolic . IEMPEMIURE: Oin Thgrotoxic Crises
mag be irregular)

Darlgmph's sign (Rim of sclera) Stellwa!'s sign

(lnfrequent blinking, lremors)

tr Joffrog's siln
lack of wrinkling on
looking upwards

Von Gravie's sign


Lid tag

. ABDOMEN HSM . UPPER, UMB: )Aoopacg (Clubbirrgf

LOWER UMB

Pretibial mgxedema

Etr Rosenbach's sign

tr

Fine lremors on 4fentle closure Mobius Sign Failure of convelgence

. IA![{D!QD. Anti-thgroid
drugs, Liver melaslasis

. PALLOR) Malignancg . cYAltogtg) Rsc

1,^?4:lw=t5

A{DOCBhIE

ilPq%l

hq, t 7;?

IN FII=GIIANCrI
Mlrg lhgrotoxicosis (<45 gears)
EI

INDICATIONS:

Pne-operalive preparalion in 2rg lhgroioxicosis. Toxic Nodule

M When Pt. is HqPerthuroid:


Neomercazole lO mg tds * Propranolol "lnderal" 80-160 mgl dag (Cardio- Proleclive) M When Pt. is Euthuroid Give neomercazole Smg x3ldag for I gear
N.B.

INDICATIONS: V 2rg fhgroloxicosis M Huge Goiler. Pressure rnanifeslalions, RSG EI Failure of medical TTT of lrg thgrotoxicosis

INDICATIONS: EI lrg lhgroloxicosis in Pt. >45 Uears after failure of rnedical TTT. EI High risk palients

FIRST TRIMESTER:

g g

Propgl lhiouracil SOmg x?8 hrs. (lf crosses Placenla io less exlenl) Add Propranolol (lnderal)

SECOND TR.IMESTER:

Surgerg.. Subtotal thgroideclomg IHIRD TR.IMESTER,: A Anfi-lhgroid drugs+ L-Thgroxine

(Bela rags.. Deslrogs major Parl of gland without affecling the adjacenl slruclures)

tr # Radiotherapg tr
g
tr tr

(To avoid thgouracil lransrnilted goiter)

DUR.ING T.ACTATION:

@ Diazeparn rnau be added


in severe CNS affeclion EI Follow up) Serial TBA measurement.

I
\
(lnderal) mag be given withoul Neomercazole for 4 dags especiallg in R8G& Conlinued fior l-2 weeks after surgerg lo anoid Poet-operalive Thgto,ioxio crisea

Preparation before surgerg: l) Thgroid funclion lesls 2) lndirecl LargntoscoPg 3) NeomercazolelO rng lds *Propranolol (lnderal) until palient is Euthgroid 4) When Pt. is Euthgroid )Neomercazole Smg tds till the evening prior lo operalion+ Lugo!'s iodine lor 2 weeks (9 Vasoularitg)

Propgl lhiouracil

EI tO Milli curie M Effecl appears afler

ry'
I
el rs.

3 monlhs

ggmpiomalic relief I EI g I weigl* gain pulee I u eUeping gerum

Anti-thgroid spontaneous remission # Radiotherapg Sur"gerg mag be done after pubertg

lN Cutr.oneN drugs wailing for

I I
I

Operalion: Subtoial f hgroideclom g Posi-Operalive: Propranolol for few dags

r+

M Anfi-fhgroid drugs *

THYROTOXCOSIS
L-Thgroxin

M lf surgerg is indicated )Subtotal fhgroideclomg is done afler slalionarg Exophthalmos for Ci ms

g g g g

EXOPHTHALMOS
Posilion, Proteclion Diuretics Laleral Tarsorraphg Orbital De-roofing

1JK4-Tm\5 ww*NV,.lF(lW

i*.q B
I

cprreR
fu'*i; "' B;'**.'
*'' *"+"q. ;:{+jl-*flE
.:
:[:;.-..

ti-

PU'Nql}G
Rises wilh

"wlmnAsnrlAr,@rrRe"
. . . .
Gland is presenl in chesl SeDaraled frorn rnain (land
I I

Nodule presenl in Chest Connecled

lo rnain gland

bg

deglutilion
Descends again {hrough lhoracic

Arises from Eclopic thgroid lissue


Takes blood supplg frorn

band of lissues
Takes blood supplg from

goiler

rnediastinal vessels

Thuroid vessels

CIINTAUHCTURE,
TYPE OF PATIENT:

It Mag be sirnple, Toxic, or Malignanl Goilre


Male with shorl neck, slrong slrap rnuscles (MEDIASTINAL WPE)

clu
T

T T

Mag be asumplomaiic Hislorg of cervical goiter which has disappeared


Severe pressure rnanifeslations :

l) Trachea )Dgspnea
2) 3)
olE:
I
T
T T

Esophagus
RLN

Dgsphagia

, . . .

RSG

Reidle's thgroiditis Malignancg Mgopathg of slrialed rns.

0f

esophegous

Hoarseness of voice

INSPECTION) Engorgernenl of neck veins, dilaled chesl veins PALPATION) Lower border isn'l palpable PERCUSSI0N) Dullness over rnanubrium-slerni
SPECIAL

SIGNS)

"Patient elevates arrn above level of head) Facia! nlelhora due to venous conoesfion "

a T

is the invest'rgalion of choice

lsolope scan
PIain X-rag )

I I

shadow in superior mediaslinum........

Flow Volume Ioop pulrnonarg funclion lesl

. . . . .

RSG

Ihgmoma lgmphoma

Aorlic aneurgsrn INS ++

g g g

Idea! lreatmenl

lf toxic
Avoid

Subtota! thgroideclomg from Neck "piece meal" Subtotal thgroideclorng after preparation with TNDERAL onlg

lnjurg of RLN , Fragrnenlation if malignancg is suspecled

?hq I L1

Autoirnmune disease: Abs against Thgroglobulin & Micrcsome )Destruclion of Follicles

9 61115

i,ri

&li.rrr'

THy'trolDrns
4AFibrosis

DEffiS (ffi)
Viral or Cornplicalion of Mumps Pain in Gland, Knee. Liver Enlargemenl of fhgroid

Middle aged Female ClO ol manifeslaiions of loxiciig (HASHITOXICOSIS) then Goitrous Mgxederna +Other aulo-immune manifesialions

O/E: Gland is Latge, Multi-nodular, Firm,


Asgrnmetrical. and Moves with deglulition

MrcRoscoPrc
Mag be associaled with: ' Reiro-periloneal {ibrosis
Mediaslinal {ibrosis $clerosing Cholangiiis

. .

@
. . .

>ACIDOPHILIC in{iltralion Lgmphocgtic ' (Features of Chronic Thgroidilis)

o/s
Multiple nodules
(Mgxederna)

T[tlrFotD sScAD.l COID Nodule

ffi
Thgroid ^ESR Anlibodies)- ve Thgroid Scan) @[I

. 9Thgroid function .AEgR

Isthmectomg

. Anti-Thurogllobulin Abs +ve . Anli-rnicrosornal Abs +ve

. L-Thgroxine + Corlisone . Surgerg if Lar"ge, Mal'rgnant

PREDNISOLONE

1L\P.4:locrr5 E{D,CF^IE

ilRqW

?AqY I

rc

Well-formed acini

askanazg eells

PRIIJIAI{/

Cancnr.nne
'. U/8 )
Solitarg Nodule Thuroid Scan > COLD Nodule

ADEhb-

MeUrr.qFy
Ahnctl|ortlA

ffi

eAlalrrdt!/,

thlotffi

(Can'l differenliate belween follicular


adenorna, Follicular carcinorna)

ChJN'CAL
g g V A Z g g A g
Rapidlg growing swelling in lower part of froni of Neck Earlg painless, Painful latelg (referred lo ear) ln{illrative manifeslalions Meiaslaiic rnanifestalions

a
g

Hemi-Thgroidecfomg Open biopsg & Paraffin seciion

SIGNS:
GENERAL) Cachexia. rnelasiasis
TOCAL SIGNS:

Hard gland, Earlg mobile & fixed lalielg Trachea fixed lo Gland, Posilive Berrg's sign LNg+ + (Delphian. Cervical LNs)

ilRt+-Twr5 flW*NY

WW

*hV I

?i

Exlernal radialion of Neck in children, Genelic faclors (Goodwen's $, Onco$ens)

Fernale 2O-4O gears wiih

Delphg [Ns

Solitary lhgroid swelling in Neck

pilrtu;1ri

e
{
(D

ll-defined rnass in{iltraling surroundings

Microscopic :

E
o
wilh vascular Cf core

I o
J

+ -

. loss of polaritg, signs of Milosis

o J o (s

CL

v
) F o + o o +t
Uq

ETI0LOGY: SNG, Follicular adenorna, Hislopatholo$cal surprise

. .

Fernale, Hislorg of 8N0 eilher:

Left wilhoul

surgerg) Follicular carcinoma

Hislopathological surprise during subtolal

thgroideclomg
Fernale

bl

8N0

40 grs.)mpid progressive swelling in Neck

Bolilarg Painful Pulsating

{ +

. Mggrylg. )Brown Unicenleric mass

'
.

Ulgrgsss&,

0steolgtic

E
o
= o

l)

Follicles wifh

rrilrble

degre

rentialion.

UU

Loss of polaritg

signs of rnelaslasis

12.

e
o
(C
Old Age, rapid progressive swelling in Neck

o o ct,
F L

(D

. . .

Ugg@qlq1)Greg
Miuoscopic:

Unicenleric mass

PRESSURE MANIFESIATIONS Hoarseness of voice RLN

l)

Clusters

of

* *

s.

2)

Separated bg Fibrcus lissue

Carolid )Absenl carolid pulsation (BERRY SIGN)

Loss of polaritg

* silns of melastasis

ilR4-Tw\5

htw*ht,ww

l'l,*V I

1L

. . ' .

DlreT{Cus:
Funclion)Thgroid funclion : N0RMAL MorDholoAu) U/S (Solitarg Nodule, Cgsl with papillarg projection) Morpholoqg & funclion : lsolope scanning )COLD Nodule
FNABC

Dlffi
TUMOR

ONurrrxeNntrp
IF INOPEMBIE:

& GLAND

Tolal Thgroideclorng +

. .

Surgical debulking Pallialive Iracheoslorng

Cenlral Nodal Disseclion Post-Op L-Thgroxin


R.eplacemenl

& IF OPEMBLE:

(ln follicular) Hemilhgroideclorng & Paraflin)

radioaclive iodine

s3rrerNg:
. CT, MRl, U/S . CXR, abdominal U/S . Bone scan (done after lotal lhgroidectomg)

LYMPH NODES
. CHILD) No Disseclion . ADULT$) Prophglactic
Disseclion of cenlral group

Tolal lhgroideclorng

* Posl&

operative Radiotherapg Chemotherapg

FNE{DEnA]TTE
0rgan profile "CBC,KF[,LF[,ECG"

of

LNs

. lf One LN is Affecied)Block
Disseclion of LNs of neck

Posilron emission tomographg (PET) .. To delecl RECURRENCE ..


Follicular carcinorna

RADIOACTIVE IODINE

.
.

Deslrog ang rernnanls of norrnal thgroid iissue, Ablale ang rnelaslasis of lurnor
STEPS:

lrcaled bg thgroidectorng

Post-op Athgroglobulin Level

Wait for manifeslalions of MYXEDEMA lo appear.. l) Give srnall dose of Radioaclive iodine Total bodg scan

2) lf there's *ve rnelaslasis) Large ablalive dose of Radioaclive iodine 3) Posl-therapu scan afler few weeks

FOLLOW UP ..

5 gears post-operative..
:

Everg

3 months do the following


Clinicalexarninalion

l)

2) Thgroid scanning 3) Iumors rnarkers


lf palient wilh
residual turnor afler tolal

thgroidectomg) Serum lhgroglobulin > Zngl ml

tvleWcAFclNo,lA r;*
ETIOLOGY:

ilPq-Twr5

ww*Nvwwl

'"J c1.,

I ffi

)'a*
) )
C-Cells
Falal MEN

. .

Sporadic
Farnilial

ll = SIPPLE's $
TYPE

\z\

CLINICAI PICTURE:
0F PAIIENT: OLD Aged patienl

Rapidlg progressive swelling in

..Secrelion of serolonin..

lhe lower parl of fronl of neck . PAIN: earlg painless, lalelg painful

. .

Diarrhea Flushing

'Bronchospasm

. Dgspnea . Dgsphagia , Hoarceness of voice, . Horner sundrorne

SIGNS:

tr tr

GENERAT) Cachexia, Melaslasis


IOCAL:

. .

Earlg mobile thgroid swelling, latelg fixed


NECK lgrnph nodes

lnfillralive)

Enlarged , Hard Trachea, Carolid sheath (+ve Berrg's sign)

SPREAD:

. .

LYMPHAIIC SPREAD) Mediaslinal LNs

B[0OD SPREAD) liver, Skull nodules, ascilis

. . . , .

INVESIIGATIONS:

) DlAGN0Slg )
SCREENING

Calcilonin, Calcium
Ug/FNABC/Calcilonin (>0.08 nglnl)

*ve

Farnilg Historu even

+ ,lt Calcitonin
Gland

$IAGING)

CT, CXR, U/S, Bone scan

Pre-OPERATIVE) CBC, KF[,

[FI,

FBS

= IOIAL IHYROIDECTOMY
if Normal

EXCIUDE PHEOCHROMOCYTOMA)

TREATMENT: fofa! lhgroidectomg

. . .

!! Jrll 9! brtull
*
Cenlral Neck Nodal disseclion

SPOMDIC CASES) All the Paralhgroid is Preserved FAMILIAT CASES)

l) Ireal
2)

(Combined Alpha

& Beta Blockers

Adrenalectomg)

. '

Preserue YzPmalhgroid gland.. (for fear of hgpo-parathgroidisrn)

Trealrnent of Complicalions

Posl-operative Follow up everu 3 monlhs

crFq-Twfi a{Docw

ww

?hEV t ++

./'

I i:,

i
t'v\

PARATHYROID ADENOMA

PITUITARY TUMOR

PANCREATIC IUMOR

t.JlEN -

llA

MEDULTARY CARCINOMA

PARATHYROID ADENOMA

PHEOCHROMOC\TOMA

tilEhl - llB

)1

vldl,6'. thytld ffi{*llD! ,qtah3 b d&lhr,lDrEd ffilmt

MEDUTTARY CARCINOMA

PHEOCHROMOCTTOMA

NEUROFIBROMA + HIRSHSPRUNG+ MARFANOID FEATURES

ilEI4-Tw$ 1a"]lW*WWW
.TRAPPING

.@[!9!

of inorganic iodide fiorn Blood of iodide bg peroxidase enzgme inlo lodine


binding of iodine wilh lgrcsine

.@ru!E!qAM!

bg Tgrosinase lo forrn M0N0- iodo lgrosine, Dl-iodo lgrosine .COUPUNG of rnono-iodo lgrosine lo forrn lg, T4

)
l-

\^J

unile wilh lhgroglobulin) Stored in Follicles

THE TIIYR0GIOSBAL DUCT; is related

to cenlral part of bone (rnoving of thgroglossal cgst up wilh tongue protrusion)


CYSI;

2. IHE T}IYROGLOSSAI

3-

MrU be present al ang level of lhgroglossal lracl in lhe midline from forarnen caecum to lhe suprastemal nolch excepl in lhe reglion of the lhgroid carlilage where fhe figro$ossal lract is pushed io one side Trealed sur$callg bg rernoval of the lracl with cenlral pad of hgoid bone (as infection is inevltable) rlmoclossAr FtsTU[A: Alwags acquired (following infeclion, inadequate remova! of thgroglossal cgst)

4-

ln long standing lhgroglossal {istula, fistula is silualed lour dorrrn in lhe rreck. PENDRED'S $: due lo de{iciencg of peroxidase enzumer in which lhe patienl is deaf, mule, but NOI blind.
IINOUAL IHYROID MrU represenl the onlg thgrcid lissue.

lt is lined bg columnar

Epithelium.

&

lt is besl lrealed bg full replacement wilh L-thgroxin or excision. MEDIAN ECI0PIC IHfRO|D) usuallg rnislaken as lhgrcglossalcgst

Forms a rounded swelling at the forarnen caecum, cause irnpairmenl of speech or respiralorg obslruction.

l&
23-

ln simple goifer, lhe mosl imporlanl faclor is dietary deliciencg of iodine (Ihe dailg requiranarl100-t25 qg) Vegelables of brassica familg, PAS, Ca, lhiocganate, Carbirnazole and lhiouracil are goilrogenics. ln diffuse hgperplastic goiter)lhgroid hormones level are normal (euthgroid). A colloid goiter is late stage of diffuse hgperylasia.
MUIIITIODUTAR GOITER,

5.

Onlg rnacroscopic nodule is found.. (Micrcscopic changes will be presenl throughoul the gland and mag be one forrn of a clinicallg solitarg nodule.
Irlodule mag be colloid or cellular, and cgslic degeneralion and hemorfiage arc oommon

0- Regading thgroid funclion 7- Regrding FNABC:


8-

lesls, no single tesl is conclusive & lf TSH is normal)lg, T4 arcn't needed.

- Ihe invesligalion of choice in discrele lhgroid surelling, Simple & quick, with excellenl patient com$ance - Cannol differenliale Belween Follicular Adenorna and carcinoma
Regardin! isotope lhgroid scan, Most useful in loxic adenoma of thgroid Cold nodule )Under aclive nodules (usuallg Malignanl nodule)

- Warm nodule )Acllve nodules - Hot nodule )(her aslive nodules (usuallg lhgrcioxi,c

nodule)

9l0-

ll-

lndicalion of surgerg in isolaled thgroid swelling are: foxic adenoma , Pressute sgrnPlorns, Neoplasia, for Cosmoslic purposes Regdin! largngeal paralgsis : -30 Yo of cases arc idiopalhic, 3-4 % of palients have congenilal paralgsis of one of the vocal cords Do lndhecl laryngoscope before ang opemlion per.forned on lhe thgrcid gland for medicoJegal putposes ) U/g Invesligalion of choice in Sltl0 lf a dominant Nodule > 1.5 cm) FNABC (exclude malignancg)

()

1,)?4-TW\5

A{DoCENV

WW

ttu

PRIMARY THYROTOXICOSIS (Grave's disease): is an auloimrnune disease thal develops in a previouslg

healthg thgroid gland where the gland is enlarged or shows mild enlargemenl.

2- Thgroloxicosis should be suspecled in :

- Children with growth spurt, Behaviora! problerns - Un-explained tachgcardia, arrhulhmia, diarrhea, loss of weighl - Resislanl heart failure

g- Effecls of Thgroloxicosis on

.
.

THYR0IOXIC0SIS

) 0steoporosis

Bone:

After operation) B0NE HUNGER.... (Osteoporolic bone wilhdraw Calcium from blood, manifesled bg Tetang)

Pretibial rngxederna:

ls a thickening of the skin bg a rnucin-like deposit. MaU be cganolic when cold, Associated with clubbing of lingers and loes.
Disadvanla(e of anli-thuroid dru[s a- Trealrnenl is prolonged

TREAIMENT OF THYROTOXICOSIS:

b-

cd6ab-

2 gears is 50% ll is impossible to predicl which palienl willgo inlo rernission


Failure rale afler
Some goilers enlarge and becorne

Advanlales of surgenl a- the goiler is removed b- the cure is rapid


o- lhe cure rale is high

if surgerg is adequale

vascular durin( lrealrnenl


Regarding ITT. schedule for diffuse loxic goiler

789-

0ver 45 gears) radioaclive iodine Under 45 gears * large goiter )surgerg c- Under 45 gears + smallgoiler anti- lhgroid drugs Surgerg is the TTI of choice in loxic nodular goiler as il doesn'l respond lo drugs rapidlg or lo radiolherapg Ihe lsl line of TTT of Grave's disease is mainlg rnedica! for hope of perrnanenl rernission. Patients on anti-thgroid drugs rnusl do CBC periodicallg for fear of AGRANUTOCYTOSI$

l0- Post-thgroideclorng slridor mag be due lo:

a. Bilateral RLN injurg. b. largngeal ederna. c. Iracheal collapse. d. Deep neck hernalorna.

ll-

lndications of surgeru in Grave's disease include: a) Large goiter which is uncornrnon wilh Grave's.

b) Failure of conservalive rneasures. o) Suspicion of malignancg.


12- PEDIAIRIC GRAVE'S DISEASE: surgerg is rnore preferred because radio-iodine is poientiallg carcinogenic and causes lale mgxederna and antithgroid drugs aren'l wilhout side effects.

13. THYROTOXC CRISES: - An ER. case manalled in lCU.. (lV {luids, lV hgdrocortisone, Digoxin for hearl failure, Lugol's iodine & propranolol) - MaU follow an unrelaled operalion, lnadequale Pre-oPeralive preparalion - SUPPR0TIVE TTT for dehgdralion, hgperpgrexia, restlessness is essenlial in Thgrotoxic crises 14- EXOPHTHALMOS is a comrnon fealure of Grave's disease (Radioactive iodine lherapg is better avoided in ttT) 15- SECONDARY IHYROTOXICOSIS (Plumme/s diseasel :

- Develope on lop of multinodular ;loiler - ln Plummer's disease lhere're aclive inlernodular lissue wilh inaclive nodules. - Cardiac sgmplorns are rnore prominenl in Plurnmer's disease lhan in Grave's disease.

lJRq-Twt5

ilpocru7ww

?AhY t

11

Rarelg caused bg enlargemenl of eclopic thgroid lissue in lhe rnediastinurn.

Asgrnplomalic and rnag presenl as dgspha$a, Palienls attend lo chesl clinic and diagnosed as "aslhma" ln severe cases lhere rnag be obslruction of superior Vena cava. Recurrenl largngeal paralgsis is nol cornrnon. TTT: Have lo be rernoved
rneal.

I.

HA$HIMOTO IHYROIDITIS:

- Presenls as rnulti nodular goiler, fealures of chronic lgmphocgtic ihgroiditis are comrnon on hislologg - lrg mgxedema wilhoul deteclable thgroid enlargernenl represents the end slage of the pathological process. - Complicaiions: Ihgroid failure is cornrnon, lnuease lhe risk of lhgroid lgmphoma. - Invesligations.. Aulo antibodies against thgroid peroxidase, thgroglobulin. - ldeal TTT. of hashirnolo's thgroiditis is THYROXIN .. (DOESN'T ALWAY$ require thgroidectomg)
- Thgroid iissue is replaced bg {ibrous lissue.. (Mediaslinal - MrU be misdiagnosed as lhgroid carcinoma - Ihgroid scan shows no uplake over lhe swelling.
fibrosis) ..

2. RIEDLE'S T}TYROIDITIg

3. DE QUER.VAIN'S THYROIDITIS Due lo viral infection

- ln tgpical sub-acule presenlalion of De-Quervian l2irregular enlarlernent of thgroid. lnvesl'rgalions: Thgroid aniibodies are absenl.

thgroidilis lhere's pain in lhe knee, liver rnalaise, and firrn

g45-

6-

Ihgroid malignancg is rnore in females lhan in male. LATERAL ABBERANI THYROID... A melaslasis in arrival lgmph from an occuli thgroid carcinoma. SPREAD: Papillary carcinorna)lgmphatic roule, Follicular carcinorna)blood & Anaplaslic carcinoma)Local in{ihration of surrounding tissue Melaslasis lo ceruical [N occurs in 50-60%. PAPIIIARY CARCINOMA - The rnosl cornmon lrg mal'rgnant lhgroid lurnor, Slowesl growing lurnor & mag lurn lo anaplaslic forrn - Dependent on T$H slimulalion. - Has a lendencg io become rnore rnalignanl wilh age. - Not associaled wilh hoarseness of voice. FOTLICULAR ADENOMA presenls clinicallg as a solitarg nodule, Best TTT is LOBECI0MY N.B. (Distinction bel. Follicular adenorna and carcinorna can onlg be made bg hislopathologieal examinalion, ln adenoma lhere is no invasion of lhe capsule or pericapsular blood vessels)
FOLTICUTAR CARCINOMA

7.
8-

Thgroid cancer with mulliple bone rnetaslasis lf suspected) Hemi thgroidectorng is needed io diagnose it. FNABC {indings are diagnoslic regarding papillarg carcinoma, bul nol a conclusive evidence regadin!

follicular carcinorna.

9.

ANAPI.ASIIC CARCINOMA

- Usuallg affects old males & cang worsl prognosis.


Iotal thgroidectorng is often impossible for anaplaslic carcinoma.

IO. MEDULTARY CARCINOMA - A lurnor of C- cells derived frorn neural cresl with characlerislic amgloid slrorna and A calcilonin. - MrU presenl wilh (Earache, hoarseness, sfridor, Enlarged cervical LN, Diarrhea due lo serolonin) ln thgroid carcinoma, Mediaslinal node involvernenl is a feature of medullarg catcinorna of lhgroid. - The level of calcitonin falls after lhe resection of the lurnor.

II.

PHEOCHROMOC\TOMA

- MrU be found at aorlic bifurcation. - Rule of len ) lO% bilateral -lOTo exlru adrenal - lOTo multible

l.

lJPt4-Twr5 hrDocRNYww
Youn! prelnanl female presenls wilh mild diffuse enlargemenl of the thgroid gland occurs for firsl lime in pregnancg and gives hislorg for the sarne condilion with previous prelnancg which fades with deliverg.

?hqv t%

DrTtse srnVle prter


2. Young! fernale with N0 Historg of lhgroid disease subjected to Psgchic lraurna, presenled wilh diffuse enlargemenl of lhe gland, Toxic C/0

Difuse to\tc lotter


3. Middle aged fernale with Past hislorg of thgroid disease presenled wilh toxic sgmptorns, 0n Palpation: Ihgroid was Nodular
Toxb Nolttar Wrter 4. Female with one palpable nodule in her neck- thgroid scan shows hol nodule.

Toxb Thyrolit Ndtle 5. Middle aged fernale wilh past hislorg lo thgroid disease with or without exposure lo a
stressful condilion presenled wilh hgpertherrnia, arrhgthrnia up to corna

Thyrotoxic 6rbes
6. Obese rnale, complaining of dgspnea, wilh hislorg of neck swelling which disappeared
recenllg , and pressure sgmploms appeared.

Retrostertal Wtter
7. Middle
nodule
aged Fernale with enlargemenl of lhgroid gland, thgroid scan shows cold

& inter-nodular lissue //as fiinoto's tltyrordrt b

8.01d female with hard thgroid nodule, pressure manifeslalions, Frozen neck, relroperiloneal fibrosis.

&rd/e's Tltyrorditrb
9. goun! female with solitarg lhgroid nodule & no toxic or pressure manifestalions

Paf'tta7 carcthor/a

10. Old female with pas"t hislorg of SNG, Rapidlg progressive swelling in neck,
picture sirnilar lo a skull abscess.. Thgroid scan shows cold nodule

ll. Old male with rapidlg progressive


hoarseness of voice.

follrfular cdrutlottld swelling in neck, absenl carotid pulsalion &

,haVlastb cdrcrloftia

12.

Old age patienl with rapidlg prollressive swelling in neck, *ve farnilg historg presenled with Diarrhea, Bronchospasm, Flushing (Carcinoid sgndrome)

,ilAnrury

carcfuottld

ilP.q-Twt5 ww.iEN0

l"Rhw

Aqv I

aa

- Give an explanation for: Papillarg carcinorna of thgroid should be


lrealed bg lotal Thgroideclorng

- Managernenl of Thgroloxicosis, Trealrnenl of Prirnarg


thgrotoxicosis

Kasr,2W)

- Managernenl of solilarg lhgroid nodule


G4il

( r4ilar

rl/,2o/2,2o//,-zml Au s/uns,2m/)
slhns2@2,2@5, r4ilar

- Manalfernenl of ihgroid Neoplasia


(r4rh

f'2@5 - r4ilar rl,L 2w.Z@4, 2fu5 )


sfians,2@5 - r4ilar il'ZO// )

- Thgro-glossal cgst : eiiologu , tupes and ClP , Trealrnenl

( ,4n

stldt/s,2M, r4ilar f,2@5 - Ay'tar ril,2m ) Multinodular goiler: investigalions, Cornplicalions


04/tar

- Toxic goiter: Tgpes and Trealrnenl


04/rar

f,2M,

rAur

f'2M)

- Huper-paralhgroidisrn: Diagnosis & Investigations


(Alur

f ' 2ob, 2@5, 2@4, r4y'ur f' 2a/)

- Relro-slernal goiter: CIP


- Ihgrotoxic crisis: lnvesligalions

fiZM,

r4y'ur

f,20b )

- Cornplications of lhgroideclorng

ctBq'41ar5 VWW

?AqVt+0

SUR(

rllrclraet lAB.BCh -

Safrut
/////uersify

ww*tv

lJ?wl

hEv t

+7.

r Cushing sundrorne

r Hgperparathgroidisrn

! Pheochrornocglorna

Wn{GlShbnoMe
trCUSHlNG SYNDROME: Chronic of cortisol levels trCUSHING DI$EABE: 4 Cortisol secondarg lo pituilary lumor

1fr14-Tw\5

ENDoCFIE

ilRqWt

?hqe t

ffi

tr

ETIOTOGY

tr tr tr

Plluilarg adenorna 80% of cases Eclopic ACTH sgndrome

tr tr

Adrenal tumor lalrolenic: Prolonged Corticosleroid

tr

CLINICAI PICTURE:

nl'$;,*,,,i,:::.",",
.
abdomen, ecchgrnosis Thin skin Hirshulism, 4 Facial hair

FAT DISIRIBUIION: . Moon Face (Face)

'.
. .

Buffalo hump (upper back) Supraclavicular Fal pads (above clavicles) Trucal obesitg 4Waiet-hip ratio >l in rnen, O.8 in wornen

'il:iH#*i:"..
tr
I
a

Cardiovascular, Renal , Endocrine . Hgperlension . Diabetes mellilus

. .

Edema

1l

Menslrual irregulaillirs, amrJ,omh"r. infertilitg

INVESTIGATIONS

?EARLY) Loss of circadian rhg[hm ?t-IiIE) flevels of cortisol


(dexamelhasone

O.5rn/6 hours for 2

dags)

lnhibition'of ACTH secrelion, O Corlisol levels


I

Corliso! level$ unchanged


CUSHING SYNDROME

NORMAT

ZIr

PITUITARY TUMOR CT Scan sella lurcica, MRI

{z

= ADRENAT TUMOR
CT abdomen,

MRl, U/S,

tr

TREATMENT

Selestive adrenal venous sampling

? PITUITARY TUMORS:
lrans-sphenoidal rernoval of lurnor Hgpophgseclomg or piluilarg irradiation followed bg replacement therapg ?ADRENAL TUMORS: tr Sur$cal removal followed bg suboplimal rcplacement therapg wilh low dose slercids.. (Till olher adrenalgland recove!'s from suppression) ?MEDICAI THEMPY FOR PRE-OPEMIIVE PREPARAIIO!{ .. C-metgrapone

tr tr

lLlPq-{wr5

A\lDpC4hlV

lJRhWl

?A v I

++

tr tr

DEFINITION: Turnor of chromaffin tissues secretin! Catecholamines


ETIOLOGY:

tr tr

tr

Adult <lO7o Bilateral lOTo malipnanl,lOTo

tr tr
tr

child

50% bilateral Mau be oarl of "MEN ll"

E E

Forrned of Embrgonic Chrornaffin cells around abdorninal aorla that Normallg atrophg during Childhood

Maior sites of Exlra-adrenal Pheochromoculoma

tr

CTINICAL PICIURE

. Sueening of

Hgpertensive palients for Pheochromocglorna Recenl onsel of relinopathg wifh DM Sgmplornatic HTN Vasomolor phenomena or DM HTN (e.0. Postural HTN

t d
d

d6

\r t . \- -

. HYPER,IROPH IC CARDIOMYOPATHY . FEATURES OF "MEN II":


Medullarg carcinoma Hgperpamlhgroidism . ..U.".... Neuroftbromalosis

Iachgcardia, Palpitation Swealing, pallor Anxielg , Trernors Arrgthmia, precipilalion of angina

tr INVESTIGATIONS

. LABOMIORY ... 4 Urinarg VMA, Calecholarnines, Plasma Catecholarnines . MDIOLOGY ... Abdominal U/S, CT scan, MRl, Seleclive adrenal vein sampling

tr TREATMENT:
. ADRENALECIOMY of diseased side afler Pre-operaiive preparalion bg Alpha blockers 7-lO dags followed bg Beta blockers for 3-4 dags before operalion N.B. avoid using HALOIHANE in aneslhesia lo avoid arrgthmia

H
ADENOMA:

5"Rq*Twr5

rNDoCEtl' XRhWI

?Aqv t +6

,trOlDlSM
Compensalorg
hgperplasia due to prolonged hgpercalcemia

tr

gz%ofcases
Middle aged female

tr

After prolonged
secondarg

Ectopic secrelion of PIH bg small oell bronchial


carcinoma

hgperparalhgroidism

Affecls I gland

Olher causes:

(e.9. CRF,
Malabsorption)

e.g. Hgperplasia, Carcinoma,

tr CLINICAL PICTURE:
MOOD.. ( MORE !N PAilENTS >60 YEARS)
BONE
I

- Bone pain - Pathological fraclures - Ostitis fibrosa cgslica


GIT

rl

Apathg, loss of concenlralion, Depression

Anorexia, Nausea, Vomiting PU, acute pancreatitis

STONE.. ( MORE rN PAT|ENTS <60 YEARB) Recurrent Renal slones - Nephrocalcinosis

tr

INVESTIGATIONS: O Serum calcium except in 2rg


hgperparathgroidism V Serum Phosphorus O Serum PTH X-MY: multiple bone cgsls, reabsorplion

tr ffi...MOSTACCUMTE tr CT scan tr TCnn

FOR LOCALIZATION IN RECUR,RENT CASES

TREATMENT

tr tr
tr

Surgical removal of enlarged gland PRIMARY HYPERPARATHYROIDISM - Adenoma) reseclion - Hgperplasia) removal of 43 ol gland & implanlalion of l/3 ln deltoid . SEOONDARY HYPERPARAIHYROIDISM - t alpha hgdroxgl Vitamin D3 - Calcimimelics TERTIARY HYPERPARATHYROIDISM - Total autotransplanlalion of parathgroid fragment equa! lo normal size in arm Muscles

parathgr

1JR{4-TW\5
^IDOCRNV

ilPq%l

Regarding PARATHYROID HORMONE (PTH):

- A peptide hormone - f Phosphorus excrelion in urine. - PTH serurn levels are Ain chronic renal failure. - Require vilarnin D as a Precursor.
ETIOLOGY OF HYPERPAMT}TYROIDISM: Hgperparalhgroidism resull from single adenorna (the most cornrnon cause) or mulliple adenorna, Carcinorna is a rare cause.

CIINICAI PICTURE OF HYPERPAMT}TYROIDISM

l-

2-

Hgperparathgroidism associaled wilh mulliple bone cgsls, can Presenl with renal slones. asgmplomatic commonest presentalion As regard hgperparathgroidism,

lhe

is

3-

hgpercalcemia. Clinical fealures relaled lo hgperparalhgroidism a- Bone pain, multiple bone cgsls, palhological fraclure b- Renal slones. c- Abdominal Groan d- Psgchic rnoan

45I

Chvoslek's srgn is twitchin! of the facial rnuscles produced bg lapping over the prorninence of facial bone in fionl of lragus of the ear in a person has lelang. Pancrealitis is a recognized complicalion of hgperparathgroidism.

NVESTIGATION$ OF }IYPERPAMT}IYROI DISM : The biochemica! findings related to hgperpatalhgroidism:

l-

2-

alkaline Phosphatase 1 Ca in urine. Radionuclide scan is the besf wag of preoperalive localizalion of paralhgroid adenorna.

r J Serurn

TREATMENT OF HYPERPAMTHYROI DISM : Hgperparaihgroidism can'l be cured bg using anli- parathgroid hormone drugs. 2- TfT. of hgperparathgroidism l'e: Surlery 2ry : rnedical 3ry: surterg

l-

ilR{+-{wr'

ww,PNY

XMW

AqY | +6

tblichaet
lr',B.Edh
Arn

s/uns unirersl;4

cJ,,Eq-Twr.t5

htpOCFNE

f/-tp4B{ ? Aq I 60

Liporna

Neurofibrorna Hernan$orna Vascular rnalforrnalions Derrnoid cgst Fistulas Sirnple ganllion Miscellaneous lopics

l./{Pq-Twn5 a.Doc*hlE 5JR4W

?AEV t d

@@

SlfE: Forehead
Nol allached lo skin NO slipperg edge Lirnited mobilitg

@ glTE : Back, shoulder, Bullocks @ Attached to Skin @ Well de{ined slipperg


edge

@ Firm @ @ @

DDiagnosed bg MRI DDD: Osleo-arthritis, Baker's Cgst

ODANOEROUS)
COMPTICAT!ONS:

Respiralorg obslruction lnlussusceplion

@Related to Long!, flal bones @Diagnosis: MRI

@Site: Spina! cord

BUTIHHITN
@CP:

@Sile: Ihighs, shoulders


@OE : becornes rnore {irrn on Muscular

6ifi

@ Mobile

Pressure rnanifeslalions

conlraclion

swelling, of gradual onset

:IC

MISCELLANEOUS
R,ETRO-PERITONEAL> Premalignanl DCTRADURAL) Pressure

'F

@ @ @

Neuro-Lipoma Dercum disease Complicated lipoma

SUBMUCOUS> Respiralorg Obstruclion & lnlesiinal lnlussceplion

MICRO$COHCPICTURE: Aggregation of Fat separaled bg fibrous liesue, contains Blood vessels tNVESTIGAIIONS: ... Clinicallg diagnosed... BPECIFIC: Excisional biopsg, X-rag, Spira! CT spinal cord Treaimenl of choice is Enuclealion of tumor frorn its

o"lb)@,

Palient: Fernale, postrnenopausa! patient @ Site: lower limb @ Clinical oiclure: Small, rnulliple,
@

manifeslalions

@ @

Painful swellings

Relro-periloneal lipoma SC lipoma in fhighs, Bul^locks


(Slighrlg higher incidence)

il84-T0ur5 wwtxNr' a^Pqw ? hq, t


DEFINITION:

61-

Mal-arrangemenl of Normal tissues

CONGENITAL

OTHERS

Hernangiorna
Slrawberrg
Hernangiorna

Vascular rnalforrnalions
Low Flow

. Pigmenled skin Iesions . Neuro-fibromas . Lung!, brain hamarlomas

High Flow Arterial


Cersoid Aneurgsrn
,=rrJ

Sgndrornes
A-V Fistula
.Slurge weber .Klippel Trenaunag . Kasabuch Merrill
Acquired

Capillarg Porl Wine


sfain
t-sgufuib.[r

Venous
I

Lgrnph
I

Salrnon Patch
loJ +rb r rrr i.t

Cavernous Hernan$orna

Cgstic Hggroma
(Cavernous Lgmphangioma)

Congenital

prrS .g.url ,=lifr: Loi


Venous malformalion

pf,1i

(traumalic)

lRq-Twr5

A.DoCFNE

5tM4W

AqV I m

@DEFINITION: Tumor like rnass forrned frorn Nerue sheaih

MOST COMMON TYPE

Caf6 au lait patches

rYPE(l):

PTEXIFORM NEUR.OMA @ Cgstic swelling in lhe face


@ Palpation: Sensalion bag of worrns

- AD, Chrornosorne

17

of

@Site: Scalp, face, lrunk @Consistencu: Sofr

CTINICAL PICTUR.E: Tenderness + Caf6 au lail palches

@Congenilal disease @Site: Limbs @Clinical picture: Hgpertrophg

+Pheochromocgloma

(if a part of MEN llb $) - Special characler in fgpe(l):

Alnlra cranial iension


TYPE(ll) ACOUSilC NEUR,OMA: - Chromosorne 22 - Associaled with Acoustic Nerve lumor - CtlNlCAt PICIURE: Painful , leading lo Deafness & vertigo

C/O: painless swelling, of gradual onsel, progressive course o/E:

@ Not atlached lo skin @ Moves across Nerve aLoUiJJI iirrl,ii


Caf6 au lail palches
COM Ptl CATI ONB :_Mag

lurn Mal'rgnant) "Neuro-fibrosa rcoma"

TREATMENT:

lf sin$e) Excision lf Multiple: "Let lhe patient die in peace nol in pieces" !!

, . .

DEFINITION: Benign furnor of Endolhelial cells INCIDENCE:7OTo growing during lhe first gear CLINICAT PICTURE: palch with irregular surface MOST COMMON SITE: Face Appears at birth or shortlg a$er birlh, 4 in size in lhe first 6-12 rnonlhs lnvolulion starts afler I gear: (5O% bg 5 gears, TOyo bg 7 gears) The remnanl of after-involution is better lhan scar d surgerg COMPLICATIONS: , Ampglopia, Blindness, Squinl TREATMENT:

* Erylhernatous * * * * *

MNesrAlN
t I

Appears

NO sponlaneous lnvolulion CLINICAL PICTURE: Deep purple lesion, NOT RAISED, Pressure causes blanching :: Mag be parl of SIURGE WEBER, $ ... if associaled with similar lesions in meninges :: COMPLICATIONS :

r-iglriri Lr.lgc

Trealmenl :

Decolorized compressible swelling "KASSABACH'g MERRI $"

ttlO sponlaneous lnvolulion INVE$TIOATIONS: Arteriographg, CT scan TREAIMEIIIT:

Appears

Hgper-echoic lesion in liver

U/S)

AI'IGIOORAPIIY) Cenlripelal arrangement of dge

lJ?{44wr5 ww,PNY ilRq%l

?hqv t

55

.w.
*

Mosl common sile . gCAtP (lemporal , Occipiia! relion)

N. C/O: Headache + cosmelic disliguremenl


O/E: Waler harnrner pulse, lrregular swelling with norrnal overlging skin, Pulsaiing with machinerg murmur on auscullalion

'
.

!.Eyes!!Et!ons.! Doppler, Duplex 2l ECA an$ographg 3) Xrag) Rarifaclion of bones Trealmenl :

l)

(Semisitting posilion, Hgpolensive GA . Pre-operalive Ernbolisalion , ligalion of ECA )

APPears in Neonales
Nurnber

M
Single
Site
Size Shape

Rool of neck in Posterior trianfle, suoerlicial lo slernornasloid ms.


large Rounded irregular il! de{ined Lax, Custic
I
T

Surface Edge Consislencg


Special

characlers

DD : Branchial Cgst

frealment:

ilRq-Twr5 A{rcruV

ffiqw

Thq* t

5b

Sequeslration

Tubulo-epiderrnoid

Teralomalous derrnoid cgst

lmplanlation dermoid cusl

DD

of Derrnoid cgsi: Sebaceous cusl (epiderrnoid cust)

crrsr (enOennmD q/sr)


. .

.
.

Bile: Angwhere in skin relaled lo hair bul Appears after adolescence )Grows slalionarg with NO sDonlaneous lnvolulion CIP Slowlg growing SC swelling attached lo skin al a point) sebaceous rnalerial which can be Squeezed

Cornplicalions :

! (ulceration of sebaceous horn)) BIOPBY (D.D. SCC)

MffiAnol.l
I t

g/sr

DEFINIIION: An Acquired derrnoid cgsl


EIIOTOGY

I I

PATHOTOGY Site: ln the tip of fingers


CLINICAL PICIURE:

endings)
I !

COMPIICAIIONS: as anu cgsl..


TREATMENT

ilPq-Twr5 ww*NV IJP^W

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67

. .
,
.

Infeclion )rupture Inadequale excision of cgst

Since birth

. Rupture . lncornplele
excision or incision

Opening is near midline or the Left side Viscous discharge or pus

lo

. Parliallu deep to sternornasloid


rnuscle giving Mucoid discharge rich in Choleslerol

N.B. Branchial cgst, Thgroglossal cgst

...

See Pedialrics surgerg

DEFINIIION: Chronic cgsl conlaining rnucoid malerial, relaled lo a lendon EIIOLOGY: Mucoid degeneralion of {ibrous lissue of lendon sheath C/O: Painless swelling al dorsurn of hand or around ankle

o/E:

Moves across lendon Mobilitg V bg Pulling on lendon


coMPUCATTONS:

INVESTIGATIONS:

TREAIMENT :

M
@ @
Port wine 2rg varicose veins due lo A-V fislula

e.B4-TooN5

hlDoCFlNtr

ilRhwl

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56

roPlcs
Cornmon associalion wilh Port wine stain

@ Hemangioma
@ Vascular

@ Capillarg vascular rnalformalion @ Leplo-rneningeal AV rnalforrnalions @ AV Malforrnalion in Exlremiiies

Ihrombocgtopenia lumor Ieading to 9Platelet & other bleeding disorders

@ Complicalions: DIC

lhgroid membranep @ Cgstic swelling in the Neck @ Becomes hominenl on Straining


@ Weak poirrl in

@ Hernialion

of Lung apex lhrough Sibson's

@ Cgstic swelling in Supra-clavicular region @ Prorninenl on slraining

On one side of longue @ ORIOIN: Sub-lingual gland


@
@ Cgstic, Translucenl

Sile:

iijglLuLtll iiy
rnembrane

gaJJI ,

[l+JI

ii 14rtr a

@ Blood vessels ovel @

il, Mucous

@ Crossed bg Wharton's ducl

lf ruplured)

Pass belween lhe Muscles

io lhe neck (PLUNGING TYPE) @ Trealmenl : Marsupilizalion (deroo{ing1)

Exlends begond the edges of lhe wound @ Site : Face, neck, fionl of Chest & abdornen @ Comrnon in Negros @ Have inherited lendencg @ Acule: 1';o; ) Chronic: Uirf.li

@ Pre-patellar @ Olecranon

: Housemaid

: Sludenls @ Over head of shoulder : Porlers @ Over big toe : Bunion

of the back of kna,rr @ lf ruptures) Severe pain (DD : DW)


@ Occurs in rnidline

@ Locallg malignani lurnor in a Mutipara fernale @ Cornrnon with OARDENER @


$

Site: - Al site of previous sur$cal incision - From the reclus shealh, Rl >Li

at

NEVER IN MTDLINE

@ Best invesi'rtalions @ Treatmenl:

: MRI
2.5 cm

Surglical excision with safetg rnargin

Post-operative radiolherapu lo

avoid

recumence

ilRq*TwN5
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?h Y I E

Acuie Bacterial Sialoadenilis Salivarg slone Salivarg fistula Salivarg turnors

5er4-Twt5

hlpoC^RNE

5WW

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Sffi
inflammation of salivarg gland (PAROTID)

* Organism ...... STAPH , pneurnococci .r Predisposing faclors... Posl-operalive


&

dehgdralion, Poor Oral hggiene, Obslruction bg Slone Route of infections ......Direcl from lhe mouth, Blood born.

HECTIC

fever , T

* Severe pain on side * Gland:


of the face

* fon ealing or on
ingeslion of lernon or acidic iuice

. . .

Enlarged

Firm, lender Raising, lobule of lhe ear DUCT is inflamed

(Don't wail for fluctualion) * Duct) Erudalion of Pus

.r *

GENERAL.... Chronicilg , Baclerernia, seplicemia, Pgernia, Toxemia LOCAL... Slone, fistula

* CBC: 4ILC, 4EgR, ACRP * c/g * Plain X-rag) 9TONE


.r

Prophglaclic l)

* *

..avoid PDF faclors General) Resl, Analgesics, Antipgretics, Anlibiotics

Blaire incision under G.A.) Suroical drainaoe of subrnandibular Abscess: lncision 2 qn parallel io lower border of mandible below& infronl of angle of mandible )Helton technique 2) Complicalions of draina!e.... Fislula Facial N. injurg Freg's post-operalive

:OConcenlration in saliva) ... ,;J,; g figif+a 6rii Lrs pgrp Ulroi 6-0r: Hihon's lechnique C&S Drainage

l)

Condition following surgerg or injury of the parolid gland or fMJ PAIHOGENEBIS: Cross regeneration of Parasgmpathetic & Sgmpathetic fibers CLINICAL PICTURE: Flushing, Sweating of Skin innervaled bg Aurieulolernporal N. whenever salivaiion is slimulaled

xRq,-Tw.J5

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lncidence Submandibular > parotid (50:l) More viscid secrelion , 40oncenlralion ol Ca*z Ducl ascends upwards ... lnadequale drainage Ori{ice lies in lhe floor of moulh ... Could be blocked

. .

faclors lnfeclions(ex: Chrcnicsialoadenitis) ofren's $)

...

MAINY ASYMPTOMATIC ...

Episodes of pain afler eating followed bg relief in the side of Face

. Submandibular slone (radiopaque)) appear with x-rau (Closed mouth) . Parolid slone (radiolucent)) appear with Sialographg . U/g) Echogenic stone * acousiic shadowing
frealment
Submandibular )submandibular sialo-adenectomg Superficial conservalive PAROTIDECTOMY Parotid Gland glone in Duct) according to place:

l)

2) 3)

Slone from ori{ice of Parolid Gland) Mealolomg Blone in ducl) Removal under loca! aneslhesia lf Recurrerrl) Submandibular sialo-adeneclomg

@ Ett"t"gs;l
- Trauma, inflammalion, Neoplasm

@-IUGI

Exlernal) requires TTT

lnfernal)

requires no TTf

Clinical

lF EXTERNAL) Waterg discharge from opening Trealmenl


T

Eczema of skin around opening

Submandibular fislula) submandibular Sialo-adeneclomg PAROTID GI-AI{D CON8ERVATIVE: Parasgmpathetic drugs for I week Avulsion of auriculolemporal N. or superficial conseryalive parotideclomg lf fails) fotul conservalive parolidectomg

PAROTID DUCI:

MAS$EIERIC) Excision with end lo end anaslomosis PRE-MA$8EIERIC) re-implanlalion of ducl in Buccinalor

4ilP.14:loN5 A'DoCxhlE 1,,Mh#}l


r 4Gland size ...flumor
I I

VGland size ...4Malignancg Mosl lumors are BENIGN More common in parolid

I (Wharton's lurnor). (Adenolgmphoma)


(Papillarg cgsf-adenoma-lgrnphornalosurn)

MUCO.EPIDER,MOID CARCINOMA

. Mosl common lgpe . Sheers of Columnar + squamous

epilhelium

2T

ttr at

tvt

[0

rt

[l)

rvl

tll iI 2 I

ll tI lrttll
lncidence

117t
lOTo

,l

ADENOID CYSTIC CARCINOMA . Most cornrnon rnalignancu arnong Minor salivarg glands
I I

ol Parotid lurnors,

More comrnon in Males


Macro. Micro.
Malignancg

c/o
Sile
Size Shape

Mullicenlric * lncomplele Capsule Epithelial cells * rnucinous rnalerial Benign .. Malignanl lransformalion occurs after lO uears (rare in 2-3%l Painless, slowlg growing swelling in the side of lhe face Parolid )Superficial parl Parolid Superlicial parl,

Old aEe, smokers Cgstic, encapsulaled lumor Colurnnar eoilhelium * Lurnohoid lissue

(Mgo-epithelial

epithelia! cells)

ACINIC CEIT CAR,CINOMA

Serous acini, ONIY lN PAROTID GLAND ADENOCARCINOMA Bad prognosis

...

CAR.CINOMA EX.PLEOMORPHIC ADENOMA UN DI FFER.ENIIATED CAR,CI NOMA

Surface Consislencg Mobililu


Special

Variable lrreqular Lobulated

Firrn or cuslic.. (NI:M:EIElIl-rl freelq mobile

m
I I

Sgrnploms . Pain: Awith maslicalion . Swelling on the side of face . Dislurbance Of funclion .... Facial N. palsg Signs of rnalignanl turnor ... SWELLING

characler lnvesligalione

. CTscan . Tc99 ) COLD spol (Avascular) . Free needle biopsu


SURGICAL

Cfscan

Tc99

HOT spot

. Firm lo hard . lrregular, Nodular surface . lll-defined edge, lnfillralive lo skin, . LNs **
+

vessels

Trealrnenl

ITI ....( see Ialerl

Conservalive supet"flicial parolideclomq

lnvesl'rgalions: . For diagnosis) fc99 (COLD) . For staging) CT, FNABC

Biopsg

ilR+-TWr5

,N90C8N' *fr@l

?hqv I v)

PARTID GLAND:

. .

Superficia! conserualive parotidectomg Tolalconservaliveparolideclorng (preserualion of facial N.)

gU BMANDI BUI.AR GI.AND GLAND:

IF OPEMBLE: Total radical parctideclomg folal block disseclion of neck LNs Posl-operafiveRadiolherapg IF OPERABLE:

. . .

gubmandibular sialadeneclorng 3 nenes could be injured: Facial N. (Ceruical & mandibular Br.) Lingual N.

l)

2l

COMMANDO OPERATION

PARIID GLAND:

Buper"{icial conservativeparolideclomg

. .

Tolal radical submandibular sialadeneclomg Hemi-mandibuleclomg Block disseciion of LNS

5,R4-TW'V wu[r*N?ilRhry

?hqv I

b+

t. Lipoma is a universal lurnor. 2. Plexiform Neurofibrornalosis NEVER affecls


TR,IGEMINAT NERVE

3. Branchial cgst is best differenlialed from cold


abscess bg conlaining cholesterol crgslals. 4. CYSTIC HYGROMA can be the EARLIEST $WELLING OF THE NECK lo appear in life. 5. Cervical LNs are "300" oul of the 80O lgmph nodes in the bodg 6. T}MOGTOSSAL FISIULA: MaU follow infeclion, inadequaie remova! of lhgroglossal cgsl. is lined bg columnar epitheliurn and never be congenilal Thgroglossal cgsl Mag be presenl in ang part of the thgroglossal fracl.

- lt

t. 2. 3. 4. 5.

MNUTA is lhe MOST COMMON indicalion for rernoval of sublingual salivarg gland. Mosl cornrnon salivarg lurnor is PLEOMORPHIC ADENOMA Mosl comrnon sile for acule baclerial sialoadenilis is PAROTID OLAND Sjogren's $ affecls 4 glands) 3 salivary (submandibular, sublingual, parolid)* Lacrimalgland

' '

ll's Stones are lhe


MOST OPAQUE

. lf's Slones . . .

lt's secrelions are


mosl MUCINOUS

. ll has lhe TEAST . ll's Tumors


MALIGNANI TUMOURg

are lhe MOSI MDIO-IUCENT lt's secrelions are lhe mosl SEROUS ll has MOSI IUMOURS ll's lurnors are Most
BENIGN

.
.

EOTI of sativarg slones arise from Submandibular Gland Gland secrelions: Viscid + ACalcium concenlralion Ducl ascends upwards: Orifice lies in floor of rnoulh

are mosl

ww/Pw1frqw
l.
Middle aged male or fernale complaining of painless swelling in shoulder accideniallg discovered. Clinical exarnination shows lhal it is lobulaled and attached lo skin bg mulliple poinls but mobile over deep slrucfures.

?hqv I

Sttbcttanarc lrpna,

2.

Palienl complaining of

lim

painless swelling in the forehead

't

have a slipperg edge.

Sfu filtU lryna,


4. Palienl presenled with painless swellings lhal move onlg across lhe neFves of gradual
onsel slowlg progressive course associated with dark brown palches on lhe back. Ihe patient lives positive familg historg to lhe same condilion.

Qeteralful ilerofibronatosrb Ylil fuklrhg llatset s dbasd.


5. ChiH presenls with dark puryle lesion not raised above lhe surfiace. Pressure causes blanching of the color. Molher sags that if's presenl since bidh.

Pofi

fftrle

stam

Adult male presenls with slowlg growin! painless subculaneous swelling wilh black spof. On squeezingil discharges sebum.

Sebaails cyst
Female patieni arcund 2O gears old presents with a slowlg growing painless swelling at lhe laleral side of lhe uppel part of lhe neck protruding benealh the anlerior border of

sternomastoid

Bratcltra/

cyst

8. An adull male presenls wilh painless swelling rnostlg al lhe dorsum of the hand, lense, cgslic, rounded relaled lo a tendon and its mobilitg decrease bg pulling on lhe lendon.

SrnVh ldrdtotl
9.
ltlewborn presents wilh large single cgslic swelling al poslerior lriangle Trans-illuminalion lesl is posifive.

of lhe neck.

6yshb lrygrona,
lO. Patienl presents wilh cgslic, bluish ,translucenl swelling wilh prominenl blood vessels on ils surfiace on lhe floor of the moulh.

foMa t.
Adult male C/O of painful swelling in the sile of lhe face, Awilh lernon ingeslion.

.+xte Baterral shlo afuiitrb,


2. Adull male presenied wilh painless slowlg
growing swelling in the side of lhe face elevaling lobule of lhe ear. On examinalion lhe swelling is irregular, Iobulated, freelg mobile, no ceruical LN enlargemenl.

PlnuaVhrb d&tllfi/a

?ifr+IwJ6

6lD0CFt'1tr

lrRqBY

?hqv I

I Give an explanalion : Slones of lhe Parolid salivarg


gland ate rare and less cornrnon than lhose of the
subrnandibular salivarg lllands

I Salivaru neoplasrns

(Kasn

2@n 2d/ )
) )

! Manalernent of salivaru slones


r Managernent of paroiid abscess
(

( Kasn

r4ilarf'2W
(Kdsr'2M

r Liporna : fgpes, Diagnosis, TTT


r sebaceous cgst :
Manalernenl
Kasr, ZO@,

Au shans,2@4, r4lur rl/, ZooZ) Cornplications, Pathologu,

r Derrnoid cgst

Kasn

2@Z Ail siaills,2005,


( ,4trar

,4y'tar

f, 2@Z 2@4)

I Cgstic hggrorna
r Neurofibrornatosis

f,2@6, ,4y'tar;,29p( )
G4h

siafils,2M)

O+i/

sfiafils,2M )

1Rq-TWr5
a a

A{DoCFhltr

XMW

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10

Definition

aaaaaaaaaaaaaaaaoaaaaaaaaaaa

iologg (Org, PDF, Roule

* Organisrn ..................r........ * Prgdisposin! factors ....t........ * Roulg of infgctions ... . ... .. . . ..


. .

Sitg .................r....
gngSJS
a

* Patho

......................

. Definition . Etiologg . Palhologg . Clinical piclure . Complicalions . lnveslitalions

. . .
Cornoli

Pain: Dull aching then


Throbbing Swelling of lissues Loss of function
a

. .

HECTIC fever , Tachucardia

Swelling) Hot, red ,lender

LNS) Enlarged, elastic,


lender, Mobile
aaaaaaaaaaaaaaa

* Genera! >Baclerernia, seplicemia, Pgemia, foxernia * Loca!: Chronicilg, Pus loculus, Spread
lnvesti

* CBC )Leucocglosis in mosl of infeclions * c/s * Plain X-rag * lnvesligations according lo sile...
D

Trealrn

General) R.A.A.A...
I I

Resl, Analgesics, Anfipgrelics, Antibiolics (AUGMENITN)

* Local
Hol Fornenlalion Aclivg lrgalrngnl: ...................

SJRq.-TW]'S

rNDoCFX.ltr

ilRhw

?hqv I

?r

Definition
*SKIN,

... Localized suppurative inflammation

iolo{u (OTI- PDF, Route


ABSCE$S) Sraph (coagulase *ve), ABDOMINAL ABSCESS> EOoli. * PDF) Bad general condition, Slasis, Bad hggiene * Roule ) Direcl, Blood, Lgrnphatics, lhrough nalural Passages. Peripheral zone) rSlrlro!
NECK Hgperemia
ff '(J

lntermediale zone)69!5 Granulalion tissue

ra
Cenlral zone) 6+rh? iiJ{io Mimo-organisrn# dead WBCs

CP (Sgmptorns,

. Pain : Dull aching)


. .
Loss of funclion

Throbbing, V bg elevalion of the part Surelling of lissues

$wellinS) Hol, red ,lender

tale

fluctualion

Special signs according to tgpe : Breasl, brain(4l0T), Lung (pus on poslural drainale), Liver, peri-nephric, Sub-phrenic , cold abscess

O O

Breast

icalions
* *
General Local :
@ @ @

o Parolid O Perineurn o Pulp space

Proslale

Bacferemia, septicemia, Pgemia, Toxemia

ANTIBIOMA

Chrcnicitg, Spread, Sinus, Fistula

& CBC

Leucocglosis

* c&s * Plain X-rag,

CT scan, MRI (According lo site of abscess)

:: INCISION & DRAINAGE ::


O Under general aneslhesia

* TTT. Of Predisposing factors * General)Resl, AAI (flugmenlin) * Local

. . . .

Resl, Hol Fomeniation ) @ lncision & Drainage ................. Aspiralion tf Amoebic liver abscess, Brain, Cold abscess Chronic abscess: tf Thin walled) lncision & drainage , !Ilh!g@!!gd) Excision

O lncision )(long, dependenl, never crosrs a skin creaser parallel lo imporlanl Slructures) O lntroduce {inger lo break ALL septae O Packing for 48 hours O Dressing everg dag unlil OFor importanl strrtfur"*

co@

xfrq-Twr5

E{rccFhlE

ilPAW

Aqv
I

lt

Non suppuralive infeclion of loose

Conneclive lissue :qD dllrh OENERAL)FAHM

r+ppi

Non suppuralive infeclion of Superficial Lgmphatic vessels r)A>i


olal\ rEonn oiVeubtq o:qp
q d\irJ\

Seplicemia Post-strept GN (after skin inf.) Facia! ergsipelas) Cavernous Scarlel fever sinus lhrombosis slRs (coMMoN coMPIcATloNs) Recurrence) Block lgmphatics Lumphederna, R.heurnalic hearl A/M + Rest *Hol fomenlalion Palient is isolaled ( lf no response >48 hrs)euspecl abscess ) (As disease is highlg contagious)

* * *
*

o o o o

Tender

.... LOCAL)Pain, swellinq, disturbance of funclion O Firg red swelling in face &
exlrernilies

Duskg red Hot area wilh induraled edge

* * *

Give Erulhromucin

if Pl. is

Infeclion

of

Perifolliculilis

ORGANI$M: Slaph. Aureus ..()Nemoloxin)

ciultrn iln: (Boil subsides leaving thick indurated arca)

TREATMENT) lmprove general condilion (Control DM, nulrilion, Vitamins) + MA Resl, fornenlalion - Antibiotics Flucloxacilin or(Augmenfin)

I
o o o o o o o
ORGANISM: Slaph

aureus) Necroloxin )lnfeclion of SC lissue

:,X,I'lii#li'mn ffi [ffi :HHl lnfeclion slarls in follicle)


)

hair Spreads to SC fissue)Loculafed abscess PATHOIOGY: Each bursl on Surface individuallg CIINICAL PICIURE: Multiple puslules appea? on surface COMPLICATIONS: Chronicilg, CAVERNOUS SINUS IHROMBO$I$ IR.EATMENT: - Resf, AAA (Flucloxacilin), lrnprove leneral condilion

- lf

Pus is formed: Cruciale incision& Debridemenl of necrolic tissue Glgcerine Mg sulfate lill sloughing occurs Dressing until healthg lissue is fomed Skin Graft

. . . '

tirlt+f

ffiNq
TOUTE OF SPREAD: ROUTE

cJ'JF.q-Twr5

,NDocElNltr

IJRqW\

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71

)EFINITION: DEFINITION: O Bilaleral diffuse Cellulitis of floor of mo ORGANISM: )RGANISM: O Mixed infection (e.g. SIREPT... moulh

Due

to Direcl spread frorn infecled

of longue or submandibular sialoade


CLINICAL )LINICAL PICTURE: ,?\ ,.t/ar \n^..^-^ J..^-L^r!^ O C/O)Bevere dgsphagia

o o/E:

O- h..^--^ Dgspnea, surrtruarru,r &

-CERVICAL: Swelling in submandibular region

EI{TiERGEilCT

TREATMENT: O EARLY)massive doses of Antibiotics (Amoxicillin, Melronidazole), Resl in semi-sitling posilion O SUBMENTAL CURVED incision of skin & Deep fascia

TRACHEOSTOMY

if needed

DEFINITION: O Nemosis of a nail edge which is embedded in skin & SC lissue of nail sulcus
ETIOTOGY

Betrore

&

PATHOLOGY:

O Sile : BIG TOE O Etiologg : Faultg nail lrimming, wearing lighl


, Nail abnorrnalities as Hgpercurved nai!)
IREATMENT:
CONSERVAIIVE

shoes

O Gauze soaked in anli-seplic lo separate Nail {rom Nai! bed O Correct trimming (square trimming) O Avoid tighl shoes O Keep fooi clean & drg
OPERATIVE

O DEFINIIIVE IREATEMNI) WEDGE EXCISION O Excision of Nail with periosleurn O lf Heavilg infecled ) Left lo hea! bg 2rg inlenlion

1fr4=Tw\5 hlD0cB[lpf/,M@

Th
F
I

17+

rtal mrF
Definilion
Organism

r)

Acule speci{ic infeclion leading to 4 nervous excilalion due lo release of neuroloxin. Clostridium fetani : Gram *ve

Acule specific infeclion leading lo spreading of gangrene wiih excess gas formalion
CI.WELCH

. '. .

ll (Sacgharolqticl,
:

An-aeorbic Spore forming DRUM STICK aDDearance Secreles Neuro-loxin

. . . .

Ct. HI$TOLYTICUM (Proteolulic)


Gram *ve An-aeorbic 9pore forming Secreles Aloha-foxin

PDF

. Aorganism contenl ) Conlaminalion in {ield & slreels s>\io . VO2 conlenl) Deep laceraled wounds, lschemic limb, shock, Compadmenlal . Lack of proper sierilizalion of cal gul & inslrumenls p\il\ qe aibAl
r) WOUNDS, endogenous 2) Posl-operalive ielanus 3) Telanus Neonalorum Oroanisrn release EXOT0XIN: . ANTI-CHOLINE ESTR.ASE) fonic rigidifg of muscles at NMJ OExcilabilifg of motor neurons al AHC) Clonic conlraclion LOCAL) Minimal inflammalorg

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Pafhologg:

. .

SACHCAROLYTIC

GP.)

.
.

acls on CHO of dead muscles) Gases) Elevale sarcolernma) Cul blood supplg
PROIEOLYTIC

GP.)

reaction.

.
. .

acls on Proleins) Arnmonia) H2S) mix wiih lron of Hb) IRON SULPHIDE "Black color, Bad odour" GENERAL) RBC hemolusis, de(eneralion

clP..
IP gYMPTOMS

. .

l-21 dags General) FAHM (low grade fever excepl during convulsions) pain, swelling, dislurbance Local Of funclion (Convulsions)

General FAHM (slighl fever or even subnormal femperalure) Local) Pain, BIack swelling wilh offensive odour, loss of funclion Jaundice, MOF

l-2 dags

S!GNS

GENEML: Slage of lonic conlraclion :

GENERAL:

Opislhotonus, dgsphagia, dgspnea, slridor Slage of Clonic conlraclions: Clonic Spasm on lop of tonic
spastic muscles LOCAL) Red, hol , tender wound
Complications

IEG,

Risus sardonicus,

LOCAL:

. .

Wound crepi+us, Black color, foul odour (Burnt sweel or Spoiled eggs) Sulures appear afler lension Loss of sensalion & Ms. conlraclion

.
.
!nvesl'rgalions

. CBC) Leukocglosis . CSF) Normal . SPATULA TESI .. bed-side test

'

MORTALIW 45% Hgperpgrexia , Exhauslion Asphuxia, ResDiraloru failure & HF Smears from Wounds) organism Organ profile, ABGs

MORTAUW >25% leciihenase is lhe mosl dangerous loxin Severe loxemia, MULTI-ORGAN FAILURE cT, MRt (THE BEST)

' ' . .

TLC

Leucopenia, anernia

4Bilirubin
Smear from discharge Plain x-rag) fissue gases

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l)
$kin incision
r) R.esuscilation

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I 75

& Moniloring

2) Open Deep fascia 3) Ms. Debridernenl 4) Wash with H2O2 5) lf <8 hrs) Close skin looselg wilhout deep fascia 6) lf >8 hrs, excess necrolic tissue or heavilg
conlarninaled) wound is lefl opened

2) lsolalion in dark roorn, Nulrition bg NG tube 3) RESPMTORY PROBLEMS) 02, lracheostomg

.. lnjected in the

proxirnal porlion eutralizes circulaling loxin

2)

Patienls who is previouslg immunized in the last lO gears

. . .
Tetanus toxoid

Conlrol of convulsions bg Valium, barbiturales ln severe cases > VENTILATOR. Conlrol of Hgperpgrexia bg Cooling

r)

Give Boosier dose

of

lelanus loxoid (o.5 ml lM)

lnitial dose (O.5 ML) 2) 2 doses given with 4 weeks inlerval

IIG (25O units lM)


Cornplele irnrnunizalion course

anlibiolics

. . . .

Vaccinalion bg DPT 2,4,6 rnonths Booslet al 18 muscles HRG should be vaccinaled everg 5 gears

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2) 3) 4) 5) 6)

Skin incision Open Deep fascia Ms. Debridernent Wash wilh H2O2 lf <8 hrs) Close skin looselg without deep fascia l+ >B hrs, excess necrolic lissue or heavilg contarninaled) wound is lefl opened

r)

Isolalion 2 ) Resuscilalion & Monitoring 3 ) !V fluids . BIood lransfusion

2)
T

It's lhe least imporfant step ... lO million lU/dag

I
T T

Sterile instrurnenls, sutures lsolation Polgvalent Anti-gas gangrene serurn Antibiotics ... Penicillin G

. Massive tgpe)H'Eh amputaiion above all a{fected .


rnuscles Localized tgpe)excision of muscles, dusling wound with penicillin powder, drainage of wound

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Definition: Non-specific infeclion ihat follow surgerg or Hospital admission

tr tr tr tr tr

Stah. aureus
MRSA

Sierpt. Enlerococci
Pseudornonas

tr tr tr tr

Age

Obesiig

Malnulrilion
lnrrnuno-

tr tr tr tr

Foreign bodies lschemia Hemalorna Unlidg wounds

tr tr

Poor lech. Long time

cornpromizalion

@ lnfection

< 30 dags afler

. . .

Pain

. .

Ewellin8

Dislurbance Of function:

Wound : red, hol, tender, wilh oozing pus LNs : Enlarled, lender, elastic,
mobile

surgeru @ lnvolve skin & SC onlg @ Purulenl DISCHARGE @ lsolaled Organism

tr CBC) tr c&s

Leucocglosis

. . .
I I

Non-lraurnalic wound in Glf, uilnarg, Respiratorg tmci Risk o{ SSI <2% gurgerg inlo lracls with No significanl spillage Riskof 8Bt 2-5% Open aocidenlal wounds , Gross spillage from GII

ffi
Risk of

Perfioraied viscus accompanied bg high

38! up lo

4OTo

g
V

g g

NO Prophglaciic anlibiolics in clean surgerg lN CLEAN CONTAMINATED) Aniibioiics are $ven 3O min. before skin incision & Repeated intra-operative with insertion of FB (e.g. Mesh) lN DIRTY WOUND) Antibiotics are Curalive

CUMIIVE TREAIMENT OF WOUND INFECTION: - Drain, anlibiotics, Dailg dreesing

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Definilion

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Organism: Predisposing factors working, housewives Route of infeclions

)bad

hggiene, bad general condition, manual

' . .
Corn
SWELLING: according to sile.. Ederna al dorsurn.of hand Pulp space )distal phalgnx

SWELLINGS:

- Hol, red ,fender


LNS:

Enlarged, elaslic, tender, Mobile

Acule parongchia )Nail fold

DI$TURBANCE OF FUNCTION:

* *

General )Bacterernia , septicemia , Pgemia , Toxemia

Local

: Accordin{ to tupe of infection : / Pulp space infeclion )Thrombos:s, Osteomgelilis / Acule parongchia )Subungual abscess
DM

I
.F

* lf FB is suspecled )X-rag * tf recurrent )Blood sullar for

l) General aneslhesia 2l Bloodless field gl lncision al site of seleclion


(never cross skin crease, avoid rnidline incision in digirs) 4) Rernove pus 5) NO DRAllllg) Tullgrass 6) Drg dressing changed after

BEFORE SUPPURATION
Oeneral Resl, analgesics, anlipgedtcis, antibiotics , Hot Fornenlalion

AFTER SUPPURATION
lncision and drainage

tocal

a) b)

Posilion of resl Position of exercise if sliffness

lsl dag, lhen every 2 dags

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DEFINIIION:

lnfeclion of lissues surrounding Nail bed

EIIOTOGY: Organisrn

. '

Baclerial
Bad lrimming of Nail Thorn driven under nail
>rd\.!

Fungal

PDF

Hands frequentlg emerged in water ,!otl\ z\l tl>u\ J\ 6Nt


Itching Nai! becomes Whitish

ClP: Sgrnploms

' ,

General) FAHM

Signs

local)
Local)
, uellow

Swelling of Nail fold

Genera!) Hectic fever, tach cardia

... Cgstic

&

U-shaped

coMPUCATTONS IITIVESIIGAII0NS
TREATMENT:

Cullure on Sabouraud's agar

As Scheme *.... rNCrSroN : tr Oblique at lhe anlle of nail Ouler fold, excision of lhe % of nail
is all around

tr Drgness of hand tr Topical antifungal


lf failed :

tr

Nail fold is laid open

&

Nail

Exlraction
shaped from ihe cenler of lhe free edge)

DEFINTTION: lnfeclion of space belween subungual epithelium lheir periosteurn r ETIOLOGY: Prick benealh Nail
I

&

CLINICAL PICTURE:

Severe pain, Litlle swelling Maximurn Tenderness) Benealh free edge of Nail IR.EATMENT: Rernoval of small "V" From center of fiee edge of Nail

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Conlents

l)

Fat 2) Fibrous septae

3) Food: D'rgifd arlerg) Thrornbosis) Osleorrgelitis of ienminal phalgnx exeepl ils epiphgsis

@ lncideRce; @ Etiologg

)Prick

@ CLINICAL PICTURE: as scherne

* ....

@ Cornplicalions Osleomgelitis of lerminal phalgnx excepl its epiphgsis

.... Treatrnenl: As scherne Anterolateral ineision on lateral side of dislal 43 ot distal phatgnx Or al point of maximurn lenderness For severe cases )Counier ineision For sequeslreclorng

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sgnovial sheath

ol

>le

6i.

..uilie ,i>9>e!or>d
on l4i

sgnovial shealh

rf.

PUIP l8
.lniib\

FREE q6,gS\iili'Jt
op

shealh drrO " CULDO$AC trri s t>i en a,ip

a\oi3

MDIAL BURSA
$li . lendon of flexor pollicis lonlus 5N c . FID(OR REIINACUTUM d\oiA . Space of parona n o! FOREARM I >q,i .
Ihenar spaceJl
+

IhumbJl0iilhe

ULNAR BURSA
Aidlr\lnll oldihe$t . Mid-palmar spacell re Jui . Medial 4 lingers g\lllexor tendonjlSur . tjtluj c FLEXOR REIIIIIACULUM Jt *llsr .
Space of parcnaJtop FOREARM

CLINICAL

l) Tenderness 2l
3)

PICIURE: as scherre

* ...

over infecled sheath Especiallg (affecled finger is semi-flexed with limitalion of movemenl)

SPECTAL STGNS:

of Little finler, ) srTil.T?, q swelling 'rn,


2)

Semiflexion

parl ot rn, digtal dislal paH of rcreari forearrn

&
swelling of fhumb, lhenar eminence, distal parl of forearrn

(fenderness over infecled burcae belween lransverse palmar crease & Hgpottnnar Me.)

COMPLICATIONS: $loughing of lendon, Adhesions, Osteomgelilis, arthrilis

TREAIMENI: As schenre

+ ....

Catheter Betadine fransverse incision over proxirna! Cul de sac l) UTNAR BURSITIS) lncision : Along radial border of Hgpolhenar eminence 2)RADlAt BUR8ITIS> Along Ulnar border of thenar erninence & Slop proximallu 1.5 inch distal to the dislal eease of wrisl (to avoid injurg of Molor branch of median N.)

ht
O friangular region al base of lingers (Dorsal & Venlra! surfaces) O From Free border lo palmar crease O Contain fal, vessels, neles, lumbricals & irrlerossi.
3'd

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?hEV I 6L

t*t

& ?d web
lo

sPaces Connecled

@space
Elmai
space

& 4h web spaceg

Connecled ro

c[r$CArWrtrFE:
As scheme

+ ....
.. {ingers can't be approximaled

@rinrdtnorts:

ffi

As scherne

+ Spread to deep mid-palmar sPace & adjacent

web space

As scheme + ..... lNClglON )Transverse incision over web space ln severe oases courrler incision

. .

I crn from free mar$n

s#l
+ .....

O Anlerior{ )Palmar

O hnterior | {lexor lendon of medial 3 {ingers O lPosleilor l)Fascia coverin! inlerosseii O lLateral l){ibrous band from palmar irrlercsseii to 3d melacarpal o MAla[gl) {ibrous band fiom palmar
(Obliteration of palm concavitg)

As scheme
coMPUCAilONg

TREATMENI

COIIAR-STUD ABSCES9: 3 points ... 8ub-culicular whitlow (loculue in SC tissue) 2- Leulus in superficial palmar space 3- Hole in oalmar aDDoneourosis conneclino lhem . lncision: Transverse incision . !4p!q; Transverse incision over space at line of oease ovel site of . Posilion of funcfion: semi-flexion of {ingers . lf complicaled bV web space infeclion) rnaximurn tenderness . HELTON's TECHNIOUE: Counter incision from web space Palmar fascia is divided

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ldea! anlibiotic surgica! prophglaxis should start before skin incision and conlinue for one dag after surgeru. 2. lndiscrirninale use of antirnicrobials can lead to the developmenl of antibiolic resislant microorganisms. 3. The rnosl important cause of posl-operaiive wound infection is presence of dead space. 4. Fournier's lanlrene is caused bg bacteroids, califorms & peptoslreplococci, bul nol clostridia. 5. Bacteroids a?e a parl of norrnal flora of oropharunx, colon & vagina, bul nol urinarg fracl. 6. The main organisrn of endotoxin release in multiple organ dgsfunction is E.coli. 7. The mosl cornrnon anaerobe in Colon is B. FRAGILIS 8. The rnost frequent cause of Endotoxic shock is E.Coli. 9. The mosl frequenl organ:sm associated with neck abscess in children is $laph. Aureus. lo.Adequate wound debridemeni is the most imporlant measure in management of coniaminated wounds. ll. Cenlral venous pressure {CVP} rnag be decreased bg Grarn-negalive sepsis. 12.CLOSTRIDIUM TEIANI: has a drum stick appearance, is slrict anaerobe, and Produces h'rghlg resislanl spores. l3.A palient who has recovered from lelanus requires a dose of loxoid l4.Gas gangrene infection is caused bg anaerobic spore-bearing closlridia, has a veru shorl incubalion period, Cornmon lo occur in deep wounds of lhe thigh, but nol associaled with high fever. ls.Trealment for clostridial mgonecrosis (gas gangrene) includes Adminislration of Anlitoxin, Wide debridemenl, and Adrninislralion of hgperbaric oxggen l6.The rnosl lelhal loxin of Cl. Welchii is LECITHINA$E (cr - loxin). 17. Fool infection in diabeiic palients is predominanllg caused bg rnixed organisms. ls.Midpalrnar spcace infection is mosl oflen due lo direct spread from inlrathecal whillows. l9.Ihe hand infeclion which carries the highest risk of osteorngelitis is distal pulp space infection (felon).

l.

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l. Patient complaining of lender, duskg red hol, non suPPurative area with
induraled ill-defined edge al medial aspecl of lhe leg. lnguinal LN are enlarged, elaslic, lender, mobile.

Gelhlrtb,

2. Pallent oomplaining of tender, duskg red hot, non suPPuralive area wilh
indurated well delined edge al lhe face, slighflg raised

En1srplas, 3. Old patienl complains of suffooalion, severe dgspha$a, and severe dgspnea.
On examinaiion edema of the floor of lhe rnoulh, lhe longue is pushed upward and bach,uards.

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4. Manual worker
presenls with $a,elling in nail bed. Dull aohing pain. On examination nail bed is induraled gellowish cgslic.

I dtqttta

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5. Youn! male cornplaining of neuosis of the big nail sulcus with persislenl irrilalion of his nail.

hgnyyt tu- tarl @tyclrun1fiu H,


6. Patient farmer preienls wilh conwlsion. fhe relalives $ve hislory lo
severe headache 12 hour ago. On examinalion the patient has a swollen wound and severe pain al sile of wound.

Tetarus.

7. Palienl presents with

deep laceraled crush wound, lhe wound is black edematous with foul odour and waterg diecharge.

&
gdillroile,

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Discuss Aetiopathologu , ClP and TTT of acute Puogenic abseess

r Gas gangrene
r ClP and TIT of Tetanus
( ,4r'tar

( Kasn

2d/ )

f,2M- Arfl sfiams,zfu )


b4th sllafils,

r Short account on : ergsipelas

2d/ )

sfiafils,2M Factors affecting wound healing, cornplicalions of wound healing ( r4lur)/,2M -r4ltarf,2M,2@5 Kasn 2@7 - Kasn 2d/ ) Genera! principles in rnanagernent of hand infection ( ,4y'rar f, 2@Z 2@4 - ,4y'rar ,il, ZooA) Tenosgnovilis of lhe finlfers of the hand G4i/ sfiafils,2M ) Managernenl Pulp space infection ( Kasr 2@7) ' Delection of wound sepsis afler surgerg and ils
O+i/

rnanalfernent
( Kasn

2@n

"(g

I NY

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"v-

tUbhael
AAF

tth .. Altr

snrversrttt

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r Polg-fraurna lized patienl

t Hernorrhagic shock
r llernomhage

r Acute wounds r Wound Healing

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INCIDENCE:

)r Mosl cornrnon cause of death among middle aged paiients


)1 3'd Mosf cornrnon cause of death among al! groups

resffioF
Will die anuwau whether theg received medica! altention or nol
Will suruive ONLY lF theg received timelg medical al-lenlion in the GOLDEN HOUR, "{irst hour" are Iimited
WILL survive angwag whelher theg received medical altention or not

lf resources

YELTOW CODES arc lrealed

{irsl

L{

TRlr.iODAt DlsrRlBonohl
Within rninutes Due to injurg to vital slructures

...

re

OF DEJtr+t

-H

Due lo hemorrhage, or maior fraclures

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@ @ @ @ @

OF

A: Airwag patencg & support mandible B: Adequale breathing (look, feel, listen) C: Circulation ) Gonfrol ang bleeding D: Drugs "Analgesics"
Cover wound wilh slerile dressing Avoid flexion of spine lo avoid dislocalions M ls patienl able lo speak or not? EI Is airwag patent or nol ?

@ @ @ @ @

A: Airwag

HFJTDToTOE e><A.,ilNIFION
@
@ @ @ @ @ @

fr Breathing
Q
Circulalion D: disabilitg
Exposure

Head Neck

f,

Neurological ... Chest Abdornen


DRE Limbs

sbg
aitwag
,

$fiPleslsron#
@ @

!nspeclion

- Palpation -Ausculialion

@
@

gHOCK (Hemorrhagic. cardiogenic, Neurogenic) AVPU evaluation (Alert, voca!, Painful slimulalion , Unresponsive) a Foleg's ICalheler Resuscilaiion & moniloring ... NG tubeI g Radiolortical assessrnenl

Allergies Medications Past Medical Historg Last Meal Event of injurg

OFGFitrlffiAFrB,
@ @ @

EAslcuFE gJ'PFo'Fr

LAB : HB%o, Glucose, KFT, ABGs , PO2,PCOZ RADIOLOGICAL : X-rag ,CT ,MRl .U/g , Duplex INSIRUMENTAL : Endoscopg, Centesis

T[{EN.. DEFINffi\'Effi&

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"GCS,,,
U+rirql
Flexion * Withdrawal srt+ll

Ug'=F.lr aii+{

'-l :r^
Ug

r-.llol'rll g r-llg,,iu

arra,,plgl +Iiii 9 r.lLip


Orienfed, Norrnal Localize painful slirnulus

Exlension

to painful stirnulus
us$hll
drrSc

Flexion

lo painful
sr$bll rr{Sr

stimulus

De-cerebraled

De-corlicaled

REsttrohlsE Merarcud
EBB Pl{AgE l<24 hours) OEnzgrnalic activilg & OZ consurnplion E Lactic acidosis CATABOLIC Pl{AgE (g-to dage) 11 Fat, Prclein rnobilization 11 4Urinary Nilrogen excretion AilABOtlC PHA8E (tO-eO dags) Resloralion of Fal & prolein slores

)r

al

OSecrelion tr Aldoslerone) 4Na, HzO

ffil\IE
reabsorplion

tr

!r GH, Prolacfin, ACTH

rr CA) V.C., Tachgcardia tr ADH) H2O retention

AB+TUD{r, E\m,fbEAE#t

DEFINITION: Discontinuitg of ang bodg structure bg Phgsical injurg

os(

arac

lo friclion with a rough


Due
blunt objecl

Due lo pressure bg

qi olerp

Due lo Heavg blunl lrauma Producing sevene lissue damage

sharp object

oUui!

frealmenl:
Antibiotics t Betadine anliseplic

lncision bg sharp cufling object (Clean, tidg cut)

Wound is Untidg, irregular devilalized edges_

Ecchgmotic skin patch due lo btunt lrauma Trealrnenl: Fomentalion (Cold ) Warm)

Collection of blood freatmenl: o Fomenlalion (cold) Warm) o Antibiotics o Aspiralion if large

.. See Orthopedics ..

ci,Rl4*TC0r5 ftlgpc*tlE ilRqWJ

?AqY I

oFnlooxp
ENBAT
@lipucAnoNs
OF HEJUTNC
Hgpovolemic Septic Neurogenic

SPECTFTC (TB, gas gangrene)

@ NON-gPEC!F|C
(Seplicemia)
@ @ @

Crush injurg Compartmenlal

lnvesligations :

Staph. Strept. Pseudornonas

Telanus Gas-gangrene

O Contracture O Chronic ulcer O Keloid O Disfigurement O Lgmphederna

Mgo$obinuria Complicalions : Acule renal failure Trealrnenl : B Resuscitation & Antishock rneasures n Alkalinization of urine

lr * *

Hgperkalemia CK > IOOO U/L

. . fr

Fluid

Diuretics (lV mannitol) Vilamin K Fasciotomg

Management of Polglraum alized palient ..(see before).. Management of Wounds ..(see Vascular surgerg)..

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@ IRRIGATION WITH SALINE
@ @

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PRIMARY SURVEY ... ABCDE ... SECONDARY SURVEY & Examination from head lo toe * Resuscilalion * lnvesligations t Moniloring SYSTEMIC THERAPY

@ DEBRIDMENT * Skin )Excision ol l-2 mm of edges * Fascia )Fasciotomg * Muscles )Excision of dead muscles

* * *
*

Bones ) Deconlaminalion bg cureltage Nerve )Mark wilh black silk lhen delaged repair Blood vessels ) (nT=!oni,.,,,,'u,Ir) Ligalion or repair rr Accordino to {o slale slalc of wound worrnd Skin closure ) According

Closure withoul Tension

Delaged closure or gra$]ing

@ IMMOBILIZATION & POST.OPEMTIVE CARE

* * * *

Observafion Antibiotics

Anti-letanic serurn
Anti-Gas gangrene serum

fuxp
DEFINITION:

fl/F4-ToohlS g{rucxlNE lJ?qw

?hh6 115

Mechanisrn bg which bodg reslores integritg of injured part

NG,

NfENTION: EsririrroJl r'S

t{EAtlNqSrAH: x4
INFLAMMATORY PHASE
Vascular response (hemoslasis * Vasodilatation) Cellular response : Following bg Neulrophils, Masl cells

@ tidg wounds, slrong @ Seals l-2 dags @ Heals l-2 weeks @ Full power 3-6 Ms

scarc

(lsf 4 dags)

SECONDARY INTENTION: <lpral! r-r h


Unlidg wound with gapping edges @ Weak scar @ Takes much rnore lirne TERIIARY INTENTION: .l.rLiGil Ufyfg Lir.#ai iir'i6 3i-i{ Wound is lefl open for 5 dags then requires a delaged prirnarg sulure after being clean.

tAG PHASE (3rd -Sth)


Endothelium, Collagen , MPs

Wound Conlraction

PROLIFEMTIVE PHASE (sth

-2lst

tigfr ii+tr
)

Epithelial regeneralion Granulalion lissue forrnalion (healthg, unhealthg) Conneclive lissue repair Wound Conlraclion

Wound Conlraclure ii rfr rg ii?Lt

REMODELING PHASE
TUp"

(>

Igear)

lll Collagen )Tgpe I

FACronS AFrECTING HEATI}G'

@rtlpucArloNs oF r{EArrNG,
@ TUp" of wound (Tidg. untidg) @ Site of wound
(Wounds over flexures )lension)
@ @ @ @ @ @

Age of patient Obesitg Medical condilions

lnfeclion,
hernalorna Dehiscence

iijglUuLtll 1,i [r,Ul iir..rfil


@ @ @ @

@FB @ Vascularinsufficiencg

Malnulrilion Medicalions
Smoking

Scars Hgperlrophic scars Keloids Marjolin ulcer

HE

wp.q-rw$ 1aJlw*Nexww ?hqY t fu

State of peripheral circulalorg failure due to sudden blood loss or shift from peripheral circulalion.

fl g g

Blood volurne due

lo

Whole blood loss Plasma loss Waler & elecirolgte loss

Phgsiological rnechanisrns To reslore blood volurne Fail if blood Loss

Delerioralion of

funclions of
brain, kidneg,

Mu[i-organ failure

>

15%

Hearl, lung

(lf Treatment fails)

nGrunei,
OF COMPLICAIIONS

tr Weakness, fainling tr Palienl feels Cold ,fhirslg tr Altered rnenlal slalus tr 9BP, Weak lhread pulse, 9PP tr Hgpolhermia tr Tachgpnea, air hunler tr Skin becomes pale, tr Capillarg refilling > 2sec tr Oliguria )Anuria & Renal failure
OlEz

clo:

tr tr tr tr

Exlernal Hge lnlernal Hge Burns lntestina! obstruclion

tr tr

Anuria ARDS

ORGAN PR.OFILE
Exclude bleeding lendencg CBC, ABG, Electrolgfes, PH, KFT. LFI

DETECT THE CAUSE

COMPTICATIONS

f prJl

lJt+3

tr Head CT scan

tr Abdorninal US

1Tr. OF
E ABCD

ilE+TW

ew

A{poCXt\tE

ilR(#l

?Aqv t

ArHcFrrAt(td{r)
tr Airwag )patent tr Breathing )Mainlained tr Circulalion)Slop bleeding tr Drugs )Morphine lo relieve neurogenic shock tr 3 ANII - : Anlibiotics, Anli-Gas gangrene, Anli-Telanic serurn tr
tr tr
Elevalion of tegs ..

E STOP HEMORRHAGE

E RESUSCITATION:

tro/2

tr tr

E FIRST AlD
lmmobilizalion of fraclures Warming

RYIE )evacuale slornach LINE >2 Cannulas for fluid replacernenl & Samplint

FLUID REPLACEMENT:

tr

MONITORING

SUPPORT

Slart with Crqstalloids


Until blood lgping, cnoss rnatching are done

tr
tr tr tr tr

Viial data
"Pulse, BP, Ternp. Respiration" ABGs , ECG Urine Oulput Cenlral venous Pressure

t) Norrnal saline (+K*t 2) Ringer (+ 3) Ringer laclate


N.B.
:

Buffer)

O O

Crgstalloids mag be given alone )Pf. with Hgpovolemia due lo waler & Electrolgte imbalance # Glucose 5% )leads lo dilutiona! hgponalremia

Pulrnonarg arterg wedge pressure

tot
earlg delection of Lt side HF in old pafients. Arlerial Line )Monilor ABP, essessrnent of ABG

tr tr

Colloids:

l) Plasma subsilitues

2) Dextran
Blood

m oF cAusE tr lnjured vessel)surgical repair tr Burns) fluids, wound care m OF COMPtlCATlOttlg tr DIC) fresh frozen plasrna
SECONDARY SURVFT

in hemorrhagc Shock if HCI <gO 7"

After stabilizafion..

ilRq-Twr5

flW47NY 1'RhW

?hqv t

Bleeding:

g a
V

Venous blood : dark, profuse Arlerial Blood: red, spurling, oscillaling Capillarg Blood: red, oozin!

't' -ht

Accordin! lo tirne of Hernorrhage:

g g
V

Prirnaru Hernorrhage : al sarne lime of operalion Reaclionarv Hernorrhaqe: within 24 hours Secondaru Hernorrhaoe : within 7-14 dags ... main cause is infeclion

Normal Sgstolic BP

ODiaslolic BP

Capillary re{ill

Replacemenl bg Ringer laclale 3 times delicit

Hernalocril SO % urine oulpul SOm7hour CVP rises lo lhe upper /z of norrnal range lf CVP is risin! & Patient is NOT imprcvin! (Shock search for: a) fension pneumolhorax b) Cardiac larnponade c) Heart failure

g g

zfCVP)

frealrnent

l.

$loD hemorrhaoe: (posilion - pressure - packia$ e.g. Elevalion of the limb above the heart level , Balloon larnponade

2.@Accordingtotheclassofhemorrhage...seebefore...
3. 4.
Optimize oru{en deliveru: 4O% oxggen is $ven for class ll and IOO% for classes Ill and lV. General care of lhe patienl: absolule bed rest and analgesia (Morphine is contraindicated in head injurg and in oases of respiralorg and liver insufliciencg)

5. @gI!Dg:

Urine output, core lernperalure, hernalocril and cardiac moniioring ECG for earlg deleclion of shock-induced arrhgthmias is important). as above + CVP, ABGs and PH ln class lll or lV hemorrhage

ilRq-Twr5

nDgcRNV

il?4ry

Thh'* I

fl

"MOST SERIOUS WPE OF SHOCK', ,,MOST DIFFICULT WPE TO BE IREATED"

ETIOLOGY:
Etr Or(anism: MOST COMMON ORGANI$M lS GRAM -VE BACILLI

E E

Source of

infecfion: Perilonilis, Cholangitis, UTI

Predisposin{

faclors:

Exlrernes of Age, DM, Irnrnune-comprornisalion, Malnulrilion

CLINICAL PICTURE

... 2PHASES ...


& confusion

. . .

Reslless

gKlN)

Flushed, warrn, drg

. .

SKIN) Cold, Clammg


VITAL DATA:

VITAL DATA:

x .

Fever

>38

tr Tachgcardia tr Tachgpnea
^COP

tr Oliguria tr Sgstolic BP<90 mmHg tr lachgcardia

.
g g

11 Tachgpnea

vcoP

$FS
(sYsTEMrC r NFLAMMATORY
RESPONSE SYNDROME)
Etiologg:

g g g g

a ffir@

Evidence of infeclion ... *ve Blood cullure Refraciorg Hgpolension Ang 2 wltefia of the following ... Hgpervenlilation (RR,>20 breaths/min) ABG (PCO? <32 mmHg)

V V A

WBCs

<4000- >12,000 cd!s/mm3

Polg-lraumalized patienl Major burn Acule pancrealitis Neglected hgpovolemia

CRITERIA FOR DIAGNOSIS:

a) Iemp >38c , <36c b) HR >90 bpm

80%

MORTATITY
MOF

c)

dl

RR >20 breath/min WBCs >12000 , <4000 lmmS

Dtc

INVESTIGATIONS:

tr

FOR GENER.AL CONDIIION:

tr CBC: 0TLC, V Platelets tr ABG, Electrolgles, Blood sugar


FOR EIIOLOGY: lsolalion of organisrn, C&S, Localizalion of seplic focus FOR COMPLICATIONS: KFT, LFT, ECG, Coagulalion profile

tr tr

ilRI4-T1a.t5 ,NDocE[.],
TREATIVIENT..

ilRhw

hhv I

r00

ADMISSION TO ICU THEN ...


ERAD!CATION

RESUSCITATION
CIRCULATORY SUPPORI

MONITORING

OF INFECTION

tr tr

FTUID REPLACEMENT: RINGER LACIATE

tr Vital silns E Urine output


E ABGs, CBC,
Coagulation profile

tr
E

Eradicalion of sepsis
Parenieral anlibiotics

DRUoS

(if Patient rernains HYPOTEN$IVE despite {luid replacernenl)


Dopamine, Dobularnine

tr CVP, Arlerial line tr Prophglaxis against


DW, slress Ulcers

REPIRATORY SUPPORT

tr

O2 bg mask

tr lf PO2 < 60 mmHg


)
Mechanical venlilalion

RENAL SUPPORT
Hemodialgsis in ARF

DIC?

Fres.h frozen plasma

PROGNOSIS: 80% MORTALITY

ffiffioF
g

Cmuoqpt{CstlodK
MOSI COMMON CAUSE Ig MYOCARDIAT
INFARCTION

CtINtCAt PICIURE:
CONGESTED NECK VEINS TR,EATMENT:

ACVP

g A

TTT

oflhe

cause

Dobulamine (inolropic agent)

EI Most imporlanl lrealmenl of

ffileSHocK
EflOTOGY:

Anaphglactic shock is lV hgdrocorlisone

M Mosl importanl causes of


Endocrinal shock : DKA, Addison, Mgxedema

High spinal aneslhesia,, Transaciion of spinal

cord
CLINICAL PICTURE:

. . .

BMDYCAR,DIA

M Ang prolonged hgpovolemic shock )seplic shock


EI Ang prolonged hgpovolemic shock in elderlg )cardiogenic shock

WARM SKIN
LOW BP

g
a a g g

re

1JP4-Tw.t5 1a{lw*Nv lJRhRl

?hqv I

suruive in slored btood from

llfi

Blood group mismalching can be accepled in LIVER lransplanlation

Donor & recipienl are onlg malched for ABO compalibilitg All componenls for slored whole lend lo Vovertime excepl Polassiurn Donaled blood should be roulinelg screened for Hepatitis B, C, HIV
CMV is screened :n high risk groups (Ex: lC palienls) Best guide for blood transfusion in hernorrhagic shock is

"

CVP "

FEERITE
tr tr
TTT

: stop lransfusion, Anfi-hislaminic, Hgdrocorlisone

AII^BCICREACTIoN.

fficAr
tr tr tr tr

Transfusion of 2500m1 of blood al one lirne or 5000 ml or more over 24 hours

tr C/P: urticarial palches up lo Iargngeal edema. tr TII; Anlihislaminics & corlisone, slop the lransfusion.

Delaged hemolgsis Post-lransfusion purpura

HEitolr/rlcREAcrloN:

tr ETIOLOGY: lncornpalible blood transfusion tr CLINICAL PICIURE:


Fever

a-lron ovedoad (Hemosidrosis). b-fransmission of diseases as:

&

r'lgors

Chesl, lurnbar pain. Dgspnea. Headache.

. . . . .

Fever

& rigors.

Hgpolension, Tachgcardia. Cganosis. Ol[luria. Renal failure.

. . . . . .

AlDg. Brucelloeis. CMV (Ihe MOBI C0MMOttl) Malaria(onlg bg RBCs) Viral hepatitis. Sgphilis.

tf patient is under anesthesia or comatosed


lncompalibilitg is suspecled bg: . Bleeding tendencg (oozing of blood)

tr

Progressive uneplained hgpolension, fachgcardia.

trWHOtE BLOOD: Hernorrhage, operalive replacernenl, severe


burns trPACKED RBCs: severe anernia trPI.AIELETS: I'u or 2's lhrombocglopenia, platelet dgsfunction trFRESH FROZEN PLASMA: burns, rnalnulrilion, coagulopathies trCRYOPR,ECIPITATE: hemophilia, DlC, Wt/D

TREATMENT:

. . . . . .

Slop lhe transfusion irnmediatelg. lV fluid(ringer laclale* corticosleroid). Alkalinizalion of urine bg NaHCoS Mannilol20% l0O ml (forced alkaline diuresis). Repeal palienl's blood lgping & matching.

Noll+M

Complication of maseive blood lransfusion


Acidosis, Hgperkalemia, Circulatorg overload, Hgpothermia, Cilrale toxicilg, Bleeding lendencg

Z-Ait embolism. 3-Thrombophlebitis at the site of injeclion. 4-Complicafion of lranefusion of stored blood Acidosis, Hgperkalernia, f O2 affiniig

TFIBRINOGEN: DIC
trLEUCOCYTES: Severe leucopenia, Agranulocgtosis

lJRq-Taq'$

E{Docxhly

XMR'I

hqv I

WL

r Nutrition (Enieral, TPN) r Posl-operative cornplicalions

r Acid base balance

r Hernoslasis r Bleedinlf disorders r Bodg Waler r Sodiurn, Potassiurn, Calciurn

cilRt4-Iwr5

A{D0CEI{E

IJP^W

?AqE t

Cornrnon pathwag: Faelor l, 2,5,10, l3 Assessed bg PT, PTT Exlrinsic pathwag:

V g

EI Vilamin K is essential for aclivation of Factor 2 ,7 ,g ,lO Iheg are prolonged in Liver disease, Vitamin K

Faclor 7 Assessed bg PT Affects Oral anfi-coagulanls Prolonged in Liver disease, Vilamin K malabsorplion (obslruclive jaundice) tnlrinsic palhwag:

g g V V

M M

rnal-absorption (obslructive jaundice) Cournadin effect can be reversed bg Vitamin Anti-thrornbin 3, Pr.otein C, S, Faclor 5 leiden have anli-coagulanf effecl (Measured in a recurreni DW in a goun! patienl)

g 8,9,11,12 g Assessed bg PTI g Affecls Heparin

tr tr

Half-life of factor is 8 hours Mosl cornrnon cause of defeclive hemostasis is fhrombocglopenia

lnlrinsic pathwag
ogq ++lJl

CLOTTING CASCADE:

O 4BT (platelels) , 4PTT


o o o o o
Long acling acls on factor Xa Given once dailg Eliminated via kidnegs Causes no bleeding lendencg: NORMAL PTT(better in

O INTRINSIC PAIHWAY O EXTRINSIC PAIHWAY


Wthin few
minules Within few seconds

vil
tx xt

vil
EXTRINgIC

Reduce lhe concenlration Vitamin K dependent clofting

xil
INTR!NgIC

faclors Half-life : 36 hours Crosses lhe placenta (Should be avoided in pregnancg) Doses should be reduced in Liver
disease

PATHWAY

\. ^'

PAIHWAY

v
lt
!

(Prothrombin) (Fibrinogen)

Controlled bg lNR, (aboul 2-3 iirnes double the norrnal value)

xlll

lRq,'IWr5 A\$gCRtl, flRqW

?AqY I w+

NG,D
g g g g g g g d g a
Deficiencg of faclor Sex linked

13)

A , Faclor

9)

Bleeding during circurncision Posl-lraurnatic bleeding (e.g. Hemo-arlhrosis) INVE$TIGATIONS: value of faclor = 5-2OTo Normal value TREATMENT: lnfusion of deficient facfors, FFP, Crgoprecipitate

!M lnjeclions ::
De{iciencg of Factor , Aulosomal dominanl CLINICAL PICTURE: Echgmosis, Purpura, Bleeding from orifices INVESTIGATIONS: ABT, 4PT, APTT, De{iciencg of factor 8 TREATMENT: lnfusion of Deficient VW factor

g g

V Mosl cornmon cause : SEPTICEMIA


CtlNlCAt PICTURE: PARADOX.. Thrombosis Bul bleeding rnag occur

VPlatelels, 4PT,PTT, VFibilnogen, 4FDPs V IREAIMENT: TREAIMENT OF UNDERLYING CAU8E, FFP, ugoprecipitate

INVE8IIOATIONS:

REJECIION
Chronic reieclion is the rejection Hgper-acufe rejeclion is rnosl cornmon in lransplanl of KIDNFf Acule rejeclion occurs within 6 months Chronic rejection occutts in the form of lschemic librosis

LIVER TRANSPTANIATION
lndicalions : a) Primarg sclerosing Cholangitis
Biliarg alresia c) Fulminanl hepatic failure d) End stage liver disease secondarg Hepalitls B,C Hgper-acuie rejeclion is almost
PREgEItIT

[[[![[[[p[fupeof

b)

g a

g g

I\IOT

Acute rejection occurs in 30-50 % of palienl, reversible is possible bg sleroids Chronic rejection is irreversible, needs re-transplanlalion ABO malching is a musl, wtrile HtA malching is nol a musl Irnrnune-suppressive drugs: Cgclospodne inlerferes wilh produclion of cgtokines V OKIS ie more sneci{ia

lRq-TwV

1a{lwC*NY,',RqAl

?hqv I

Total bodg waler =

of Bodg weight We1


EcF lt/3) 20% of adult bodg weight

rcF

(As)

40% of adult
bodg weight

lnterslitial fluid lO% of adull bodg

lAq

weight

Intravasoular fluid (t/g) 5% ol adult bodg weight

Waler balanoe is maintained bg adjusting waler intake & waler loss..


LOgS

. lnsensible water loss (t2Oornl)


EXOGENOUS ENDOGENOUg

(2500 ml)

(soO ml)

4o0ml) Expiration through lungs . Urine (l600rnl), 0lT (2Oornl)

8oOml)perspiration lhrough skin

M Osmolaritg of BLOOD depends on PROTEIN M Osmolaritg of ECF depends on Na, Cl, HCO3 EI Osmolarilg of ICF depends on K, Organic phosphorus .BODY O$MOIARIW = 300 mosrno7Kg ..(Double Na leve!)
'ADH is conlrolled bg Plasma osmolarilg , ALDOSTERONE is Conlrolled bU Na*, K+, Renin

. VTNTAKE:
.

availabilitg Difficullg to swallow AOUTPUT: Fever, Osmolic diuresis

AINTAKE: - Pre-operafive waler enema . TURP $ - Posl-operalive over infusion of Glucose 57" lV - Neurosis

rlprallEpJiir
fhirsl, weakness, Oliguria
Hgpoiension, Tachgcardia
TREAIMENI

MODEMTE: 4udne volume, OBodg weight MARKED: Brain edema, Nausea, vomiling

R.eplace bg Na free waler

.MILD TOXCITY:

.BEM!IA!!!!BE

V waler inlake
Dialgsis

.EBA!UEDE@, Mannilol, Cortisol, Hgpertonic saline (lf lhere're CNS


manifeslations)

crffi4-Twfi

ww*wflMw

?Aq I ttu

g
V

g a

Major exlracellular calion Normal leve! " 135-145 mEq/L Mosl comrnon sile is BONE Main route for excrelion is Kidneg (reduced after lrauma) Main regulalor is Aldoslerone

ETIOTOGY

DITUTIONAT (MOST COMMON TYPEI .. Waler inloxicalion .. EI 4lntake.. Post-operative infusion of Glucose 5%, IUR.P $ EI VOuQut.. Rena! failure

NON. DILUTIONAL .. Shock ..


EI V dietarg inlake EI 4Plasma, GlT, Rena loss
CLltrllCAL

RETATIVE HYPERNATREMIA: EI Mosl common cause is WAIER DEPLEIION, Na wilh inadequale replacemenl ABSOIUTE HYPERNATREMIA EI AINPUT .. Post-operalive adminislralion of Saline EI $ALT RETENIION.. Cushing $, Conn $, Hgperaldesteronism
gpertension, Tachgcardia, Enlarged Neck veins, Ederna, CNS manifeslations ending bg seizures, Corna
H

PICIURE

MIID CASES (VECFI:


Hgpolension, Tachgcardia, Oliguria, Emptg Neck veins, Sunken eUe, DrU longue, Drg Skin

ADVANCED CA$ES (OICFI: CNS manifeslalions EI lF REIAIIVE: as waler inloxicalion

EI Active lrealrnenl:

AB$OIUTE HYPONATREMIA: - Mild lo rnoderafe) 0.9% NACI - $evere) 5% NaCl ..(oNa lrnEq/hour) N.B. lf more: demgelination of Nerues

Sodium-free waler
(Correlaled wllh duralion of hgpernalremia)

m.

Of Cause

EI

TII. Of Cause

ilRq-Twr-5

ANDoC4qhE

ffiqw

?Aqv I

V A g g g g

Main lnlracellular calion 198%) N. level 3.5-5.3 mEq/L , Dailg need : 60rnEq/L Non-diffusible lhrough cell rnernbrane lnsulin, 82 slimulanls, alkalosis)K lransfer inlo cells 9O% oI {illered K* is reabsorbed through PCT

4K levels in

(Succue intericus = inleslinaljuice sarne conc. As PLASMA leaking occurc: rnelabolic acidosis with N. anion gap)

)if

ETIOLOGY

RENAT

tOgS

MMost cornmon cause is VBnd rnost cornrnon cause is Renal failure EIDfiRACETLULAR, SHIFI:
Tissue damage (Hemolgsis, Rhabdomgolgsis, Acidosis, insulin de{iciencg)

ElDiurelics MAntibiolics "Carbenicillin" MCrohn's disease, Cushing


GrT

tosg

EICrohn's disease with {istula EIK losing tumor "Villous adenorna " Mlnlracellular shift: Alkalosis, insulin

o o o

Asthenia

Alonia (ex: paralgtic ileus )


ARRYTHMIA

o o

Asthenia, Alonia, Arrgfhmia, Apathg Conslipalion

g g

ECG: Flal or inverled T wave Prorninenl U wave Depressed S-T segmenl lnvestipalions for lhe cause

. , .

V g

ECG: Prolonged PR

. . r

Wde QRS
zfr

S-I segment

lnveslioalions for lhe cause

V
EI RULE OF 40 - Urine oulpui musl be >40 mlhour - <4O rnrnol K* added to I L {luid - lnfusion rale should be al rale <40
mmoUhour

Trealrnenl of cause >7 meq/L )Dialgsis

-=---E
c)
d)

a) Sodium licarbonates lV b) lnsulin regular infusion


Olucose 25% Calcium .. anlalonize Polassiurn effecl on heart

E
EI

ESTIMATE K+ DEFICIT

(4.5

serurn K* concentration) x IOO in Norrnat PH of an adull DECIDE OML OR IV K*

ilR4,-ToAr5 E{DoCFNY rJ,l?4W

?hq* | 08

V V g V g

N level :

8.5 -10.5 m7dl

Mosl cornmon sile is BONE$


Serurn calciunr exisls in 2 forrns:

50% ionized) ACTIVE FORM 50% Non-ionized ... l4O% of which is bound to albumin) Albumin's half-life in circulalion is 15 dags Delerrninalion of Prolein level is essenlial in analgsis of Calcium levels

I
ETIOTOGY

r1 IIrIrl Ig 1[' l7t

Il2: :IglITD: ill7t

'

. . .
CLINICAT

Mosl cornrnon cause is after thgroideclomg


Alkalosis Hgpoalburninemia Acule pancrealilis

Mosl cornrnon cause is


Hgper-parathgroidism Thgroloxicosis

PICIURE:

BONE, MOOD, STONE, GIT

. . .
lnvesligations

Carpopedal spasm, $lridor, Convulsions

LATENT HYPOCALCEMIA: CHOVESTECH SIGN: tapping over branches of Facial)twilches in facial Ms


TRAUSSAU SIGN

:: see clinical picture of


hgperparalhgroidism : :

. Measure serum Calciunr

. Measure serum Calcium . lnvestilations for cause:


- HVDerDaralhqroidism :: see invesl'lgations of hgperparalhgroidism : :

-Bone secondaries) Bone scan


TTI

lO% :
TTT. Of cause

l0 ml lV slowlt

MEDICAL TREATMENT g lV fluids , Bisphosphonales TREATMENT OF CAUSE:

fl

Patient with Hgperparathgroidism ,exposed lo slress EI CLINICAL PICIURE: - Polg-urea, Sevete dehgdration

TREATMENI:

a)
b)

Ringer Laclaie

Hgperparalhgrcidism :: see lrealrnenl of hgperparalhgroidism :: Bone secondaries: - lf operable) R.adical reseclion - lf inoperable) Palliative reseclion, chernolherapg, Radiotherapg

c)

ffi(rTwt5

E{Docxht,

ilEqw

AEe

Iq

, Producls of melabolism are predominafelg ACIDS (CO2, organic acids) . Mainlenance of slable PH is achieved bg BUFFER 8YSTEM . Mosl imporlanl buffer is HCOS ... (easilg manipulated bg lungs & kidneg) . HCOS is controlled gtOWLY bg KIDNEfS ... Change is MEIABOUC
PCOZ is controlled RAPIDLY bg TUNGB

ACIDP/ISE
... Change is RESPIMTORY
are assessed bg ABG

CE

. Blood Pll , Elecfrolgles . NORMAL VALUES:

:7.95 -7.4 HCO. : 22-26 mmoUl


PH
PO2

75-l00mmol/L , PCO2 95-42 mrnol/L

PH

= Pka +

Log HCO/H2Co"

Bicarbonale, Carbonic acid ratio is 2O:l

. ln ang melabolic or respiralorg

disorder...

OMPENSAITON will reslore Normal arlerial PH PARTIAILY

Metabolic acidosis) Hgpervenlilalion (VPCOJ Metabolic alkalosis) Hgpoveniilalion (APCOr) Respiralorg acidosis) HCO, produclion bg kidneg Respiratorg Alkalosis) HCO. excretion

Eliologg:

vPH, V

HCO3

4HCO3

4PCO2

VPCO2

4Production o{ H+: -DKA, Mgocardial


infar"ction

^PH, loss of H+:


-VOMITIN0, diarrhea -Paradoxical aciduria
(CHP8, Pgloric slenosls)

lmovE[il.ATtoN
CN0 depression,

^PH, HYPERVETII.ATION
Hgslerioal, Hgperpgrexia

Ms. Weakness
(Mgathenia

-lacllc
shock

acidosis

-Seplicemia, seplic
HCO" Loss:
-aa-

-Diurelic therapg
(Ihiazide, loop diurclics)

gravis), COPD

O HCO,:

-Renalfailurc
-Diarrhea, inielinal {istula
-

-44

inlake of

arrlacids (NaHCO")

Urelro-sigmoidostomg

Clinical

4Raie, depih of
Breathing ..KUSMMEL'g BR.EATI{"

piclure:

- C.P. of cause - lfsevere) Ielang

- Cganosis - lrrilabilitg
Mechanical

Respimiorg rale
anesl)

(Tetang, Respiratorg

TTT.

-m. Of cause
-lf severe) NaHOO,
(Bodg weighl x 0.3

-m.

Of cause

Palienl respirc irrlo


a Paper bag

-!V saline -lf severe) Arnrnoniurn


chloride Slowlg

venlilalion

x Base deficient)

Xeq-fwg

,NDoCFNE

X,V^W

?hqv I m

UEq GJ
METABOLIC DISORDER,

RESPIMTORY DISORDER

VPH, V

HCO3

4 HCOs
^PH,
Cornoensalion:

vPH,

4 PCO2
^PH,

VPCO2

CornDensalion:

-0PCO,
(Hgperventilation)

-oPco2
(Hgpoventilaiion)

Cornpensalion: -fHCO' (Buffer

-VH* lRenal lossl

-VHCO. (Renal)

sgslem) -VH* (renal lossl

MIXED DISORDER
RESPIRATORY,
]VIETABOLIC ACIDOSIS

euiq

lJlllft COz, HCO3 Jl

eJ

RESPIRATORY, METABOTIC ALKALOSIS

VHCO3, 4PCO2

aHco3, vPcoz

Represenls Anions NOT usuallg measured

. Value: 10-19 mmo7lilre . Calculalions: CAfIONB (Na, lq - ANIONS (Cl, HCO3)

MEIABOLIC ACIDOSI$: - Due - Due

to VHOOa.. NORMAT ANION GAP 1XCO, srii)


(RF, diarrhea, Inteslinal fistulae)

Other alkaline juices : Succus entericus Bile i

to

H* .. 4ANION GAP lncia tusi)

(DKA, Lactic acidosis, Septic shock)

ANa,ACl, AH*, No HCO.

c*fr.4:lw.t5 ww*NY 1.R@l

h{10

lll

INDICATION$ OF ENTEMT NUITRITION: V In Palienls where ORAL inlake is inadequale : (Cornalosed patienl, Severe dgsphagia, Neck surgeru, Burns) PATIENT REQUIREMENTS: M Stp FEEDING: Whole food bg mouth (fluid formuta) EI Tueg FEEDING TECHNIQUES:

NGT: Rgle'e tube

GASTROSTOMY) Liquid diel, Juice, Milk JEJUNOSTOMY) Partiallg digested or elernenla! formulae

OOMPTICATION$ OF EIITEMI NUITRITION: MECHANICAL: Malposition, displacemenl, BIockage, Breakage, Leakage INFECIIVE: exogenous or endogenous GII: Diarrhea, bloating, Nausea, vomitin!, abdominal cramps, conslipalion METABOLIC/ CHEMICAL: Elecirolgte imbalance, malnuitrilion

TUTAt

T{OM

INDICAIIOIUS OF TPN: M Blocked GlT... Slricture, Neoplasm, Exlrinsic rnass M Shorf GlT... Short Gul sgndrome EI Fistulated GlT... Enteroculaneous {istula EI lnflammed GlT... lnflammalorg Bowel disease EI Unsuilable condition... GIT can'l cope as in severe traurna, hgper-catabolic slate PAIIENT REQUIREMENTS: EI Suqical patient needs 40 KcallKg bodg weighl,24OO Kca7dag

M
EI

Energg given:

(lgm CHO=4Kcal, lgm Protein=4Kcal, lgm Fat=9Kcal) Ratio in a well-balanced diel is .. (CHO 5OTo, Prolein 157o, Fal g5%) Requirernenls are liven in 2-4liters of Fluids as following: CHO) Glucose 5O% + lnsulin Varnine or Tolarnine Prolein Fat) lntra-lipid l0%

COMPTICATIONS OF TPN:

Nutritional & melabolic cornp!!ca]!ons;,


(Hgperglgcemia, Hgpokalemia, Hgponalremia, Hgpercsmolar coma) Cenlral venous Catheter comPlicalions: (Hemolhorax, Pneurnofhorax, Nerue injurg, Cenlral venous calheler infection & Sepiic thrombophlebitis)

1.R4-Toq..t5 1^m,RNY 1JWW

?hqv I w

tr

tr tr

GENEML COPLICATIONS: Fever (Most cornrnon 4O%), Bed sores, Confusional slale LOCAT WOUND COMPLICATIONS OTHER gYgTEMg COMPLICATIONS

ResDiralorv ... $ee Cardiolhoracic surlery ... Cardiovascular cornplications: Hgpotension, Hgperlension , DVT Gasiro-inteslinal cornplicalions: Posl-operalive Nausea, vorniling!, lnleslinal obslruclion, jaundice UrinargcomDlicafions: Renal failure, Acule relenlion, UTI

DAYS (Reactionarg- Lung Urine- wound) EI 0-l )Reaclionaru : Ebb phase of inflammalion

V fl5-7)DW,UTt V > Tdags) Wound infeclion or sub-diaphragmalic abscess

fl

2-S 3-S

) )

Atelectasis of Lun! Thrombophlebitis at the site of cannula

FOR UNCOMPTICATED PATIENTS)

LITERS OF FLUIDS

lO.9% g 2.5 Lilers iYo Dexlrcse (Glucose) V K* is liven afler 48 hours: - Saline is replaced bg KADALEX (Contains 27 mmolK+ll) - Polassium Chloride supplemenls lo avoid fluid overload N.B. Correclion fluids irnbalance should be

EI

5OO ml saline

NaCl)

CONTM-indications: EI Biliarg operations

M Coma
EI CNg problems EI Respiralorg depression Withdrawal effects: Agitation, Vomiiing, Diarrhea .riiill gJorJl.cl+i Ef pto!rJrk

cJJR{+-TooN5

1r"l{[rr'*Nv

ARqW

?hqt t v

l.

Focused abdominal sonograrn for iraurna (FAST) assesses for blood in pericardial sac, hepalorenal pouch, pelvis & spleno-renal pouch, bul NOT in relroperilonea! space.

2. Small inlesline is the rnosl commonlg affecled organ in penelrating injurg of abdomen. g. The rnosl irnporlanl slep in lreatrnenl of septic shock is drainage of septic collecfions. 4. Allowing blood which is readg for lransfusion lo remain for 4 hours in warm environrneni
5. 6.
7. encourages bacterial proliferation & septicemia. Donaled blood is nol roulinelg screened for CMV. The mosl cornrnon problem resulting in hernoslasis is lhrombocgtopenia. Warfarin has half-life of about 36 hours. Warfarin crosses the placenta & should be avoided in pregnancg. Half-life of faclor Vlll is 8 hours.

8. 9.

l.
2. 3. 4. 5. 6. 7. 8.
9.
lO.

ll.
12. 13. 14. 15.

Newborn infants have the lrealesl proportion of total bodg waler (total bodg waler decreases steadilg wilh age). Females & obese persons have a decreased percenlage of TBW. ln a healthg adull, exlracellular osmolarilg is lhe same as inlracellular osrnolaritg. Norrnal saline conlains 154 mmd Sodiurn & 154 rnmol Chloride. HARTMANN'S $OLUTION conlains calcium bicarbonale. The major anion in lhe inlracellular fluid is PHOSPHATE . Sodium urinarg excrelion is reduced after lraurna. lnlracellular concenlralion of K* is 150 mEq/1. The averuge dailg need of K* is aboul 60 mEq/I. The rnosl serious consequence of K* irnbalance is cardiac abnorrnalilies. Magnesiurn is lhe 2^d rnosl abundanl inlracellular calion. Ihe cardiovascular effects of hgpomagnesaemia are similar lo those of hgpokalemia. The rnosl significanl inorganic plasma buffer is bicarbonale. The 3 mosl important buffers in bodg fluids include: bicarbonate, phosphale & prolein. Ihe ideal infusion fluid for correclion of hgpokalemic alkalosis due lo pgloric obslruclion is norrnal saline.

Locallg invasive lurnors include basal cell carcinorna, rnixed salivarg lumor, bronchial adenorna, adamanlinorna & osleoclaslorna. 2. Genelic predisposition to cancer is relaled lo inueased chrornosomal fra$litg & defect in DNA repair enzgmes. 3. Thgroid, breasl & lung cancers are cornrnonlg melaslasizing bg blood.

leq4w-tS

,ND0CRNY

l"RqW

?h

I r[4

Clinical picture of seplic shock KasnZM )

aa

Managernenl of septic shock


G4ilar trl,

zoll
(Kasn

Patienl wilh seplic shock have a worse prognosis than those with hgpovolernic shock

2M

Discuss Etiopaihologg and clP of hgpovolernic shock Kan 2o// - 5u sfiams, zoo/, znz - Alur rlrL zo/, Tgpes of Hernomhage and their rnanalernenl ( Kasn 2@7 ) Factors affectin! wound healing
,4ilar rlr1,2W - A** Cornplications of wound healingf
(

zml

f,2@6,2@5 - Kasn 2@f )


( Kasn

r Cornplicalions of Blood Transfusion


Kan 2@f
- r4y'ur f,

2d )

r Cornplications of spina! anesthesia


Kar, z@r-

2@f Z@4, 2@/, 2fu5, 2M ,4y'rar rl/, zmz 2@6, 2@4, 2@5, 2@/1
,4y'rar

2M-,4lr

sfiarrls,

2W, zfu

ril,2@2,2@/,2m F,2@22@6,2Ut4 )

r Cornplicalions of general aneslhesia


(

,4y'ar

r Enurnerate posl-operaiive cornplicalions r Post-operalive fever


(

Ailar f,2@O - Ay'rar rl/, Zm/ )


(

r Posl-operative pulrnonarg cornplications


,4ilar

Ailar

f,2@7)

f,2@4 - r4y'rar rl/, ZnC)

(Kasn2M

Brain

Ji,gi;ietr

r'ell

Arms

SLrtertor

!8lia taYa Q'!a

',-.,i2('ot .iefia

lleoa',lc ', elr Hepaiic c0ta1 'jerii

i-iver

?e.tall ie::l !i,aa':e,,.


Lo!"jea

;!Cv :i':S rels

rilbrtael Safwat
/1ABBClt

slaws

leq-fw$

EFTDtrXNE

g,^?4W ? hh ! tq

DEFINIIION: Lack of blood flow due to eudden occlusion of previouslg patent arterg with NO lirne for collalerals fo open.

Severe, in lhe rnosl peripheral part of limb Pallor Marble white 2) Mottled ,pp. After 6-12 hours 3) Fixed blue slaining of skin ........

l)

tr

E Young age

tr PDF:
. . . .

lncidence: FlA, Fernoral l4o%)

tr tr

IR.R,EI/ER.SIBLE
@ @

Pulselesness dislal

lo sile of embolisalion

Paralgsis Earlg in arterial, lale in venous obslruclion Paraslhesia (Anesthesia) LATE, bul reversible after TfT for few monlhs Progressive Coldness

tr
/ /
/ //

Mitral slenosis with AF Lefl alrial Mgxorna Mural lhrornbosis Frorn Larle arteries) Alherosclerosis, aneurusrns . Veins) Venous thrornbi, VSD, ASD, Eisenrnenger $ LIMB : $udden onsel Pale, while,

. .

OLD age PDF :

ETIOLOGY

Alherosclerosis Slasis,Hgper-viscosilg
(Diarrhea, polgcgthemia)

E Open E Closed
lalrogenic E lntra-arterial drug lnjection
Etr

tr

/ / /

LIMB : Acule bui less drarnalic Pale, white


TROPHIC CHANGES ANGTO> +VE COLTATERALS

clo:
E Historg of

// /

tr
tr tr

lraurna Bleeding Shock Hard signs vs. Soft signs

o/E:

Pasl Hislorg of lnlerrnitlent claudicali

tr

s acc.
To affecled arterq :

VIAEI-E THRPtTBIED

lffi
Fixed color changes

. . . . .

Brain )TlA, Stroke Relina )Arnaurosis Fulax Mesenleric vessels Spleen ) Loca! pain Kidnegs ) Hernaluria

)Gangrene

a&q'-tw.$ 6{Doc^PI.lE IJRqW

AqY t

Ytn

Srrpor rMpIGnoN
V g
PRE.OP INTRA.OP )For fhreatened limb

oFETpl.Oq/ g ECHO, ECG)Deiect AF g X-rag ) lnjuries V US ) Aneurgsrn

oFffi
tr tr
Muscle Necrosis : 4TLC, 4CPK, Acidosis Hgpovolemia : 4Hb, Crealinine, BUN

Block of main arterial lree

+VE collalerals

FERIPHERATffi
H/AFD StqlUS

vS

sEoFT sltGIUS

tr 6Ps tr Pulsatile Hemorrhage tr Pulsalile Hernaloma tr Palpable thrill, bruit

tr tr tr tr

Hernaloma non pulsaling, non-expanding Nerve injurg Wound is near a rnajor vascular slructure Delaged capillarg refilling time

Urgent lnvestigations

lLlq.q:l}r/,.r5 1^9rr/PNY IJRqW

?AEi; I

Wl

PREoffi
g g g d d
Hospitalizalion Oxggen, d'rgiialis Anlibiotics Morphine Heparin : SOOO units lV

nfrnAcrffi
oFCAGEE
eryleoust/l tr Anli-coagulants tr Anti-arrglhrnics

Podroffi
OFGOME
tr
Gangrene

T{roMBoclls
Eleclive BYPASS

tr tr

eMgo;StJl
tr lf wiihin 6 hours:
URGENT EMBOLECTOMY (Fogerrg catheler) Cornrnon femoral lransverse arteriotomg 2) Aortic bifuricalion) Bilateral Femoral arteriolomies Late :

ffi
VIAETE

AI{IERLIIL T{FEATEDb
Urgenl ANGIO
URGENT R.EVASCULAR.IZATION SURGERY

$[rt,FI/

Arnpulafion Volkrnan's contraclure Tendon lransfer Crush $ lV fluids, Alkalanizalion

l) Fernoral arterg)

lffi
AMPUTATION

of urine

MCS
I

tr lf
tr

Fasciolomg (To prevent cornpartmental $) S'rgns of adequale emboleclorng: . Pulse fell . Color, ternperalure . Fleverse bleeding . lnlra-Op angiographg

Follow up clinicallg and angiographu

No wlFno\lErllntr
I

tr tr tr

URGENT

Re-vascularization

Streplokinase Pulse sprag or lV Loading dose, followed bg rnainlenance R.ecenl) Recornbinant Tissue plasrninogen aclivator

TIT oF FERIF|{ERAL AnrrmrAU INJ,F!/


n
fr
PRIMARY SURVEY: ABCDE
SECONDARY suR.vEY

1R{4:locllt5

.^*,,*NYilPq*'

hq

t w,?-

....
lo

Head

Airurag, breathing, circulation, Drugs, eXposure loe Exam, AMPLE Hislorg , lnvesligalions (An$o ,Doppler)

MOFAIilEFRACTT'RE
WAII fior 20 rninutes
Pulse relurns
DEAL WITH THE FRACTURE

No pulse
D(PLORE

&

DEAL

ODEN
lrrigate wilh saline & Wound debridrnent
tr tr tr tr tr

ch.m
t{tfttourrE(R
Spasrtt
I

Skin)

I{ITHTEAR
PAXTIAT,

Excision of l-2cm
Open lense fascia

Fascia)

Mg.)

Excision of dead Ms. Mark with black silk

CortnstoN
I Excision

Corinere
>l/2
I

Nerue)

Blood vessel

Deal as

Clo.sed injurg wilh tear...

Painting Or lntra-arterial papaverine

of the

<l/2
circumference
I Repair with proline sulures

conlused segmenl and saphenous graft

circumference

Treal as
Cornplete

Repair in obligue mahher 2) Mobilize arterg 3) Cul branches 4) Baphenous vein grafl

r)

cqnoN penrPl+*ALffiDlslEASE
DIAEEf,IC
PRESENILE
AIHEROSCLEROSIS

lJ?q,-Toqr5

E{D0CXNE

ilRhW

?hh? t

w7

BrrItcFRS

ffiffi

ffi'S

chrNrcAr srAgEs (Fs,trAllG)


.ASJMTMdUS
tr tr
TYPE OF PAIIENT

Male>S0 Uears wiih risk Aiherosclerosis faclors (DM, HfN, Obesitg) Male 2O-4O Year. Heavg smoker Buroer's gYMPIOMg

tr

tr i tr , tr

bg walking, V bg & resl Cramp-like PAIN, Prcgression shorter claudication dislance, 4Period of rest Affection of other sgsierns CNS : TlA, slroke
,1.

tr

r .

WPE OF PAIIENT Alherosclerosis Male>SO gearc wilh risk faclors (DM, HTN, Obesitg) Burper's )Male 2O-4O Yr , Heavg srnoker REST PAIN Severe pain lhal awakens Pl. from sleep

I.

tr

Itr

tr tr tr tr
2.

CI.AUDICANT LIMB

Kidneq : Pain. hernaturia, hgpertension @!!g!.;. Leriche sgndrome OENERAL EXAMINAIION Vilal s'rgns : . Bgslolic Bruit )(Aneurgsrn) . Conlinuous Bruil )(arterio-vehous fislula) LOCAL EXAMINAIION) LIMB IIII LAYERS

. ryq HF .

tr

tr

tr tr tr
2.

4bg REST, AT NIGHT, ELEVATING LEG


Vbg Hangn! foot down
NEI/ER above Ankle Drg gangrene ...... (Wef if HF, lnfection) ABSENCE OF PERIPHEMT PULSATION

UICER, RESISIANT FOR, HEATING: Tender ulcer Between Toes, dorsurn of foot Edge Punched oul Margin Black, rnumrnifted Floor Granulation Base Diflicull to palpate

) )

GANGRENE

1Rt4-{our5

E{DocxhrE 1,^Phwl

?A6F I

tr CBO)Anernia,

DOPPIER
, r.al1-r4l
Biphasic flow (Collaterals)

PFEOFENffi\IE

,-l
. i..

W
-

lFITF)MRA

iiqLit
Normal >l O.5 : CLI ln diabelics ) foe Brachial index

. .

ABP!

.ADVANTAGES: - Site of slenosis - Exlenl of stenosis


Collalerals Run in & off

tr tr tr tr tr tr

Polucvlhernia (Anernia eggravaled ischernia) FBS >DM KFt >Alherosclerolic kidneg LFt lrnpaired

ECG

)IHD

CXR )Promineni aorlic knuckle. calcified atherorna L:pid profile

.TECHNTQUES:

DrrPl^D(

- Direct femoral arleriographg - Trans-lurnbar arteriographg


(if bofh femoral pulses aren't pulsable)

- frans-axillarg arleriographg
(if fhe whole dislat aoria is occluded) . COMPLICATIONS: - Neurologica! deficit

Hernorrhage Pulsalile rnass

lnfeclion al punclure sile Allergic reaction to lhe conlrast


rnedia Thrornbosis

1JP,440qr5

AWOC*hIE

1,,RqW

?k e I w

BES;rMDIGATTIT
tr RISK FACTORS MODIFICATION

PFEffiAT.IGIW
+\,E DISTALFTJNoFF

. . . .

Cessation of srnoking Proper conlrol of DM

- \rEDlsrALlg6laryp

Conlrol BP Lipid lowering


Aspirin 75 mgldag

S${oncrSrcfiertr

roD.Gsrciltatr
ARTERIAL BYPASS
AFO/E EE.olr,

*:Htfl#.DtS
AN
PG

tr

ANTI.PIATELETS

g V

Endartereclorng Balloon Angioplastg Wth or wilhoul Stenl

UI SYMPATHECIOMY EI Arnputalion

tr
tr

tr

(lf patient is inloleranl) Plavix) Clopidogrel VASO ACIIVE DRUGS CARE OF FOOT DGRCI$E (to Oclaudicalion distance)

'

uqAirrtr
Sgnthefic graft (,i[r.ArmAu . lF Hf) AortoAorto- Bifernoral Bgpass lF UNFIT (e.g. cardiac patient)) AxilloBifemoral Bgpass

${qor.lAL

h.lclorl.ht TEAFJtT
Saphenous Graft

rMffir{o{+Mffi
a
V

D{sm,
Femorodistal bgpass

FartsnsED
FemoroPopliteal bgpass
fuJl a#hi fuJl g +.r-tll

fernoral bgpass IF UNFI' Fernoro-Fernoral


Bgpass

SYNTHETIC
KNITTED
DACR.ON

+i.lall

5E44wr5 ENDOCXI{E IJRqW

?Aqv t wo

DEFINITION: a cornplex pathologg in a diabetic patient's fool which is relaled to duralion & Control of the disease

tr Painless tr Deep tr Al pressure siles tr Fool is :


Bounding pulse Dlslended veins Duplex : Norrnal or high Flow
TTT

tr

Lirnb is: Swollen

Red, hol, lender


(lnflammalorg reaclion is weak as Pt. is lrnmunocompromized)

aNGretuy
I

tvlrchor

Mrcho. aN6ontn+r
tr tr
tr tr tr
Pulse is fell No bleeding
I DEBRIDMENI Antibiolics Dailg dressing till the wound is TIDY) FLAP !

trler
On top of
INFECTION

tr tr

/ / /

Wann

tr

Mag spread Osleorngelitis, Septic shock


TREATMENT:

NO PULSE
I

: conlrol DM,

fool care. Vilamins

-Debridernenl -Antibiotics -Dailg dressing -lf gangrenous Amputaiion

DOPPLER & ANGIOGRAPHY


Run off + SHORI segrnent
Run off +LONG segmenl

Arnpulalion

Ulcer

PTA

BYPASg

vAsoPAsrl

lJpq-Taqr5

A{DOoFINE

*PqW

? AqV

IW

DEFINITION: Recurrenl ischernic al-lacks precipilated bg exposure to coldness or emolional slress

//

DtS=.(Sri
ETIOLOGY:

,/

ETIOLOGY:

- 'lt sgmpathelic lone - Psgchologicalinslabilitg - Abnorma! sensilivilg of hand to coldness


CLINICAT HCTURE:

CollaAen: 9LE, Scleroderma


$

- Youn! fernale "ii'lUrilrr Jsgl{JI

r-".s

ldf 11| iiJ:ro

fi

16rJl

lJ, tli{

//

Arlerial obslruclion: Burger's disease Nerve injurg: fhoracic oullel $, Carpa! tunnel Druss: Beta Blockers CLINICAL HCIURE:

- MAYAFFECT@
.

- [[ tuophic changes - Peri-pheral Pulsatiohs are trE

- @ Trophic chanles - [EP"ripheralPutsalions


Drugs

Care of

Patienl

Care of Hand

Surterg
Sgmpatheclomg (Cervico-dorsall

. Slop smoking . Avoid cold . TTT. of anernia


if preseni
weaiher

.
.

Drgness Woolen gloves Exercise

TTf of
CAUgE

. . CCB

Vasodilalors Babg aspirin

Vasodilalors (Avoid Bela Blockers)

Sgmpathectorng
NO BENEFIT D(CEPT: . lf vasculilis occur . Crgo-anlibodies (Makes sgrnpalheclorng ineffecfive)

. &&()YAW, Sgmpalhectomg is EFFECfNE . EpI$I-EIIE Emerlencg m) lmrnersion of affecied parl

in Warrn waler

l40-44o)

lJPr+-Twr5 r^Jiw*Nr.eruW

?Aqv I w3

M
Cr-lpNlc
yoot{GpffiED{r
oLD PArlED{r
Biopsg jl 69iao Other Narnes:
I

Angio g .-otluiS

@
Affects Big
vessels e.g. aorta

@ Chernodecloma @ Polato Turnor

Angiographg: @ Widening of the Carotid Arterg bifurcation

Excision or ligation, wilh presen ation of ICA

Surgica! iniervention

* * t)
2l

lndication: >7O7o slenosis if Sgmptomatic or >8O% if Asgmplomatic Method : Carotid Angioplasig & Stenting
Endartereclomg

@ Hgpertension
NOT responding

lo medication
@ freatrnenl: Balloon dilatation & Stent
dlte
efnraya been a hlgh addever, alwayc crrlvlng 6oc

hcH, grrcaer.-.rrd now audden[r lrrr cqioliled to c.ltle for &hycri blood prrer{}unc and lers cholcstcroI?t,
blggcr,

1,,Rq-IC[/,f5 a{DocPtE
BOUNDARIES OF IHE COMPREggINO IRIANGLE:

1r{oRA(,lC,
DEFINITION: Cornpression of N. (Brachial plexus) & arterg (Subclavian A.) while crossing through lhe narrow triangle ir;the base of Neck

apaw

Ah[, I

W1

Etiologg
Cervical rib Scalene $ o+lvrr#slJl Hgperabduciion $ Uirl6ill Mal-union of Clavicle EI Pencosl lurnor

-Scalenus anlerior -ecalenus rnedius -Firsl rib

SylbnoMe
GltpNtc lscltBtlA oF(L

E E tr tr

Cornpression of Lower lrunk of brachial Plexus

Cornpression of Subclavian Arlerg

FGTSnED{snC

Compression of Subclavian Vein (Rare as il's oulside lhe triangle)

DlrArffioN

Effort fhrornbosis

On Ulnar side of Hand & Forearm

Small Muscles Of Hand

Alrophg &
Weakness

Claudication 2rg Ragnaud


pain with exercise Phenornenon
SIGNS:

Emboli to lndex & middle {inger (DrGrrAr GANGRENE)

&DW

)
Angiographg: - Cornpression of $ubclavian arterg on Elevalion of arm

Radial pulse becornes weak

tr tr

There'sPosl-slenoiicdilatation

Plain x-rag) Cerivcal rib Nerve conduclion velocilg is prolonged

M!LD (NEUROLOGTCAL)

gEvERE (ARTER|AL)

tr

Phgsio

&

Shoulder exercise

tr tr

R.eseciion of Ceruical rib or lsl rib Scalenotorng

ilPq,-Twr5 wwIJNYxMRJ

Tfi{1V

IW

DEFIN!IION:

l2-

Sac {illed with blood comrnunicaiing with an arlerg Permanent localized dilatation of an arlerg l-5 limes lhe norrnal

,{

ETIOTOGY: Congenital, Atheroselerosis, Sgphilis, Traumalic

TYPE OF PATIENT: Old patienl (Atherosclerolic) Yount palient (Traumafic, congenital)

SYMPTOMS:

MrU be asgmptornalic ... Swelling, Pressure & lschemic rnanifeslalions

SIGNS:
I I I I I

Cgstic Along course of arlerg the arterg Cornpressible or partiallg cornpressible (thrombosis)

Moves

Auscullalion) Bruil

COMPTICATIONS:
I I
T

Pressure rnanifeslalions) V,A, N. lschemia

I t

Ihrombosis, Embolism,Alherosclerosis

lnfection) Rupture, secondarg hemorrhage

INVESTIGATIONS

. ,
.

Screening) @ Diagnoslic)
Best pre-operalive lnvestigations)

N.B. Angiographg doesn'f show lhe true diameter of aneurgsrn

Conservative

r-TREATMENT-r Surgerg if indicated


. INDICAIONS OF SURGERY - lf sgmplomatic

Follow up everg 3 months bg U/S

Diarneter)Scrn
High risk palient Excision & grafl Exclusion graft

'SURGICAI PROCEDURES

lnlra-luminal selfinflatable graft

cilq.q-Tmr5 flpmxnr

rtlBt

?hqv t vl

ABDOMN{ALAOFilC
INCIDENCE:

. -

95% due io alherosclerosis g5% below origin of Renal arleries


75% ASYMPTOMATIC
Vague abdominal pain with backache

CLINICAL PICTURE: COMPLICATIONS:

* *

RUPTURE:

Shock, acule abdominal pain, Pulsating epigaslric rnass Dista! ernbolization Sponlaneous) Blue loe $ 2) lalrogenic) Trash Fool

l)

INVE$TIGATIONS:

For aneurgsrn) U/9, CT, MRA, Anliolraphg For olher sgslerns) ECG, CBC, Lipid profile

Conservative

r-TREATMENT_r
risk patienl

Surgerg if indicaled

Follow up every 3 monlhs bg U/S

. INDICAIONS OF SURGERY
lf sgrnplomalic, Diarneler>Scm,High
PROCEDURES

. SURGICAL

Excision & grafi Exclusion grafl

lnlra-lurninal self-inflalablegraft

. .

INTRA-PERITONEAL:Fatal RETRO-PERITONEAL (IEAKING A.A.): Epigastric pain

& thock

O/E: Pulsating popliteal A. in a palienl who's nol thin


COMPLICATIONS:

il?4-Tw\5

A{DocEN?

"ilK#,] ?&

t1?-

Ul,;dl rF.t r-g tir+ij pgF


. Hgperdgnamic circulation in the
growing lirnb
(Hgpendgnarnic circulation in a growing lirnb)

. ln thigh )Butcher's Thigh . ln Axilla ) ii+h r,',!r$l r:lg


.ofar iiirs g uUgrJl dgs lJo !l oJrU g rsplp

. Manifesied bg

*j rji

"$r

. . .

IIIITT.

Pulsalile Thrill & bruit Cornpressible Or Partiallg compressible

General

pulse Jl rJs{ fil5otl


Pulse rll

sfr rsrl!Ir:i .

ujf rsu! rJ+iri


INVESTIGATIONS:

.IREATMENT:

ilPq4wt5

nrccFNtr lRh%l

?h

Iw

Mauoscopic dealh of tissues due lo loss of blood supplg and is usuallg associaled with baclerial invasion

E[]OLOGY: l.

) 2. 3. ) 4. 5. lnfective ) Epecific infeclion or Non-specilic infeclion 6. Phgsiochemical ) burns, caustics, froslbile,...

lschemic thrombosis, embolisrn, vasospaslic disease. sgrinlomgelia, leprosg. Neuropathic Venous Ganglrene (see below) fraumalic direct (bed sores),or indirecl (aderial injuries)

TYPE$ OF GANGRENE:

Causes

Chronic ischemia

- Acule ischemia

Chronic ischemia wilh pre-existing ederna (cardiac, DW).

PRIMARY: lnfection of lissues with virulenl organisms leading to gahgrene $ECONDARY: lnfection of slerile Qan{rene

Palhologg Putrefaclion
Odor Gross picfure

Minimal

Manked Veru offensive - Ihe part remains of lhe same size and consislencg. - Color: dead white )purple or greenish black. ill delined (no lime for evaDoralionl Spread SKIPPED LESIONS

liftle or no odor DrU,Wrinkled, Murnmified. Hard, Dark

Line

of

well de{ined Separalion ) Leaving a conical slump

demarcalion
Fale

clP

of local death Lost (pulsation, Sensalion, Heaf, Funclion of affecled part, fxed color changes)
The five cardinal s'rgns

l.

- fhe affected limb beeomes

..... Press & see How Color fades ..... 2. Minimalloxernia ) 3. Severe loxemia )
betler general condition.
Trealmenl

swollen, edemalous and markedlg inflamed. Ihe skin )moisl wilh bullae offensive odour & mag crcpilale

poor genera! condition.

Limb salvage

- Ampulalion tillihe
level of pulsalion

(conservalive amputalion). Non-conservalive ampulalion.

- Ttt of lhe cause if


possible.

ilPq-Tou\5

,ND0CRN?

ileqW1

?hqv t

OF
Etiologg

$ite>

over, bong prominence

(sacrum, ischial luberositg or heels)

Trealrnenl

Prolonged pressure. After irnrnobilizalion of paraplegic palienls, elderlg & diabetics. ..Bong prominence culs the blood supplg of

PROPHYLACTIC TREATM ENT - Air rnallress - Skin should be kept drg & clean. - Frequenl change of posilion everg 2
hours.

ACTIVE TREATMENT

- Debridemenl - Leave lhe wound open unlil healing - Repeated dressing with llgcerin rnagnesia
- Anlibiotics

. . . l)

Sudden onsel of scrolal inflarnrnalion sudden onsel ofgangrene Mag be associated wilh necroiizing

. .

Caused bg exlensive lhrombosis of lhe rnajor peripheral veins (phlegrnasia cerulea dolens)

fasciilis
Trealrnenl.

flealmenl:

l)

Elevate limb

2)

Antibiolics & wide surlical excision. Laler) skin graft lo cover lhe leslis.

2) 3)

Anticoagulanl lherapg is started. Thrombeclorng or fibrinolglic lrealrnenl should be considered.

5UP.4-Tffi\5

ENmflf.lV5WR1

?h lW

5R4:lwr5
^',,*NY

lRqW

?hqY t ttu

TI{FOMBO$S
N.B.
VTRCHOW IRIAD: VELOCITY, VlgCOglTY, VEggEL WAIL

TIRoMBoP+lr-EErilS
DEFINITION: OCCURS WIIH: - Visceral cancer - Burger's disease - Polgcgthemia, PAN - Ulcerative colilis, SLE

TGRAD,IS

lJlI;el

uri !

VeinsJI

A tgpe of superlicial thrombophlebitis lhal resolves sponlaneouslg in few weeks then appear in anolhet a?ea

"The Earliest sign"

DEEP
CLINICAL PICIURE:

T]IROMBO$S
T,

. .

ASYMPTOMATIC: Mosl cases are silenl bul are suspected bg unerylained Posl-operalive fever,

gYMPIOMAIIC:

. * * . . .

GENEML C/P: Fever, LOCAT C/P:

COMPLICATIONS:
GENEML: Pulmonarg Embolism
LOCAL:

EARTY: Phlegmasia ALBA dolens, Phlegmasia CERULA dolens LATE: Post-phlebitic limb leading lo 2rg Varciose veins, Venous gangrene

INVESTIGATIONS:
FOR DIAGNOBIS:

Colored Duplex Recenllg: SPIML CI, Radioactive Fibrinolen FOR PULMONARY EMBOLI$M: SPIRAL CT, V/Q LUNG SCAN, Angiographg, Chesl X-rag INVESTIOATIONS OF DW IN YOUNG PATIENI OR RECURRENT CASES: PROIEIN C&S, ANTI.IHROMBIN-3 , LUPUS ANIICOAGULANI

AEV

t t1l

FOR ALL

FOR HIGH

PAIIENT

RISK GR,OUPS

DW

FOR COMPTICAIIONS

tr
tr

tr

Earlg ambulalion Active exercise Post-op. Hgdration

E lnlra-Op Inlermitlenl

tr

Pneurnalic Cornpression Prophglactic LMW heparin

GENERAL
Bed rcst for 7-lO

DRUG

gURGICAL

dags, Vilamin E, Elaslic slockings

Ind'rcalions:

. Confra-indication

to Anlicoagulanls e.g. :

ANII.COAGULANTS

FIBRINOTYTICg .
ln lhe lirsl 3 dags 9treplokinase, urokinase
Rece

- Hgpertension - Past Historg of


Migraine, On

. Heparin for lO dags . lnfroduce Oral anli-coagulanls

. RECURRENCE OF P.E.
inspite of ful! heparinizalion

NAglDs)

PU

'

at the 7* drg Elop heparin at lhe lOrh and conlinue oral anlicoagulanls {or 3-6 ms (tf l't DW), I gear (if 2"d), or For life (if 3d)

lNDlCATlOItlS:

lsolaled llio-femoral DW lmpending venous gangne "Phlegmasia cerula dolens"

CONIRAINDICAIIONS:

- Wthin lO dags of rnajor operalion Wrthin 2 monlhs frorn sfioke

l0 mg Loading then 5 mg/dag


PTI lwice normal :25-36 sec

P[, INR (2.5-3.5 times) N :ll-14 sec

TTI OF COMPLICAIIONS:
- PUTMONARY
EMBOLISM: Morphine, O2, Thrombolglics, Anticoagulants, Emboleclorng

- POBI PtltEBlIlC

LIMB: Compression Bandage

erylpur
Etr

StilAr

lmpacled in the eripheral arlerioles

I -

nches

of

E Recurrence)
Pulrnonarg hgpertension

ClP: Severe pleurilic pain


Dgspnea

Hemoplgsis

ETIOLOGY:

lo DW, lnfeclive endocardilis, Other emboli INVESTIGATION$: . SPIML CT: ... Clot appears as lilling defecl ...
Secondarg Pulrnonarv anoio(raphu: "Mosl accurale D.DIMER: (if +ve) Conlinue invesfigalions,

bul

-ve)

" Sfop)

Blood lesls:

4LDH, Serum Alkaline phosphatase Norrnal Bilirubin .... (,1.1t HF occurs) ABG) Hgpoxia, Norrnal PCO2

Radioloou:

ECG) P-Pulmonale, Axis devialion to lhe R''ghl CXR) Normal inSO% of cases, Wedge shaped peripheral capacilg

TREAIMENT:

'.

Prophglaxis
CURATIVE

&

TTT.

of DW

frealment of pulmonarg embolism:


$MALL & MEDIUM SIZED EMBOLI) Anticoagulants MASSIVE PULMONARY EMBOTISM Cardiac cathelerizalion 2- Thrombolgtics) $lrepfokinase 3- Assess Cardiac function/G hours urgenl pulmonarg emboleclorng after NO irnprovernenl

l-

lf

6 hours

R,ECURRENCE

Prophglaxis bg IVC Filter

cJ'R4-TWr5

1allw*UVfl,Rqw ?h

0lln

DEFINITION: Dilaled, elongafed, lorluous superficial veins

of

L.L.

) a
Etiologg

tr E

[iffi Lq {II llri FI YIrr-[E


rt I

::

I g Vacular

gl ! r,rl{;3

tr
E

Congenilal rnesenchgrnal Weakness: (Marphan $, Ehler danlos $, Askar $) Congenital valvular incornpetence

tr tr
E E E

M (Most common cause) AV Fistula: - CONGENIIAL: Klipple lrenaurg - ACQUIRED: Butcher's Thigh
Aneurgsrn Burger disease Pelvic lumors, PreAnancu

AElrevatin( faclors: Fernale. High paritg, marked obesilg, prolonged standing


I

Pathologg

ncornpelent Perforators Dilated superficial veins

Incornpeleni Perforafors, Dilaled supeilicial

veins*ffi

Clinical piclure: tr Sgtnplorns:

tr

Cosmelic dis{igurernenl, Sgmplorns of complicalions (pigmentafion, ltching, Ulcer) Dull aching, sensalion of heaviness with sense of holness al ihe end of ihe dag or on prolonged slandin[

tr PATIENI: Around 3O gears tr PAtN,:[@ tr PAIN IS RETIEVED BY: (deeo veins are inlacll
S'rgns:

E PAIN: tr PAIN Ig RETIEVED BY:


r

}1

SWE[[!NG:

tr GElrlERAt: - Signs of mesenchgmal weakness tr IN$PECTIOIII: - Multiple dilated tortous vein along long,

tr
-

tr

GEIIIEMI: Pulse, BP changes) AV fistula Hearl examinalion) AV lislula lilSPECIrOtrl:

;
-

short saphenous veins Blow oul al sile of perfioralor

SKIN COMPLICAIIONS: tess


PATPATIOIII:

tr

P'lgmenlation, Derrnalilis, eczema, resielanl ulcer, Lipodermalosclercsis

on cough al incornpelent saphenofernoral junclion - Dilaled, Elongaled, fodous, Soft, Compressible lubules Defect if felt in deep fascia opposile lo BLOW OUI.

- Ihrill

tr
tr

PATPAIIOIII:

EiliflftIs)
PERCUSSIOII|:

tr

Sarne as lrg V.V. + .... AUSCUTIAIION: Machinerg murmur) AV ftstula gPECrAr SrGil8: Sarne as lry V.V. + ....

tr
tr -

dgs Ujlori,

i',ri [o

UrrUJs

gPECtAt StGrrtS: Localizaiion of incompelenl perforalor) TRENDTEilBERG IE8I, Multiple tourniqut DEEP 8YSTEM) Perthe's Tesl, Modi{ied Perlhe's fesl

EARLIEST SIGN OF CVI Ankle/Maleolar flare) Dilated subdermal veins at the medial malleolus wilh thin fra$le skin) BIUE BLEB

x,Rq-Tw.6 1aJlw*NvrRflw
lnvesligalions

v tw0

DOPPLER, DUPLD(
- R.eversa!

of Blood llow wilh Vlasalva maneuy$ ol Muscle squeeze

I1 ARTERIOOMPHY (A-V Fistula)

-Thrornbosis
- Dilated Tortuous veins, lncompetenl

valves

tr

INVESTIOATIONS FOR COMPTCIATIOIIIS:

-Plain

X-mg)

Varicose ulcer

Perioslills

PH}iAFY
UNCOMPTICATED UNCOMPTICAIED COMPTICATED

rTT. OF THE CAUSE

& ASYMPIOMAIIC CONgERVAIIVE

& DISFIGUREMENI

OR PAINFUT

INJECTION

SURGICAL

. .

Earlg,uncomplicated un{il for operalion

. . .

Moderale cese C/O: Disligurcrnenl RedisualV.V. a#ter

r larte prirnarg W . Complicaled cases

R.e-assurance

m.

Of PPI faclors Elasiic stocking LL elevation

Warnins,

lf Al! Perforators)

vEilolotrllcS

tr
E

tr

Bruisee, discomfort , Pain Nerve injurg (sensory, molor) Venous lhrornbosis

ON,EFS
tr
E [L edema
Etr

IAUPUS EQUTNUS

tr
E

Posl-lraurnatic
Hemorrhage Euperlicial Thrombophlebitis

tr

tr

Pigmentalion, derrnaliiis, eczerna Varicose ulcer Lipodermaiosclercsis

Cleanlinees, Rest, Limb elevalion

Cotisone, Znc 0xide

Earlg) Consenvalive ITT. Recunenl) Cockel& Dodd


If failed)Excision& flap

Operation

*+:f30{f, 6.m,FM XP#l

?AqY

IH

DEFINITION: Disconlinuitg of epithelium resuliing in a 3D conical

defecl in relalion fo high venous pressure on L.L.

ETIOLOGY
Aclivalion of the enlrapped WBCs in the fortuous capillailes

Ftogrir ffldri

tr SITE: Gailer area fusl above the medial rnalleolus) tr 9lZE: Variable tr NUMBER: Solitarg tr EDGE: lrregular)Sloping, serraled) Punched oul tr FLOOR: Granulation iissue tr BABE: lnduraled tr MARGIN: Plgmenlalion & dermalitis tr LNS: Enlarged if there's secondarg infeclion

COMPLICATIONS: E lnfecfion, Hemorrhage,

Osleomuelllis, Perostitis, Marjolin ulcer

INVE$TIGAIION$: E For lhe cause: Doppler, Duplex

VAtr'CGE\EINS

ffi
E E

sGgraAr
tr
lF FAILED: Excision & Covering bg Cross leg skin Flap

tr

Trendlenberg's Operation SC Slripping

tr tr

Resl, elevation of limb Compression slockings Dressing with saline, anliseptics Debridemenl

FOR, PREVENTION OF RECURRENCE:

tr

Conlinous usage of elaslic slockings Leg elevalion

?AEV

I W)

tr

GEI\IERALIZED AFFECTION:

tr

IOCAIZED AFFECTION:
Mediaetinal [Ne Mesenteric Utle

Miliarg TB Pulmonary, rcnalIB

Pathologg

tr

Organism reaches LNs fhrcugh

tr Affects tr NO ...
Affectbn of capsule, Matfin!,
Caseation, Cold abecess

ASecls

Affection of bapsule, Maftin!, Casealion, Cold abecess

tr
Clinical pic{ure

... perforates

deep fascia

tr
tr

Manifeslalions of Pulmonarg IB.. Dgspnea, Gcough, Epecforalion,


hemoplgeis

tr tr

IB foxemia, manifeslations of Pulmonarg TB Affected Lltls:

Affected Lftls:

tr
Nol lender

Nol fender Cold abscess) Flucluanl

.MtrI

Enlarged

tr Egslemic spread tr Cold abscess, 8inus, l{OT COLD abscess (2rg infeclion)
lnvesfigalions

tr tr tr

hessu?e manifestaiions Caloilicalion TABOMTORY: Leuoopenia with relalive Lgmphocgtosis EgR>100 FOR tNS) Aspiralion, 8mear, Biopsg under O.A. FOR PULMOITIARY IB) X-rag, fuberculin fesl, Sputum analgsis

E E

- f

(sun, air, nuifuifion) Anli-TB drugs

(lNH

Rifampicin

* * * * *

s:
Failure of medical TT Biopsg Single accessible group of LNe
ldrNlegfions: Banalorial & MedicalTTT Aspiralion bg Z-lechnique

Streptomgcin )

Multiple grcups (BLOOD BORNE) Bad general condilion

*lnjection of
Blreptomgcin
OR

*Banalorial & MedicalTTI tRepeated dressing wtth Streplorngcin


Powder

*Excision

lncision wilh No application of drains

1*+4W'{r, A{W*IV7'.E#I

hEY

I vf1

DEFINITION: Accumulalion of lgmph in lhe interstial space due obslruclion with edema of +he overlging skin which becomes

lo

Lgmphatic

INCIDENCE:

More in

!f Familial)

ORGANISM: W. BANCROFTI

ffirrrrL
* t
Lgmphedema Congenilal, Precox, Tarda Varicose Lgmphatics

* * * *

Filariasis

lrradialion

.f Malignant Obslruclion (Brawng edema)

C TNCAtPICf,UFE

Cellulitis

* * *

Discomforl Swelling & Heaviness.. Disturbance of function : Thickening of skin, Reslricled mobililg, Recurrent lnfeclions

Pffi
Etr Exercise

soFqrcAr
Etr Knodoleon's Op
Etr

lnlermiftenl pneumalic Compression lntermitlenl Compression Pump A 4lagers- Band tr Anlibiolics tr TTT of Cause

E E

tr

$wiss Roll cake' Op Ampulalion if hugelg swollen, ulceraled, lnfecled N.B. Results of surgeru aren't promising

,rco.6 a.|m,Phvilgw

hEv I

v15

Paihologg

tr tr

TYMPH NODEB:

tr

LYMPH NODES:

tr

- $lTE$: @[! llower deep ceMcal) Axillarg Mediastinal LNs) MACRO$COPIC PICIURE: - Enlarged, discrete earlg) mafted laler - Rubberg - CUT SECTION: Pink homogenous with loss of archileclure, lnlacl capsule gPtEEItl) Tofree Alrnond appearance MICRO8COPIC PICIURE: . REED.SIERNBERG CETLB

- 9ITEB: More ihan I group


(MULTTCENTRTc)

tr

MACROSCOPIC PICTUR,E:

- Earlg discrele) Amalgamated

. PLEOMORPHISM - loss of archilecfi.re


Clinical

ACE&

BD(: Adolescenl & middle age male

picture

CONSIITUTIONAT SYMPIOMS:

tr tr

tr

tr
tr
lnvestigalion

- Fever, llching, loss of weighf - Anernic rnanifeslalions. SWEILING: - 9lowlg progressive, rubbetg) matted PAIN: - Pain & itching (Affet alcohol inlake "Gordon's leslo or lale afrer in{iliration) PRES8URE MANIFEEIAIIONS: dgspnea, dgspha$a, - Mediastinal L.Ns hoarseness & Horner's.

tr

ACE& 8EX: Exlremes of age, Male SWEILING: - Rapidlg progressive, Hard) Amalgarnalion lafer PAIN: - Pain & itching (After alcohol "Gordon'g tesl" or lale after in{ihralion) ABDOMINAL SWETLING: - As Hodgkin's bul more common

ABDOMINAT 8WELLINO:

- Splenornegalg, Para-aorlic 1.N., inleslina!

o o

Obslruclion & obslruclive For diagnosis excision biopsg if t.N. is involved. For D.D. & staging: a. CBC ( pancgrlopenia, & ESR > 100) b. LFt (Obilirubin due lo obelruclive, HC or hemolgrtic) KFf (t uric acid due lo lumor lgsis $) d. CXR, Abdominal U/B & C.f., BM puncture. e. Staging laparolorng is rarelg used (replaced bg SPIRAI CI Scan).

c.

frealmenl

I.
2.

GENERAL IREATMENT:

CHEMOTHERAPY

Vrtamins, Blood lransfusion, lron lherapg DEFINIIIVE IREAIMENI ... according to siage...

...(Multi-centric)...
As Hodgkin's lgmphorna *... tN NODUTAR [YPE) Chlorambucil

- la, lb, lla) Radiother.apg - Ilb) Radiotherapg + Chemotherapg - ll!, lV) Chemotherapg
tr tr
E

IN DIFFUSE TYPE Cgclophosphamide, Vincilsline & hednisone.

tr gtage l) Enlarged I group of Lil. above or below diaphragm tr Stage tl) Enlarged more > I group of LN. above or below
tr Btage lll) Enlarged L[tl. above & below diaphragm tr Sfage lV) Extra-nodal afleclion (liver & bone marrow)
diaphragm

Highlg rnalignanl B-celllumor Eliologg : EBV, Malaria Easlern Afiica


t

tr Sile:

MicroscoDic Diclure:

ilE+:IW'{r,

htm*tfiilP#l

?hq7 I W

oF HoDqKll.l Ln lH{otr/h
(

ACCoRDINq

ro s:Ac,lhlc, )
IIb

la,lb,lla
RADIOTHERAPY
gUPRA.
DIAPHRAGMATIC LNs

III, M

RADIOTHERAPY

INFRA. DIAPHRAGMATIC LNs

t
MANTLE THERAPY

INVERTED "Y" THERAPY

Musline 2) Vincrisline "Oncovin" 3) Pro-carbazine 4l Prednisolone in ld, 4ft


r)

l)

Cgclophosphamide

(2-5) ... Vinuisfine, Procatbazine, Prednisolone ...

g g

Lowers Hgpercalcemia in late slages Relieve itching Raises lhe mood lmproves CBC, appetite

EI Biopsg EI Laparolomg

lnleslinal Obslruction

M Jaundice

SUPRA.DIAPHRAGMATIC Cervical Mediasiinal Axillarg

INFRA.DIAPHRAGMATIC

Para-aoriic Pelvic lnguinal Bplenic axis

X.E+:IW{r, A'.W;fN,VXf.#I

ARTERIAL SYSTEM

. . . . . . r .

lnlermittent claudication Mag be an indication for bgpass surgerg if it interfere which the palient normal life. Sensorg loss mag be reversible after revascularization. ln diabetic fool infeclion drainage through a small incision over lhe pointing area is enough in most patient and debridement should be avoided especiallg in presence of good vascularizafion lo avoid excessive
bleeding.

of small bones of the foot might be indicalion for ampulalion in Septic fool infection in diabeiics. Allen lesl is done lo detecl Dominant blood supplg of the hand.
The presence of osteomgelitis

an

VENOUS SYSTEM
Acule severe deep venous lhrombosis can present bg the limb A-Warm, swollen with tur$d calf muscles. B- Cold, swollen wilh sever cganosis. fhe main line of lreatmeni of lipodermatosclerosis is Cornpression elaslic slockings.

LYMPHATIC SYSTEM

. .

Hodgkin's disease can presenl wilh 2rg lgmphedema if the inguinal LNs are involved. Purilies is nol a marker of poor prognosis in Hodgkin's lgmphoma. Werghl loss more than lO%in the Iasf six monlhs, Night sweals, and Reed-gternberg cells in the bone marrow are markers of poor prognosis in Hodgkin's lgmphoma

ilP+Imfi A.mcrhEwwl

hqv t

v+8

l.

Palient wilh historg of mifra! slenosis &AF presenfs with sudden onset of severe pain in his lower limb, toes cannol be moved, complele loss of sensalion, pallor and pnogressive coldness of the limb. O/E absent peripheral pulsation. No pasl historg lo claudication pain.

,4cntc isctlaflh

2.

Old aged paiient wifh positive hisiorg to D.M , smoking, or hgpertension, dgslipidemia & alherosclerosis presenls wilh cramping pain cornes on walking &exercise ai {irsl with cerlain distance , relived bg stopping now lhe pain get worse and forces him to stop associated with cramping pain in abdomen in relation to meals.

rbclteuia dssutilttd lfffi pst +ba/ ailgrla, 3. Old aged patient with positive historg lo D.M, smoking, or hgperlension, dgslipidemia & alherosclerosis presenls with persistent resl pain, presence of

6ltmb

ll

ischemic ulcer or small gangrenous pafches.

Grfiical lmb bclwtrk


4. Young female presenls with bilateral pain and cganosis in tip of her fingers precipitated bg exposure to cold or emolional slress. No irophic changes with inlacl peripheral pulsation.

Rqruns dbasa/ n7
Youn! male heavg smoker complaining of chronic ischemia in a Iimb

Brgr s dbwa
6. 7- Uoung female complaining of tingling and numbness along the ulnar side of
lhe hand and forearm with weakness of small muscles of the hand also claudicalion pain in upper limb with exercise.

Tltwanb

atlet sytdrulla

7. Middle aged male or female presenls wiih slowlg growing


the hgoid bone, anterior lo side to side not verlical.

swelling adjacenl lo slernomasloid, compressible, pulsalile, moves from

GarotilMl fuma ( clte,nfutwttd.


8. Old
to afherosclerosis or sgphilis presents with cgslic compressible swelling a cross of arlerg, gives expansile pulsafion.
age palienl with posilive hislorg

*fer,,U ailqolstt/

1e,q*Twt5 ww/J.t71Rqw

?hqvtw

ioN
aa

DW " PDFs , C/P, lnvesligations, Fale & cornplicaiions"


(Kasn

2@Z 2W- Au shams, 2@5,2d/Azlur

f,2@Z 2@4,2M2ob,

Azhar rl/,

2M, 2mL/)
-

Acute ischernia
(Kasn

2M. 2d/- Au sl/afils, 2@2, 2M, 2M


Ay'rar

f,2@6,2M- ,4y'tar ril, Zd, ZWS

Manifeslalions, Cornplicalions and TTT. of varicose veins

6i/ siafils,2W

r Diagnosis & fTT. chronic ischernia


r Chronic Venous insufficiencg

- Ay'rar f,2@5,2@4 ,42/rar ril, 2oh, 2@Z 2@/)

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