Slides Examination Dr. Sabeeh Hussein
A 50 year old female , with history of burn in her leg 15 years ago, presented with this lesion…A- what is your diagnosis?Marjolin’s ulcer ( scc in chronically inflamed area)B- How will you confirm the diagnosis?Incisional biopsyc- what is the treatment ?Excision with 1 cm free margin with skin graft with prophylactic lymphadenectomyA 20 year old male presented with increased body weight , generalized weakness and lethargyA- what are the physical findings shown?1-plethoric face2-skin striae involving the abdomen, chest and upper limpB- what is your provisional diagnosis?Cushing’s syndromeC- give two essential tests to confirm your diagnosis.1-morning and midnight serum cortisol ,,, or 24 hour urinary cortisol with dexamethason suppression test 2-serum ACTHD- what imaging procedure you may request tolocalize the pathology ?1- CT abdomen2-pituitary MRI3-CT chestE - what are the possible metabolic and electrolyte derangement may found?1-DM 2- hypernatreamia 3- hypokalemia
A- name the physical sign demonstrated in the image.Pemberton’s test ( arm raising test)B- what does this sign suggest?Retrosternal goiter C- how will you investigate the patient?1-thyroid function test2-CXR3-chest CT scan
A 45-year- old male presented with pain around his anus A- describe the abnormalities . Swelling on the left side of anus with surrounding cellulitis and necrotic overlying skin B- what is the diagnosis? Perianal abscess C- how will you treat this patient? 1-Drainage under GA 2-broad spectrum antibiotics D- what is the possible future complication? FIA
This one year child presented with this cervical swelling A-Name the test demonstrated in the image? translumination test B- What is the diagnosis? cystic hygroma C - What is your treatment? Surgical excision
A- what is the tube seen in the picture?Sengenstaken – blackmore tubeB- what is the indication for its use ?Bleeding oesophageal varicesC- describe how it is used.1- can be used orally or via the nose 2- inflate the gastric balloon first with 300 cc air3-pulling the tube to apply pressure on the gastric fundus and proper positioning of the oesophageal balloon4- inflate the oesophageal balloon with air up to 40 mm Hg 5- need to be deflated every 12 hours to prevent pressure necrosis
Dx: air under diaphragm ( pneumoperitonium) -desc: x-ray of the chest and upper abdomen showing subphrenic air -DDX: perforating peptic (vescous) ulcer and most commonly post operative (laproscopic surgery ,histosalpingiography) and subphrenic abscess *if doctor said young and smoker pt. mostly it is due to duednal ulcer To be continue ,,
Continue ,,, -management: admission, NPO, bed rest, IV fluid ,nasogastric tube , analgesia , lapartomy and antibiotics . -definitive treatment : 1-closure of perforation by omental patch 2-wash the peritonium -complications: -peritonitis -subphrenic abscess -pelvic abscess *residual air is N2 . *the post operative pneumoperitonium takes minimum 2weeks to be absorbed
plane x-ray showing multiple air fluid level Dx :small bowel obstruction bcs: 1-the position is central 2-small size 3-absence of the air in the pelvis the obstruction is in the ileum bcs: no appearance of Vulvus convanantes
DX: acute small bowel obstruction (jejunum due to appearance of vulvulus convanantes)-complete opacity in the lower of the abdomen with complete vulvulas convanantes .-there are multiple fluid level and dilatation of the intestine -management: N.G. tube, NPO….ETCSubjective (analgesics and relief the symptoms)Objectives (measurement of the girth of the abdomen, the volume of the N.G aspiration and urine output) Vulvus convanantes
Small bowel obstruction
70 year old woman with sever epigastric pain , 1-What does the X-ray shows ? 2-The diagnosis? 3-The expected abdominal physical signs? 4-The treatment?1-CXR erect: Bilateral free air under diaphragm.
2- Perforated viscus. 3- Abdominal tenderness, Rebound tenderness, Board like rigidity, sluggish bowel sounds. 4- Laparotomy & clossure of perforation.A 45 year old man is referred with right loin pain. 1. What is the view? 2-what it shows?
1-. What is the view? K.U.B. film.2- What does it show? There is radio-opaque calculus located at the right renal pelvis. There are also several calcifications in the pelvis. These are not in the expected line of the ureters and are likely to be phleboliths, or calcification within pelvic veins.
50 year old man with dilated leg veins , what is the diagnosis?
Chronic venous stasis ulcer in the medial side of leg.
During an open cholecystectomy for a 35 year old woman the assistant finds something unusual. 1. What is the abnormality? 2. What is the origin of the abnormality? 3. What would you do at operation
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1. What is the abnormality? Meckel's diverticulum. A true diverticulum consisting of all layers of the bowel wall it projects from the antimesenteric side of the distal ileum. It is said to occur in 2% of the population, 2 feet from the ileocaecal valve and 2 inches long. 2. What is the origin of the abnormality? A Meckel's diverticulum is a remnant of the vitello-intestinal duct present during foetal development. 3. What would you do at operation?it depends on 3 things: -Pathology of Meckel's diverticulum :If a band were present it should be divided to prevent bowel obstruction. The Meckel's should also be palpated for any abnormal mass which would than require resection. - Age:The risk of complications from Meckel's diverticulum decreases with age. Thus many surgeons would leave an incidental Meckel's in a patient over 30-40 years of age but remove it in patients under 30 years, if it does not add morbidity to the operation being performed . Typically the diverticulum can be transected at it's neck and does not require small bowel excision with anastomosis. -If no other pathology is identified at exploratory surgery , In this situation most surgeons would agree that even in the absence of obvious pathology in the Meckel's it should be resected.
This 69 year old man presented worried about the appearance of his toe. 1. Describe the appearance of the toe marked 'A'? 2. What do you think has been marked with a cross at 'B'? 3. What is 'C'? 4. If there was a strong pulse felt at 'B', what do you think the patients main predisposing condition would be?
1. Describe the appearance of the toe marked 'A'? This toe is gangrenous. The black coloration, shrunken prune-like skin appearance and nail bed pallor confirm this. 2. What do you think has been marked with a cross at 'B'? This is most likely over the dorsalis paedis artery. 3. What is 'C'? This is a permanent ink mark outlining the extent of cellulitis. 4. If there was a strong pulse felt at 'B', what do you think the patients main predisposing condition would be? Diabetes mellitus. Demonstrating a predominant microvasculopathy.
What you call this abnormality? What is the most likely cause?
Koilonykia (spoon-shaped nails) Iron deficiency anemia3 weeks post treatment for chronic anal fissure by left lateral internal sphincterotomy. What is the diagnosis? .
What is the diagnosis?
Left Ischiorectal abscess, which is now spontaneously draining on the operating tableA 72 year old diabetic man presents complaining of pain in his foot. 1. What does the photo show? 2. How would you manage these toes?
1. What does the photo show? Gangrene of the first and second toes that is long standing and well demarcated. It is dry but there are some moist areas at the base of the second toe. The remaining foot has dystrophic skin and nails indicative of chronic ischaemia. 2. How would you manage these toes? -Swabs should be taken for microbiologic examination and broad spectrum intravenous antibiotics commenced. The toes should be allowed to dry by betadine gauze dressing which is applied slightly moist and allowed to air dry. A single piece of gauze should be placed between all the toes to separate them and allow the web spaces to dry. - Investigation and management of underlying occlusive arterial disease & FBS.
1)Spirometer: Indications:: Therapeutic to inflate lung in optimum volume as in Atelactasis, Lung collapse.
2)T-tube: To prevent post-operative obstruction of C.B.D , Jaundice and edema.
3)Chest Tube: (intercostaly) To drain air , fluid at 5th intercostal space midaxillary line as in hemopneumothorax, plural effusion and thoracotomy.4)Folly’s Catheter: (Self retaining urinary catheter)to evacuate bladder from urine as in urine retention, post op. spinal anesthesia or in critical cases such as trauma or intestinal obst. To monitor urine which reflect blood volume.
5)Endotracheal Tube: Help in breathing intubation in unconscious patient , elective anesthesia and ventilation.
6)Airway Tube: patent way to let O2 enter in.
7)Redi Vac Drain : Suction drain as in mastectomy, Fluid.
8)Nasogastric Tube: Abdominal distention, Feeding , Fluid suction from stomach , decompression in intestinal obst.9)Double Lumen NG Tube: Decompression in intestinal obst.
10)Sangestaking Tube: To stop esophageal bleeding (varesis). 3rd Lumen for aspiration of fluid. Not more than 48h. ttt: vasopressin11)True cut biopsy: for any tumor (breast), Liver dis.
55 year old lady had a lump on the back of her wrist which was getting bigger and more painful. What is the likely diagnosis? What are the clinical signs you expect ?Dorsal wrist ganglion. What are the clinical signs you expect? Clinical examination would confirm this, showing, a soft fluctuant mass, wih transillumination, no punctum, and usually fixed to the underlying dorsal wrist capsule. Sometimes they can arise from the extensor tendon sheaths.
What is the likely diagnosis?
Slowly growing in size, this lesion also has had two episodes of becoming painful and red. 1. What is the likely diagnosis? 2. What characteristic features on examination would make your diagnosis? 3. How would you manage this lesion?
1. What is the likely diagnosis? Sebaceous cyst 2. What characteristic features on examination would make your diagnosis? 1.Punctum. 2.Soft fluctuant consistency 3.Fixed to overlying skin from which it has derived 4.Not fixed to deeper structures 3. How would you manage this lesion? Simple excision including an ellipse of skin to remove the punctum.
This teenage boy was having trouble with recurrent toe infections. 1. Where is the abnormality? 2. Which operation would you perform?
1. Where is the abnormality? There is an ingrowing spicule of nail on the lateral aspect of the great toe nail. 2. Which operation would you perform? A wedge excision of the lateral great toe nail, along with nail germinal matrix.
40 year old man, mention 4 signs.
Exophthalmos: Proptosis,lid retraction, wide palpebral fissure,chemosis.20 year man with head trauma ,C.T scane done, 1- what is the finding ? 2-what are the expected clinical finding in this patient ? 3- what is the treatment?
Axial CT Scan of head show Depressed skull fracture. skull fracture either linear , depressed , compound , fructure of base of skull ..
A 47 year old woman presented after noticing a lump in her left neck What are the differential diagnoses? In that position, what is the most likely diagnosis? .
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1. What are the differential diagnoses? Lymph node - benign , malignant - primary or secondary Branchial cyst carotid body tumour carotid artery aneurysm lipoma sarcoma retropharyngeal abscess - bacterial, TB sternomastoid tumour 2. In that position, what is the most likely diagnosis? Just emerging from under the junction of the middle and upper thirds of the SCM - Branchial cyst.
Painless post auricular swelling This man presented with a mass behind the left ear.
1. What is the differential diagnosis?. Includes: sebaceous cyst lymphadenopathy lipoma inclusion dermoid dermoid cyst simple cyst The differential is large. However it can be narrowed by considering the lumps physical characteristics. It is smooth, does not involve skin, there is no punctum, and if felt it is soft, fluctuant and importantly is quite transilluminable. 2. Further treatment? A simple cyst would be uncommon in this area so it was excised and submitted for histopathology - this showed a simple cyst.Q1: Give the diagnosis? Q2: mention 5 causes?
A1: Facial nerve palsy A2: cerebral infarction , trauma . Herpes zoster ,tumorsThe Jaw-Thrust Maneuver
In unconscious patients, including those under general anesthesia,the posterior displacement of the tongue against the pharyngeal wall, softpalate, and epiglottis tends to obstruct the upper airway. The resulting hypoventilationmay lead to hypercarbia and hypoxemia, potentially leading to arrhythmiaor cardiac arrest. The jaw-thrust maneuver, which is taught as part of basic life supportand anesthesiology, improves the patency of the upper airway. It consists ofgrasping and lifting the angles of the lower jaw with both hands, one on each side,while displacing the mandible forward, and is typically performed by a clinician facingthe patient’s head or standing near the top of the bed. If the lips close, the lowerlip may be retracted with the thumbs. The jaw-thrust maneuver allows for the liftingof the epiglottis and enlargement of the laryngeal inlet and the pharynx, indicatedby an increased glottic opening and resulting in improved ventilation. Moreover,this maneuver allows for better conditions for intubation when fiberopticbronchoscopy is used. This effect can be seen on fiberoptic bronchoscopy (inset andvideo) in a patient undergoing elective oral and maxillofacial surgery during generalanesthesia before placement of an orotracheal tube.It’s supraclavicular LN enlargement with overlying inflammationIn this site, the most common cause of inflammation is TB Usually TB will cause cold lump but if it superimposes with inflammation, it will become hot and redIt the lump is hard and not fluctuating it suggests malignancy
Image Challenge
What cranial nerve palsy is most clearly illustrated in this image? 1. Left facial nerve 2. Left glossopharyngeal nerve 3. Left hypoglossal nerve 4. Right glossopharyngeal nerve 5. Right hypoglossal nerveQ:
Answer:
3. Left hypoglossal nerve The leftward deviation of the protruded tongue is most consistent with a lesion in the left hypoglossal nerve. The cause in this case was an extracranial dissection of the left internal carotid artery. The palsy recovered after conservative management.Image Challenge
This 12-year-old boy presented with abdominal pain. What is the diagnosis? 1. Cowden syndrome 2. Cronkhite-Canada syndrome 3. Osler-Weber-Rendu syndrome 4. Peutz-Jeghers syndrome 5. VonWillebrand syndromeQ:
Answer:
4. Peutz-Jeghers syndrome The presence of mucocutaneous pigmented lip lesions suggests the diagnosis of Peutz-Jeghers syndrome, an autosomal dominant disorder characterized by development of multiple hamartomatous gastrointestinal polyps.Image Challenge
This patient was trying to look right when the image was taken. What is the diagnosis? 1. Internuclear ophthalmoplegia 2. Left fourth cranial nerve palsy 3. Left sixth cranial nerve palsy 4. Right fourth cranial nerve palsy 5. Right sixth cranial nerve palsyQ:
Answer:
5. Right sixth cranial nerve palsy The neurologic examination reveals an inability to abduct the right eye with horizontal gaze to the right, a finding that is consistent with an isolated right abducens nerve palsy.Describe Dx Management
Transverse wound in the volar aspect of proximal part of index finger with clean edge & minimal bleeding. Tidy wound Hx > 6h .examination look for foreign body , assess neurovascular, tendon, x-ray to exclude fracture, antiseptic, repair of all damaged structures may be attempted & primary closure with monofilament non absorbable suture.
What the picture show why symptoms signs principle of treatment
Fasciotomy Release of compartment pressure severe pain, pain on passive movement of the affected compartment muscles, distal sensory disturbance absence of pulses distally (a late sign). pressures are constantly greater than 30 mmHg, decompressed via two incisions, This gives access to the two posterior compartments and to the peroneal and anterior compartments of the leg. soleus msImage Challenge
What is the diagnosis? 1. Cellulitis 2. Gout 3. Osteoarthritis 4. Rheumatoid arthritis 5. Septic arthritisQ:
Answer:
2. Gout The swelling over the right first distal interphalangeal joint with associated subepidermal, yellow-white material is most consistent with gout. Light microscopy of the expressed substance demonstrated negatively birefringent urate crystals, confirming the diagnosis.Omphalocel .. Defect of abdomenal wall . Central , at umbilicus . Intact sac covering the bowel .
Gastroschiasis Defect of abdomenal wall in the Rt side of umbilicus, And there is no sac covering the bowel ..
Feeding gastrostomy tube indicated : unconscious bed riding patient .. Ca . Esophagus . Ca . larynx
Release of median n. in a patient with carpul tunal syndrone
Deep yellow discoloration of sclera with dark urine in a patient with obst. Jaundice… cause : stone , Tumor , stricture…Skin graft ..types: partial thickness which either meshed or not and full thickness .. Used to close skin defect
There is wound dehiscence .. With multiple tension suture . Colostomy appliance which consist of base and bag .. Corrugated drain.. Wick drain or gauze drain ..
keloid scar .. Is abnormal scar .. Abnormal growth of epithelial tissue extra size of wound or beyond margins.. Most common site .. Wound over sternum .. Ear lobe .. Treatment .. Pressure . Silicon gel . Steroid injection .. Excision .. Radiotherapy
Donor site for skin graft
What is the test: Abdominal radiography supine position Radiological finding: dilatation of the small intestine Clinical diagnosis: small intestine obstruction. Most common cause: adhesion next step: NPO, NG, IV fluid, foly catheter, AB, S. electrolyte, BS, BU, no response with peritoneal signs +ve exploratory laparotomy42 y old man with abdominal pain and vomiting , 1-mention the findings. 2-what is the diagnosis ? What is the most common cause?- 3
VULVOLUS OF SIGMOID COLON
A. Describe. B. Complications.
A. Single-contrast barium enema study in a patient with diverticulitis demonstrates an intramural spaces filling with barium. B. Diverticulitis, pericolic abscess, I.O., Haemorrhage, fistulae, peritonitis.