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BREASI:
a a
2 g 6
7
IMUMAIOLOGY
I a I
AIUD
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
a T
:*g 'Go
. Sturg
nol,is
:*'
vx2
8lom. Sf,Eg
fieftL
VENOUS gYgIEM
btr
rc
T'
712
Gil
Urim
TYMPHATIC SYSTEM
rlt
.lumphe&r
.lgnpJm
gut
T? 75
T'
78
&|
:. !tt'r:t:::.!
ilRq-Twr5 1^w*Nv'J'R4W
t?.
I I I
T
&tACrffioN
PRECIPITATING factor CLINICAL PICTURE:
DEFINITION: Acule baclerial inflammalion lhal occurs during laclalion ORGANI$M: 8IAPH.
Pain Pgrexia
8'rgns
4
Conlinous
Attacks of remissions&
exacerbalions
l)
l)
2)
lnvesl.
r . . . .
. . . .
zfr TLC,
of abscess sile & tgpe ^EgR, ^CRP, lf no response wilhin 2 weeks U/g
:
BIOP8Y
Prophglaclic irealrnenl
Al lime of deliveru: lf
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
"J./Pq4wr5
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
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
. . . .
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
. r
r
'. . . .
. lf cgsts are
Excision
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.
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
.
NUMBER: Single SIZE: Srnall
ducls
NUMBER: Single SIZE: Largr
dsirrn
EWUtrE
ducls
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
@
)True +
CAPSUTE:
Painless Breasl lump, rnobile: wilh No LNs enlargernenl Never lurn malignanl Eneculalion (Circum-areolar incision)
..({illing defect)
Mal'rg.
TTT
Mag Turn
SARCOMA
lf srnall :
r'
Micro-dochectomg
& histopathologg
?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
. .
row
G+RADE
Exarninalion everu 6 rnonlhs Mammographg everu 2 gears bg obligue laleral view (l gear in HRG)
lE"r-'* I
?A
vt6
La
INFIffiNG@CAFCINoD.,IA
ti
lncidence
Pathologg
:t!{tlrts
fit
HIHHI
.
6%
it
ffi
,l
rl,
. . cut surface)@ .
Macroscopicallg:
.
.
. SOFT rnass
'
TNVoLVES
4ESI[E]
Cul surface)
Miuoscopicallg:
Spheroidal cells producing mucoid material
.@
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
?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
5$asag
S;rrcilNG'
* Manchester
+
bad indicalors ...
FRoGftlGlS
Good
. , . .
Invasion
Axillarg LN-ve
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
. OVARIES) Krukenberg's iumor . NODULES lN DOUGLAS POUOH) Plurnmer's shelf nodules . PERIQIQNEUM) Malignant ascitis
'T *l
\-;\
q
srAgnlq
Ta, oDg N, Mo
II(rlcgII
EARLY CANCER BREAST LOCALTY ADVANCED
BREAST CANCER
MEIASTATIC
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
LOCAL:
EXAMINE BOTH BREASTS
AXILLA
SUPRACLAVICULAR LNs
INSPECTION..
.,ASYMETRICAL
PALPATION:
. .
BREAST"
norrnat sile
2)
o o o
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
LYMPH NODES: Free axilla 2) Enlarged, Mobite 3) Enlarged, Fixed 4) Supraclavicular LNs enlargernent
l)
I
DUGD{oSIS
(,FffiCANCER
SrAglNG'
I I I
?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
(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
"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
*ve
Maslectomg
I I t I
Rernoval of breasl lurnp R.emoval of Breasl lissue Block dissection of axilla Reconslruclion of breasl
Cgclophosphamide
Melholrexale 5-Fluorouracil
*ve
g-t
t i
{ i
-,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
,/ / { ,/
Pregnanl Preference
'/
Small
/ /
I o;l -Li #
ln firsl 2 gears
f aI! 51lri n
3 monlhs
Everg
,D
,/ ./ ./ ,/
Complications of operations
Local recurrence
Disiant melaslasis
Carcinorna of olher breasl
ETIOLOGY:
AT{UAFEOTA
Resislant to usual
. .
TII of eczerna
. . . . . .
ln nipple )Erosion
NO itching NO oozing NO vesicles
lffi
Biopsg
&
Histopathologg
9.W-TWr5
A{9tr4?[.lE
XMW
?hqv t w
MRM
+ CHEMOTHEMPY
2 mulalion
lo
Etiologg :
Spread mainlg bg Blood..( LNs spread is rare & late ) INVESIIGAIIONB: Triple assesrnent)
l)
'
+ Radiotherapg
*
.:.
DEFINIIION:
Dilaled
has
* * *
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)
lJPq:Tw\5
XMW
?hqY I
uo
. .
of breast
)
(Nipples)
)along
. .
Dislinguishes scar from recurrence lmaging of breasl implanls Managernent of axilla in breasl cancer
. . . .
Occurs at pubertg. Unknown etiologg. Bilateral in 25%. Mag cause problerns during lactalion.
. . . .
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
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.
. . .
. . .
tr
tr
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
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
Dtct atasn
?hq? t q
Ailar
f,2@7)
r Discuss Trealrnenl of Milk engorgernent r Causes of chronic breasl rnass r Breast abscess
( ,4y'rar F'
(
2@6 )
,4ilar
f,2M )
r Nipple discharge
,4ilar f,2CCL4' -
r4y'rar
f' 2fu5 )
F,2M
& ttt
( Atu
sl/aus/@5 )
Kasn
,4ilar
,1r1,
2o2,2d/
2@8
( ,4/rar
)A
zma I
Alil
shafils,2m )
er{m@D:
DIH'SE
. CONOENITAL
. ACQUIRED:
xR4-Tw\5 1H'.{W*WXR@I
hEV
dpnen
| ?.1.
BEh[chl rilArqilA]tr
. Acuie baclerial
FRnTAN/ SECONDAF/
. . . .
Simple Toxic
lnflammation ileoplasm
. . . .
Neoplaslic ln{lammation
Toxic Simple
l)
2)
)Goiler
3) lf Bimple )
. .
Examinalion
of
. stMP[E) EUTHYROTD t{
. NEOPLASIIC) EUIHYR.OID . Ioxtc) Ioxc . INFLAMMAIORY) VARIABTE
(HYPER then HYP0)
',
Thav I
L1
SMru,qptrER
. Endemic) AbsoluteVlodine uocit
llrlgll
nodule)
.
. Srnoolh, Sgrnrnetrical ) . Mobile, Nol lender . No olher manifestalions
Enlarged
EI
'
l)
Same lnvesligalions as Nodular Goiter, but..
Function
2) Morphologg
3)
'
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.
)Medical thgroideclomg
Partial lhgrcideclomg
Sublotal thgroideclomg
tr 2rg thgrolo{gggElq{glg1gus
To{al thgrcideclomg
inlernodular lissue ..257o )
tr tr tr tr
Pressure on
lrachea)
Poslural dgspnea
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$/
Ptfl,rrA{/ GI.AND
h{4V
| 15
I ilil
EIIOLOGY:
Aulo-immune..flEII)
Iupe V Hupersensitivitu 0n iop of Normal Gland
Osec. from
4
SNG
sec. from
0,c,D
CLINICAL PI )TURE:
Tgpe o{
palieni
ffi
age
clo:
,,gEE
LATER'' Dominanl manifes{alions
,foxic sgmploms
, Auloirnrnune manifeslalions
Sp
rnanifeslalions
olEl
,,GLAND"
. .
.
Laboralorg
Ihrill AT3,T4
INVESTIOAIIONS:
+ VISH
r
U/S
:
- ve Antibodies
Mulliple Nodules
- ve Aniibodies
Solitaru Nodule
(Low uplake of surrounding lissues )
Thgroid scan :
Uprake)
TREATMENT:
l)
lf Pl. < 45
Years:
failure)) ll3l
(Hemi-lhgroideclomg)
'
>45
g.rr.)ll3l
Uo
ChJN
ff
6d
6dlb JiIe
o)
*,ri,
oi$6f
Diplopia t rl,Jt*te
J-trt t #J6xll
Jnfi
i
u'lN!)t 9 u'JJlaq$ Ihgroid paradoxl-J
6Jly't
!.
-nrlir o "i
t 6rU.f Jo ft 6ppU.ioist
Polguria eJ$Jl.f
"rU"p
Jdl
ACOP
HFU
-o19
JL1
r .
tr tr
ls il lrue or false?
Nafzrger
tr Joffrog's siln
lack of wrinkling on
looking upwards
LOWER UMB
Pretibial mgxedema
tr
. IA![{D!QD. Anti-thgroid
drugs, Liver melaslasis
1,^?4:lw=t5
A{DOCBhIE
ilPq%l
hq, t 7;?
IN FII=GIIANCrI
Mlrg lhgrotoxicosis (<45 gears)
EI
INDICATIONS:
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:
(Bela rags.. Deslrogs major Parl of gland without affecling the adjacenl slruclures)
tr # Radiotherapg tr
g
tr tr
DUR.ING T.ACTATION:
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
ry'
I
el rs.
3 monlhs
I I
I
r+
M Anfi-fhgroid drugs *
THYROTOXCOSIS
L-Thgroxin
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
lo rnain gland
bg
deglutilion
Descends again {hrough lhoracic
band of lissues
Takes blood supplg from
goiler
rnediastinal vessels
Thuroid vessels
CIINTAUHCTURE,
TYPE OF PATIENT:
clu
T
T T
l) Trachea )Dgspnea
2) 3)
olE:
I
T
T T
Esophagus
RLN
Dgsphagia
, . . .
RSG
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
lsolope scan
PIain X-rag )
I I
. . . . .
RSG
Ihgmoma lgmphoma
g g g
Idea! lreatmenl
lf toxic
Avoid
Subtota! thgroideclomg from Neck "piece meal" Subtotal thgroideclorng after preparation with TNDERAL onlg
?hq I L1
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
MrcRoscoPrc
Mag be associaled with: ' Reiro-periloneal {ibrosis
Mediaslinal {ibrosis $clerosing Cholangiiis
. .
@
. . .
o/s
Multiple nodules
(Mgxederna)
ffi
Thgroid ^ESR Anlibodies)- ve Thgroid Scan) @[I
Isthmectomg
PREDNISOLONE
1L\P.4:locrr5 E{D,CF^IE
ilRqW
?AqY I
rc
Well-formed acini
askanazg eells
PRIIJIAI{/
Cancnr.nne
'. U/8 )
Solitarg Nodule Thuroid Scan > COLD Nodule
ADEhb-
MeUrr.qFy
Ahnctl|ortlA
ffi
eAlalrrdt!/,
thlotffi
ChJN'CAL
g g V A Z g g A g
Rapidlg growing swelling in lower part of froni of Neck Earlg painless, Painful latelg (referred lo ear) ln{illrative manifeslalions Meiaslaiic rnanifestalions
a
g
SIGNS:
GENERAL) Cachexia. rnelasiasis
TOCAL SIGNS:
Hard gland, Earlg mobile & fixed lalielg Trachea fixed lo Gland, Posilive Berrg's sign LNg+ + (Delphian. Cervical LNs)
ilRt+-Twr5 flW*NY
WW
*hV I
?i
Delphg [Ns
pilrtu;1ri
e
{
(D
Microscopic :
E
o
wilh vascular Cf core
I o
J
+ -
o J o (s
CL
v
) F o + o o +t
Uq
. .
Left wilhoul
thgroideclomg
Fernale
bl
8N0
{ +
'
.
Ulgrgsss&,
0steolgtic
E
o
= o
l)
Follicles wifh
rrilrble
degre
rentialion.
UU
Loss of polaritg
signs of rnelaslasis
12.
e
o
(C
Old Age, rapid progressive swelling in Neck
o o ct,
F L
(D
. . .
Ugg@qlq1)Greg
Miuoscopic:
Unicenleric mass
l)
Clusters
of
* *
s.
2)
Loss of polaritg
* silns of melastasis
ilR4-Tw\5
htw*ht,ww
l'l,*V I
1L
. . ' .
DlreT{Cus:
Funclion)Thgroid funclion : N0RMAL MorDholoAu) U/S (Solitarg Nodule, Cgsl with papillarg projection) Morpholoqg & funclion : lsolope scanning )COLD Nodule
FNABC
Dlffi
TUMOR
ONurrrxeNntrp
IF INOPEMBIE:
& GLAND
Tolal Thgroideclorng +
. .
& IF OPEMBLE:
radioaclive iodine
s3rrerNg:
. CT, MRl, U/S . CXR, abdominal U/S . Bone scan (done after lotal lhgroidectomg)
LYMPH NODES
. CHILD) No Disseclion . ADULT$) Prophglactic
Disseclion of cenlral group
Tolal lhgroideclorng
* Posl&
FNE{DEnA]TTE
0rgan profile "CBC,KF[,LF[,ECG"
of
LNs
. lf One LN is Affecied)Block
Disseclion of LNs of neck
RADIOACTIVE IODINE
.
.
Deslrog ang rernnanls of norrnal thgroid iissue, Ablale ang rnelaslasis of lurnor
STEPS:
lrcaled bg thgroidectorng
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
l)
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
..Secrelion of serolonin..
lhe lower parl of fronl of neck . PAIN: earlg painless, lalelg painful
. .
Diarrhea Flushing
'Bronchospasm
SIGNS:
tr tr
. .
lnfillralive)
SPREAD:
. .
. . . , .
INVESIIGATIONS:
) DlAGN0Slg )
SCREENING
Calcilonin, Calcium
Ug/FNABC/Calcilonin (>0.08 nglnl)
*ve
+ ,lt Calcitonin
Gland
$IAGING)
[FI,
FBS
= IOIAL IHYROIDECTOMY
if Normal
EXCIUDE PHEOCHROMOCYTOMA)
. . .
!! Jrll 9! brtull
*
Cenlral Neck Nodal disseclion
l) Ireal
2)
(Combined Alpha
Adrenalectomg)
. '
Trealrnent of Complicalions
crFq-Twfi a{Docw
ww
?hEV t ++
./'
I i:,
i
t'v\
PARATHYROID ADENOMA
PITUITARY TUMOR
PANCREATIC IUMOR
t.JlEN -
llA
MEDULTARY CARCINOMA
PARATHYROID ADENOMA
PHEOCHROMOC\TOMA
tilEhl - llB
)1
MEDUTTARY CARCINOMA
PHEOCHROMOCTTOMA
ilEI4-Tw$ 1a"]lW*WWW
.TRAPPING
.@[!9!
.@ru!E!qAM!
bg Tgrosinase lo forrn M0N0- iodo lgrosine, Dl-iodo lgrosine .COUPUNG of rnono-iodo lgrosine lo forrn lg, T4
)
l-
\^J
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 $: due lo de{iciencg of peroxidase enzumer in which lhe patienl is deaf, mule, but NOI blind.
IINOUAL IHYROID MrU represenl the onlg thgrcid lissue.
lt is lined bg columnar
Epithelium.
&
lt is besl lrealed bg full replacement wilh L-thgroxin or excision. MEDIAN ECI0PIC IHfRO|D) usuallg rnislaken as lhgrcglossalcgst
Forms a rounded swelling at the forarnen caecum, cause irnpairmenl of speech or respiralorg obslruction.
l&
23-
ln simple goifer, lhe mosl imporlanl faclor is dietary deliciencg of iodine (Ihe dailg requiranarl100-t25 qg) Vegelables of brassica familg, PAS, Ca, lhiocganate, Carbirnazole and lhiouracil are goilrogenics. ln diffuse hgperplastic goiter)lhgroid hormones level are normal (euthgroid). A colloid goiter is late stage of diffuse hgperylasia.
MUIIITIODUTAR GOITER,
5.
Onlg rnacroscopic nodule is found.. (Micrcscopic changes will be presenl throughoul the gland and mag be one forrn of a clinicallg solitarg nodule.
Irlodule mag be colloid or cellular, and cgslic degeneralion and hemorfiage arc oommon
- Ihe invesligalion of choice in discrele lhgroid surelling, Simple & quick, with excellenl patient com$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
healthg thgroid gland where the gland is enlarged or shows mild enlargemenl.
- 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-
if surgerg is adequale
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$
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.
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
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
- ln tgpical sub-acule presenlalion of De-Quervian l2irregular enlarlernent of thgroid. lnvesl'rgalions: Thgroid aniibodies are absenl.
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
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%
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
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
,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
Kasr,2W)
( r4ilar
rl/,2o/2,2o//,-zml Au s/uns,2m/)
slhns2@2,2@5, r4ilar
( ,4n
f,2M,
rAur
f'2M)
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
tr tr
tr
CLINICAI PICTURE:
nl'$;,*,,,i,:::.",",
.
abdomen, ecchgrnosis Thin skin Hirshulism, 4 Facial hair
'.
. .
Buffalo hump (upper back) Supraclavicular Fal pads (above clavicles) Trucal obesitg 4Waiet-hip ratio >l in rnen, O.8 in wornen
'il:iH#*i:"..
tr
I
a
. .
Edema
1l
INVESTIGATIONS
dags)
NORMAT
ZIr
{z
= ADRENAT TUMOR
CT abdomen,
MRl, U/S,
tr
TREATMENT
? PITUITARY TUMORS:
lrans-sphenoidal rernoval of lurnor Hgpophgseclomg or piluilarg irradiation followed bg replacement therapg ?ADRENAL TUMORS: tr Sur$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
tr tr
tr
tr tr
tr
child
E E
Forrned of Embrgonic Chrornaffin cells around abdorninal aorla that Normallg atrophg during Childhood
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 . \- -
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
hgperparalhgroidism
Affecls I gland
Olher causes:
(e.9. CRF,
Malabsorption)
tr CLINICAL PICTURE:
MOOD.. ( MORE !N PAilENTS >60 YEARS)
BONE
I
rl
tr
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
- 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.
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.
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$orna Vascular rnalforrnalions Derrnoid cgst Fistulas Sirnple ganllion Miscellaneous lopics
?AEV t d
@@
SlfE: Forehead
Nol allached lo skin NO slipperg edge Lirnited mobilitg
@ Firm @ @ @
ODANOEROUS)
COMPTICAT!ONS:
BUTIHHITN
@CP:
6ifi
@ Mobile
Pressure rnanifeslalions
conlraclion
:IC
MISCELLANEOUS
R,ETRO-PERITONEAL> Premalignanl DCTRADURAL) Pressure
'F
@ @ @
MICRO$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
61-
CONGENITAL
OTHERS
Hernangiorna
Slrawberrg
Hernangiorna
Vascular rnalforrnalions
Low Flow
Sgndrornes
A-V Fistula
.Slurge weber .Klippel Trenaunag . Kasabuch Merrill
Acquired
Venous
I
Lgrnph
I
Salrnon Patch
loJ +rb r rrr i.t
Cavernous Hernan$orna
Cgstic Hggroma
(Cavernous Lgmphangioma)
Congenital
pf,1i
(traumalic)
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A.DoCFNE
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rYPE(l):
- AD, Chrornosorne
17
of
+Pheochromocgloma
TREATMENT:
lf sin$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 :
Appears
U/S)
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55
.w.
*
'
.
l)
APPears in Neonales
Nurnber
M
Single
Site
Size Shape
characlers
DD : Branchial Cgst
frealment:
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ffiqw
Thq* t
5b
Sequeslration
Tubulo-epiderrnoid
DD
.
.
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 :
MffiAnol.l
I t
g/sr
I I
endings)
I !
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67
. .
,
.
Since birth
. Rupture . lncornplele
excision or incision
lo
...
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:
INVESTIGATIONS:
TREAIMENT :
M
@ @
Port wine 2rg varicose veins due lo A-V fislula
e.B4-TooN5
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roPlcs
Cornmon associalion wilh Port wine stain
@ Hemangioma
@ Vascular
@ Complicalions: DIC
@ Hernialion
Sile:
iijglLuLtll iiy
rnembrane
gaJJI ,
[l+JI
ii 14rtr a
il, Mucous
lf ruplured)
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
Site: - Al site of previous sur$cal incision - From the reclus shealh, Rl >Li
at
NEVER IN MTDLINE
: MRI
2.5 cm
Post-operative radiolherapu lo
avoid
recumence
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?h Y I E
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hlpoC^RNE
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inflammation of salivarg gland (PAROTID)
dehgdralion, Poor Oral hggiene, Obslruction bg Slone Route of infections ......Direcl from lhe mouth, Blood born.
HECTIC
fever , T
* fon ealing or on
ingeslion of lernon or acidic iuice
. . .
Enlarged
.r *
Prophglaclic l)
* *
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
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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
. .
...
. 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
lnfernal)
requires no TTf
Clinical
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
VGland size ...4Malignancg Mosl lumors are BENIGN More common in parolid
MUCO.EPIDER,MOID CARCINOMA
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,
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)
...
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
Cfscan
Tc99
HOT spot
. Firm lo hard . lrregular, Nodular surface . lll-defined edge, lnfillralive lo skin, . LNs **
+
vessels
Trealrnenl
Biopsg
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PARTID 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
. .
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- 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
' '
. lf's Slones . . .
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
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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.
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2.
Palienl complaining of
lim
't
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.
PlnuaVhrb d&tllfi/a
?ifr+IwJ6
6lD0CFt'1tr
lrRqBY
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I Salivaru neoplasrns
(Kasn
2@n 2d/ )
) )
( Kasn
r4ilarf'2W
(Kdsr'2M
r Derrnoid cgst
Kasn
,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 )
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10
Definition
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Sitg .................r....
gngSJS
a
* Patho
......................
. . .
Cornoli
. .
* 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
* Local
Hol Fornenlalion Aclivg lrgalrngnl: ...................
SJRq.-TW]'S
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Definition
*SKIN,
ra
Cenlral zone) 6+rh? iiJ{io Mimo-organisrn# dead WBCs
CP (Sgmptorns,
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 :
@ @ @
Proslale
ANTIBIOMA
& CBC
Leucocglosis
. . . .
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@
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ilPAW
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I
lt
r+ppi
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
* * *
Give Erulhromucin
if Pl. is
Infeclion
of
Perifolliculilis
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
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
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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
o o/E:
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:
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
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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,
:
. . . .
. 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
Roule
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
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
'
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
OFffi
l)
$kin incision
r) R.esuscilation
? h{qV
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
.. lnjected in the
2)
. . .
Tetanus toxoid
Conlrol of convulsions bg Valium, barbiturales ln severe cases > VENTILATOR. Conlrol of Hgperpgrexia bg Cooling
r)
of
anlibiolics
. . . .
Vaccinalion bg DPT 2,4,6 rnonths Booslet al 18 muscles HRG should be vaccinaled everg 5 gears
5)P.q=Tw)5
A.DOCXhIE
A,EaW)
?Ahq t
7b
r)
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)
2)
T
I
T T
Sterile instrurnenls, sutures lsolation Polgvalent Anti-gas gangrene serurn Antibiotics ... Penicillin G
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l.M@l Aq I
?
T1
tr tr tr tr tr
Stah. aureus
MRSA
Sierpt. Enlerococci
Pseudornonas
tr tr tr tr
Age
Obesiig
Malnulrilion
lnrrnuno-
tr tr tr tr
tr tr
cornpromizalion
@ lnfection
. . .
Pain
. .
Ewellin8
Dislurbance Of function:
Wound : red, hol, tender, wilh oozing pus LNs : Enlarled, lender, elastic,
mobile
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
38! up lo
4OTo
g
V
g g
NO Prophglaciic anlibiolics in clean surgerg lN CLEAN CONTAMINATED) Aniibioiics are $ven 3O min. before skin incision & Repeated intra-operative with insertion of FB (e.g. Mesh) lN DIRTY WOUND) Antibiotics are Curalive
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Definilion
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PDF, Roule
.r
)bad
' . .
Corn
SWELLING: according to sile.. Ederna al dorsurn.of hand Pulp space )distal phalgnx
SWELLINGS:
DI$TURBANCE OF FUNCTION:
* *
Local
: Accordin{ to tupe of infection : / Pulp space infeclion )Thrombos:s, Osteomgelilis / Acule parongchia )Subungual abscess
DM
I
.F
BEFORE SUPPURATION
Oeneral Resl, analgesics, anlipgedtcis, antibiotics , Hot Fornenlalion
AFTER SUPPURATION
lncision and drainage
tocal
a) b)
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DEFINIIION:
EIIOTOGY: Organisrn
. '
Baclerial
Bad lrimming of Nail Thorn driven under nail
>rd\.!
Fungal
ClP: Sgrnploms
' ,
General) FAHM
Signs
local)
Local)
, uellow
... Cgstic
&
U-shaped
coMPUCATTONS IITIVESIIGAII0NS
TREATMENT:
As Scheme *.... rNCrSroN : tr Oblique at lhe anlle of nail Ouler fold, excision of lhe % of nail
is all around
tr
&
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
cilR+-TCrIr5
END0CRNtr
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PA6h
|&
1.1
"*
Conlents
l)
3) Food: D'rgifd arlerg) Thrornbosis) Osleorrgelitis of ienminal phalgnx exeepl ils epiphgsis
@ lncideRce; @ Etiologg
)Prick
* ....
.... 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
w+tw'J5
a{DocFI{E
1.8@l
?AqY I a
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
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:
Semiflexion
&
swelling of fhumb, lhenar eminence, distal parl of forearrn
(fenderness over infecled burcae belween lransverse palmar crease & Hgpottnnar Me.)
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
hlDoc8hlE
x*#l
?hEV I 6L
t*t
& ?d web
lo
sPaces Connecled
@space
Elmai
space
Connecled ro
c[r$CArWrtrFE:
As scheme
+ ....
.. {ingers can't be approximaled
@rinrdtnorts:
ffi
As scherne
web space
As scheme + ..... lNClglON )Transverse incision over web space ln severe oases courrler incision
. .
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
l-
lJP.q-TW-t5
^DoCR[{V
X,WW
?hqv t
81
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.
1fr+Tw'{f_
A.WCPhltr
lRI#l
?hqY t e+
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.
l@fi|
4. Manual worker
presenls with $a,elling in nail bed. Dull aohing pain. On examination nail bed is induraled gellowish cgslic.
I dtqttta
,futepnilFlk
5. Youn! male cornplaining of neuosis of the big nail sulcus with persislenl irrilalion of his nail.
Tetarus.
deep laceraled crush wound, lhe wound is black edematous with foul odour and waterg diecharge.
&
gdillroile,
fias
ilPq-Twr5 ww/PNYlMW
lffi
of
r Gas gangrene
r ClP and TIT of Tetanus
( ,4r'tar
( Kasn
2d/ )
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
"v-
tUbhael
AAF
tth .. Altr
snrversrttt
?hEv t
t Hernorrhagic shock
r llernomhage
5R4-Twr5 dwUWlJRhW
i ,ii I 81
INCIDENCE:
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
{irsl
L{
TRlr.iODAt DlsrRlBonohl
Within rninutes Due to injurg to vital slructures
...
re
OF DEJtr+t
-H
flJR+-Tour5
ENDo(xhlE
ilPqW
?hq? |
10
PffiEf.tr
@
@ @ @ @ @
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,
sbg
aitwag
,
$fiPleslsron#
@ @
!nspeclion
- Palpation -Ausculialion
@
@
gHOCK (Hemorrhagic. cardiogenic, Neurogenic) AVPU evaluation (Alert, voca!, Painful slimulalion , Unresponsive) a Foleg's ICalheler Resuscilaiion & moniloring ... NG tubeI g Radiolortical assessrnenl
OFGFitrlffiAFrB,
@ @ @
EAslcuFE gJ'PFo'Fr
LAB : HB%o, Glucose, KFT, ABGs , PO2,PCOZ RADIOLOGICAL : X-rag ,CT ,MRl .U/g , Duplex INSIRUMENTAL : Endoscopg, Centesis
T[{EN.. DEFINffi\'Effi&
ilR4-Toqr5
W
S fu
a{DocRNr
rlxt wt
?nqe t 7
"GCS,,,
U+rirql
Flexion * Withdrawal srt+ll
Ug'=F.lr aii+{
'-l :r^
Ug
r-.llol'rll g r-llg,,iu
Exlension
to painful stirnulus
us$hll
drrSc
Flexion
lo painful
sr$bll rr{Sr
stimulus
De-cerebraled
De-corlicaled
REsttrohlsE Merarcud
EBB Pl{AgE l<24 hours) OEnzgrnalic activilg & OZ consurnplion E Lactic acidosis CATABOLIC Pl{AgE (g-to dage) 11 Fat, Prclein rnobilization 11 4Urinary Nilrogen excretion AilABOtlC PHA8E (tO-eO dags) Resloralion of Fal & prolein slores
)r
al
ffil\IE
reabsorplion
tr
AB+TUD{r, E\m,fbEAE#t
os(
arac
Due lo pressure bg
qi olerp
sharp object
oUui!
frealmenl:
Antibiotics t Betadine anliseplic
Ecchgmotic skin patch due lo btunt lrauma Trealrnenl: Fomentalion (Cold ) Warm)
.. See Orthopedics ..
?AqY I
oFnlooxp
ENBAT
@lipucAnoNs
OF HEJUTNC
Hgpovolemic Septic Neurogenic
@ NON-gPEC!F|C
(Seplicemia)
@ @ @
lnvesligations :
Telanus Gas-gangrene
Mgo$obinuria Complicalions : Acule renal failure Trealrnenl : B Resuscitation & Antishock rneasures n Alkalinization of urine
lr * *
. . fr
Fluid
Management of Polglraum alized palient ..(see before).. Management of Wounds ..(see Vascular surgerg)..
cilP+:fmr5
ENDOCFNV
1JPqW
?hq, I T
tito0lb
@ IRRIGATION WITH SALINE
@ @
3J+JI
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
* * * *
Observafion Antibiotics
Anti-letanic serurn
Anti-Gas gangrene serum
fuxp
DEFINITION:
?hh6 115
NG,
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)
Wound Conlraction
-2lst
tigfr ii+tr
)
Epithelial regeneralion Granulalion lissue forrnalion (healthg, unhealthg) Conneclive lissue repair Wound Conlraclion
REMODELING PHASE
TUp"
(>
Igear)
@rtlpucArloNs oF r{EArrNG,
@ TUp" of wound (Tidg. untidg) @ Site of wound
(Wounds over flexures )lension)
@ @ @ @ @ @
lnfeclion,
hernalorna Dehiscence
@FB @ Vascularinsufficiencg
Malnulrilion Medicalions
Smoking
HE
State of peripheral circulalorg failure due to sudden blood loss or shift from peripheral circulalion.
fl g g
lo
Delerioralion of
funclions of
brain, kidneg,
Mu[i-organ failure
>
15%
Hearl, lung
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
tr tr
Anuria ARDS
ORGAN PR.OFILE
Exclude bleeding lendencg CBC, ABG, Electrolgfes, PH, KFT. LFI
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
tr
tr tr tr tr
Viial data
"Pulse, BP, Ternp. Respiration" ABGs , ECG Urine Oulput Cenlral venous Pressure
Buffer)
O O
Crgstalloids mag be given alone )Pf. with Hgpovolemia due lo waler & Electrolgte imbalance # Glucose 5% )leads lo dilutiona! hgponalremia
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
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
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
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 $ven for class ll and IOO% for classes Ill and lV. General care of lhe patienl: absolule bed rest and analgesia (Morphine is contraindicated in head injurg and in oases of respiralorg and liver insufliciencg)
5. @gI!Dg:
Urine output, core lernperalure, hernalocril and cardiac moniioring ECG for earlg deleclion of shock-induced arrhgthmias is important). as above + CVP, ABGs and PH ln class lll or lV hemorrhage
ilRq-Twr5
nDgcRNV
il?4ry
Thh'* I
fl
ETIOLOGY:
Etr Or(anism: MOST COMMON ORGANI$M lS GRAM -VE BACILLI
E E
Source of
Predisposin{
faclors:
CLINICAL PICTURE
. . .
Reslless
gKlN)
. .
VITAL DATA:
x .
Fever
>38
tr Tachgcardia tr Tachgpnea
^COP
.
g g
11 Tachgpnea
vcoP
$FS
(sYsTEMrC r NFLAMMATORY
RESPONSE SYNDROME)
Etiologg:
g g g g
a ffir@
Evidence of infeclion ... *ve Blood cullure Refraciorg Hgpolension Ang 2 wltefia of the following ... Hgpervenlilation (RR,>20 breaths/min) ABG (PCO? <32 mmHg)
V V A
WBCs
80%
MORTATITY
MOF
c)
dl
Dtc
INVESTIGATIONS:
tr
tr tr
ilRI4-T1a.t5 ,NDocE[.],
TREATIVIENT..
ilRhw
hhv I
r00
RESUSCITATION
CIRCULATORY SUPPORI
MONITORING
OF INFECTION
tr tr
tr
E
Eradicalion of sepsis
Parenieral anlibiotics
DRUoS
REPIRATORY SUPPORT
tr
O2 bg mask
RENAL SUPPORT
Hemodialgsis in ARF
DIC?
ffiffioF
g
Cmuoqpt{CstlodK
MOSI COMMON CAUSE Ig MYOCARDIAT
INFARCTION
CtINtCAt PICIURE:
CONGESTED NECK VEINS TR,EATMENT:
ACVP
g A
TTT
oflhe
cause
ffileSHocK
EflOTOGY:
cord
CLINICAL PICTURE:
. . .
BMDYCAR,DIA
WARM SKIN
LOW BP
g
a a g g
re
?hqv I
llfi
Donor & recipienl are onlg malched for ABO compalibilitg All componenls for slored whole lend lo Vovertime excepl Polassiurn Donaled blood should be roulinelg screened for Hepatitis B, C, HIV
CMV is screened :n high risk groups (Ex: lC palienls) Best guide for blood transfusion in hernorrhagic shock is
"
CVP "
FEERITE
tr tr
TTT
AII^BCICREACTIoN.
fficAr
tr tr tr tr
tr C/P: urticarial palches up lo Iargngeal edema. tr TII; Anlihislaminics & corlisone, slop the lransfusion.
HEitolr/rlcREAcrloN:
&
r'lgors
. . . . .
Fever
& rigors.
. . . . . .
AlDg. Brucelloeis. CMV (Ihe MOBI C0MMOttl) Malaria(onlg bg RBCs) Viral hepatitis. Sgphilis.
tr
TREATMENT:
. . . . . .
Slop lhe transfusion irnmediatelg. lV fluid(ringer laclale* corticosleroid). Alkalinizalion of urine bg NaHCoS Mannilol20% l0O ml (forced alkaline diuresis). Repeal palienl's blood lgping & matching.
Noll+M
Z-Ait embolism. 3-Thrombophlebitis at the site of injeclion. 4-Complicafion of lranefusion of stored blood Acidosis, Hgperkalernia, f O2 affiniig
TFIBRINOGEN: DIC
trLEUCOCYTES: Severe leucopenia, Agranulocgtosis
lJRq-Taq'$
E{Docxhly
XMR'I
hqv I
WL
cilRt4-Iwr5
A{D0CEI{E
IJP^W
?AqE t
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)
tr tr
lnlrinsic pathwag
ogq ++lJl
CLOTTING CASCADE:
vil
tx xt
vil
EXTRINgIC
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)
xlll
?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$TIGATIONS: value of faclor = 5-2OTo Normal value TREATMENT: lnfusion of deficient facfors, FFP, Crgoprecipitate
!M lnjeclions ::
De{iciencg of Factor , Aulosomal dominanl CLINICAL PICTURE: Echgmosis, Purpura, Bleeding from orifices INVESTIGATIONS: ABT, 4PT, APTT, De{iciencg of factor 8 TREATMENT: lnfusion of Deficient VW factor
g g
VPlatelels, 4PT,PTT, VFibilnogen, 4FDPs V IREAIMENT: TREAIMENT OF UNDERLYING CAU8E, FFP, ugoprecipitate
INVE8IIOATIONS:
REJECIION
Chronic reieclion is the rejection Hgper-acufe rejeclion is rnosl cornmon in lransplanl of KIDNFf Acule rejeclion occurs within 6 months Chronic rejection occutts in the form of lschemic librosis
LIVER TRANSPTANIATION
lndicalions : a) Primarg sclerosing Cholangitis
Biliarg alresia c) Fulminanl hepatic failure d) End stage liver disease secondarg Hepalitls B,C Hgper-acuie rejeclion is almost
PREgEItIT
[[[![[[[p[fupeof
b)
g a
g g
I\IOT
Acute rejection occurs in 30-50 % of palienl, reversible is possible bg sleroids Chronic rejection is irreversible, needs re-transplanlalion ABO malching is a musl, wtrile HtA malching is nol a musl Irnrnune-suppressive drugs: Cgclospodne inlerferes wilh produclion of cgtokines V OKIS ie more sneci{ia
lRq-TwV
1a{lwC*NY,',RqAl
?hqv I
rcF
(As)
40% of adult
bodg weight
lAq
weight
(2500 ml)
(soO ml)
M Osmolaritg of BLOOD depends on PROTEIN M Osmolaritg of ECF depends on Na, Cl, HCO3 EI Osmolarilg of ICF depends on K, Organic phosphorus .BODY O$MOIARIW = 300 mosrno7Kg ..(Double Na leve!)
'ADH is conlrolled bg Plasma osmolarilg , ALDOSTERONE is Conlrolled bU Na*, K+, Renin
. VTNTAKE:
.
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
.MILD TOXCITY:
.BEM!IA!!!!BE
V waler inlake
Dialgsis
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
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 $, Hgperaldesteronism
gpertension, Tachgcardia, Enlarged Neck veins, Ederna, CNS manifeslations ending bg seizures, Corna
H
PICIURE
EI Active lrealrnenl:
AB$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)
tosg
EICrohn's disease with {istula EIK losing tumor "Villous adenorna " Mlnlracellular shift: Alkalosis, insulin
o o o
Asthenia
o o
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
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
-=---E
c)
d)
E
EI
ESTIMATE K+ DEFICIT
(4.5
?hq* | 08
V V g V g
N level :
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
'
. . .
CLINICAT
PICIURE:
. . .
lnvesligations
lO% :
TTT. Of cause
l0 ml lV slowlt
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
PH
= Pka +
Log HCO/H2Co"
disorder...
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
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:
- Cganosis - lrrilabilitg
Mechanical
Respimiorg rale
anesl)
(Tetang, Respiratorg
TTT.
-m. Of cause
-lf severe) NaHOO,
(Bodg weighl x 0.3
-m.
Of cause
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)
-VHCO. (Renal)
MIXED DISORDER
RESPIRATORY,
]VIETABOLIC ACIDOSIS
euiq
eJ
VHCO3, 4PCO2
aHco3, vPcoz
to
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:
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:
?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
fl
2-S 3-S
) )
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)
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
aa
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
2d )
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 )
,4y'ar
Ailar
f,2@7)
(Kasn2M
Brain
Ji,gi;ietr
r'ell
Arms
SLrtertor
',-.,i2('ot .iefia
i-iver
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:
. . . .
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,
. .
ETIOLOGY
Alherosclerosis Slasis,Hgper-viscosilg
(Diarrhea, polgcgthemia)
E Open E Closed
lalrogenic E lntra-arterial drug lnjection
Etr
tr
/ / /
clo:
E Historg of
// /
tr
tr tr
o/E:
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
AqY t
Ytn
Srrpor rMpIGnoN
V g
PRE.OP INTRA.OP )For fhreatened limb
oFffi
tr tr
Muscle Necrosis : 4TLC, 4CPK, Acidosis Hgpovolemia : 4Hb, Crealinine, BUN
+VE collalerals
FERIPHERATffi
H/AFD StqlUS
vS
sEoFT sltGIUS
tr tr tr tr
Hernaloma non pulsaling, non-expanding Nerve injurg Wound is near a rnajor vascular slructure Delaged capillarg refilling time
Urgent lnvestigations
?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/
l) Fernoral arterg)
lffi
AMPUTATION
of urine
MCS
I
tr lf
tr
Fasciolomg (To prevent cornpartmental $) S'rgns of adequale emboleclorng: . Pulse fell . Color, ternperalure . Fleverse bleeding . lnlra-Op angiographg
No wlFno\lErllntr
I
tr tr tr
URGENT
Re-vascularization
Streplokinase Pulse sprag or lV Loading dose, followed bg rnainlenance R.ecenl) Recornbinant Tissue plasrninogen aclivator
1R{4:locllt5
.^*,,*NYilPq*'
hq
t w,?-
....
lo
Head
Airurag, breathing, circulation, Drugs, eXposure loe Exam, AMPLE Hislorg , lnvesligalions (An$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.)
CortnstoN
I Excision
Corinere
>l/2
I
Nerue)
Blood vessel
Deal as
of the
<l/2
circumference
I Repair with proline sulures
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
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.
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!
tr tr tr tr tr tr
Polucvlhernia (Anernia eggravaled ischernia) FBS >DM KFt >Alherosclerolic kidneg LFt lrnpaired
ECG
)IHD
.TECHNTQUES:
DrrPl^D(
- frans-axillarg arleriographg
(if fhe whole dislat aoria is occluded) . COMPLICATIONS: - Neurologica! deficit
1JP,440qr5
AWOC*hIE
1,,RqW
?k e I w
BES;rMDIGATTIT
tr RISK FACTORS MODIFICATION
PFEffiAT.IGIW
+\,E DISTALFTJNoFF
. . . .
- \rEDlsrALlg6laryp
S${oncrSrcfiertr
roD.Gsrciltatr
ARTERIAL BYPASS
AFO/E EE.olr,
*:Htfl#.DtS
AN
PG
tr
ANTI.PIATELETS
g V
UI SYMPATHECIOMY EI Arnputalion
tr
tr
tr
(lf patient is inloleranl) Plavix) Clopidogrel VASO ACIIVE DRUGS CARE OF FOOT DGRCI$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
SYNTHETIC
KNITTED
DACR.ON
+i.lall
?Aqv t wo
DEFINITION: a cornplex pathologg in a diabetic patient's fool which is relaled to duralion & Control of the disease
tr
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
NO PULSE
I
: conlrol DM,
Arnpulalion
Ulcer
PTA
BYPASg
vAsoPAsrl
lJpq-Taqr5
A{DOoFINE
*PqW
? AqV
IW
//
DtS=.(Sri
ETIOLOGY:
,/
ETIOLOGY:
r-".s
fi
16rJl
lJ, tli{
//
Arlerial obslruclion: Burger's disease Nerve injurg: fhoracic oullel $, Carpa! tunnel Druss: Beta Blockers CLINICAL HCIURE:
- MAYAFFECT@
.
Care of
Patienl
Care of Hand
Surterg
Sgmpatheclomg (Cervico-dorsall
.
.
TTf of
CAUgE
. . CCB
Sgmpathectorng
NO BENEFIT D(CEPT: . lf vasculilis occur . Crgo-anlibodies (Makes sgrnpalheclorng ineffecfive)
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
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
SylbnoMe
GltpNtc lscltBtlA oF(L
E E tr tr
FGTSnED{snC
DlrArffioN
Effort fhrornbosis
Alrophg &
Weakness
&DW
)
Angiographg: - Cornpression of $ubclavian arterg on Elevalion of arm
tr tr
There'sPosl-slenoiicdilatation
M!LD (NEUROLOGTCAL)
gEvERE (ARTER|AL)
tr
Phgsio
&
Shoulder exercise
tr tr
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
,{
SYMPTOMS:
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
I t
Ihrombosis, Embolism,Alherosclerosis
INVESTIGATIONS
. ,
.
Screening) @ Diagnoslic)
Best pre-operalive lnvestigations)
Conservative
Diarneter)Scrn
High risk palient Excision & grafl Exclusion graft
'SURGICAI PROCEDURES
cilq.q-Tmr5 flpmxnr
rtlBt
?hqv t vl
ABDOMN{ALAOFilC
INCIDENCE:
. -
* *
RUPTURE:
Shock, acule abdominal pain, Pulsating epigaslric rnass Dista! ernbolization Sponlaneous) Blue loe $ 2) lalrogenic) Trash Fool
l)
INVE$TIGATIONS:
For aneurgsrn) U/9, CT, MRA, Anliolraphg For olher sgslerns) ECG, CBC, Lipid profile
Conservative
r-TREATMENT_r
risk patienl
Surgerg if indicaled
. INDICAIONS OF SURGERY
lf sgrnplomalic, Diarneler>Scm,High
PROCEDURES
. SURGICAL
lnlra-lurninal self-inflalablegraft
. .
& thock
il?4-Tw\5
A{DocEN?
"ilK#,] ?&
t1?-
. Manifesied bg
*j rji
"$r
. . .
IIIITT.
General
sfr rsrl!Ir:i .
.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.
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
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
Line
of
demarcalion
Fale
clP
of local death Lost (pulsation, Sensalion, Heaf, Funclion of affecled part, fxed color changes)
The five cardinal s'rgns
l.
..... 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
Limb salvage
- Ampulalion tillihe
level of pulsalion
ilPq-Tou\5
,ND0CRN?
ileqW1
?hqv t
OF
Etiologg
$ite>
Trealrnenl
Prolonged pressure. After irnrnobilizalion of paraplegic palienls, elderlg & diabetics. ..Bong prominence culs the blood supplg of
PROPHYLACTIC TREATM ENT - Air rnallress - Skin should be kept drg & clean. - Frequenl change of posilion everg 2
hours.
ACTIVE TREATMENT
- Debridemenl - Leave lhe wound open unlil healing - Repeated dressing with llgcerin rnagnesia
- Anlibiotics
. . . l)
Sudden onsel of scrolal inflarnrnalion sudden onsel ofgangrene Mag be associated wilh necroiizing
. .
Caused bg exlensive lhrombosis of lhe rnajor peripheral veins (phlegrnasia cerulea dolens)
fasciilis
Trealrnenl.
flealmenl:
l)
Elevate limb
2)
Antibiolics & wide surlical excision. Laler) skin graft lo cover lhe leslis.
2) 3)
5UP.4-Tffi\5
ENmflf.lV5WR1
?h lW
5R4:lwr5
^',,*NY
lRqW
?hqY t ttu
TI{FOMBO$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
DEEP
CLINICAL PICIURE:
T]IROMBO$S
T,
. .
ASYMPTOMATIC: Mosl cases are silenl bul are suspected bg unerylained Posl-operalive fever,
gYMPIOMAIIC:
. * * . . .
COMPLICATIONS:
GENEML: Pulmonarg Embolism
LOCAL:
EARTY: Phlegmasia ALBA dolens, Phlegmasia CERULA dolens LATE: Post-phlebitic limb leading lo 2rg Varciose veins, Venous gangrene
INVESTIGATIONS:
FOR DIAGNOBIS:
Colored Duplex Recenllg: SPIML CI, Radioactive Fibrinolen FOR PULMONARY EMBOLI$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
E lnlra-Op Inlermitlenl
tr
GENERAL
Bed rcst for 7-lO
DRUG
gURGICAL
Ind'rcalions:
. Confra-indication
to Anlicoagulanls e.g. :
ANII.COAGULANTS
FIBRINOTYTICg .
ln lhe lirsl 3 dags 9treplokinase, urokinase
Rece
. 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:
CONIRAINDICAIIONS:
TTI OF COMPLICAIIONS:
- PUTMONARY
EMBOLISM: Morphine, O2, Thrombolglics, Anticoagulants, Emboleclorng
- POBI PtltEBlIlC
erylpur
Etr
StilAr
I -
nches
of
E Recurrence)
Pulrnonarg hgpertension
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
l-
lf
6 hours
R,ECURRENCE
cJ'R4-TWr5
1allw*UVfl,Rqw ?h
0lln
of
L.L.
) a
Etiologg
tr E
::
I g Vacular
gl ! r,rl{;3
tr
E
Congenilal rnesenchgrnal Weakness: (Marphan $, Ehler danlos $, Askar $) Congenital valvular incornpetence
tr tr
E E E
M (Most common cause) AV Fistula: - CONGENIIAL: Klipple lrenaurg - ACQUIRED: Butcher's Thigh
Aneurgsrn Burger disease Pelvic lumors, PreAnancu
Pathologg
veins*ffi
tr
Cosmelic dis{igurernenl, Sgmplorns of complicalions (pigmentafion, ltching, Ulcer) Dull aching, sensalion of heaviness with sense of holness al ihe end of ihe dag or on prolonged slandin[
tr PATIENI: Around 3O gears tr PAtN,:[@ tr PAIN IS RETIEVED BY: (deeo veins are inlacll
S'rgns:
}1
SWE[[!NG:
tr GElrlERAt: - Signs of mesenchgmal weakness tr IN$PECTIOIII: - Multiple dilated tortous vein along long,
tr
-
tr
;
-
tr
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!
-Thrornbosis
- Dilated Tortuous veins, lncompetenl
valves
tr
-Plain
X-mg)
Varicose ulcer
Perioslills
PH}iAFY
UNCOMPTICATED UNCOMPTICAIED COMPTICATED
& DISFIGUREMENI
OR PAINFUT
INJECTION
SURGICAL
. .
. . .
R.e-assurance
m.
Warnins,
lf Al! Perforators)
vEilolotrllcS
tr
E
tr
ON,EFS
tr
E [L edema
Etr
IAUPUS EQUTNUS
tr
E
Posl-lraurnatic
Hemorrhage Euperlicial Thrombophlebitis
tr
tr
Operation
?AqY
IH
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
VAtr'CGE\EINS
ffi
E E
sGgraAr
tr
lF FAILED: Excision & Covering bg Cross leg skin Flap
tr
tr tr
Resl, elevation of limb Compression slockings Dressing with saline, anliseptics Debridemenl
tr
?AEV
I W)
tr
GEI\IERALIZED AFFECTION:
tr
IOCAIZED AFFECTION:
Mediaetinal [Ne Mesenteric Utle
Pathologg
tr
tr Affects tr NO ...
Affectbn of capsule, Matfin!,
Caseation, Cold abecess
ASecls
tr
Clinical pic{ure
... perforates
deep fascia
tr
tr
tr tr
Affected Lftls:
tr
Nol lender
.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
(lNH
Rifampicin
* * * * *
s:
Failure of medical TT Biopsg Single accessible group of LNe
ldrNlegfions: Banalorial & MedicalTTT Aspiralion bg Z-lechnique
Streptomgcin )
*lnjection of
Blreptomgcin
OR
*Excision
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
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$COPIC PICIURE: - Enlarged, discrete earlg) mafted laler - Rubberg - CUT SECTION: Pink homogenous with loss of archileclure, lnlacl capsule gPtEEItl) Tofree Alrnond appearance MICRO8COPIC PICIURE: . REED.SIERNBERG CETLB
tr
MACROSCOPIC PICTUR,E:
ACE&
picture
CONSIITUTIONAT SYMPIOMS:
tr tr
tr
tr
tr
lnvestigalion
- Fever, llching, loss of weighf - Anernic rnanifeslalions. SWEILING: - 9lowlg progressive, rubbetg) matted PAIN: - Pain & itching (Affet alcohol inlake "Gordon's leslo or lale afrer in{iliration) PRES8URE MANIFEEIAIIONS: dgspnea, dgspha$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:
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 $) d. CXR, Abdominal U/B & C.f., BM puncture. e. Staging laparolorng is rarelg used (replaced bg SPIRAI CI Scan).
c.
frealmenl
I.
2.
GENERAL IREATMENT:
CHEMOTHERAPY
Vrtamins, Blood lransfusion, lron lherapg DEFINIIIVE IREAIMENI ... according to siage...
...(Multi-centric)...
As Hodgkin's lgmphorna *... tN NODUTAR [YPE) Chlorambucil
- la, lb, lla) Radiother.apg - Ilb) Radiotherapg + Chemotherapg - ll!, lV) Chemotherapg
tr tr
E
tr gtage l) Enlarged I group of Lil. above or below diaphragm tr Stage tl) Enlarged more > I group of LN. above or below
tr Btage lll) Enlarged L[tl. above & below diaphragm tr Sfage lV) Extra-nodal afleclion (liver & bone marrow)
diaphragm
tr Sile:
MicroscoDic Diclure:
ilE+:IW'{r,
htm*tfiilP#l
?hq7 I W
oF HoDqKll.l Ln lH{otr/h
(
ACCoRDINq
ro s:Ac,lhlc, )
IIb
la,lb,lla
RADIOTHERAPY
gUPRA.
DIAPHRAGMATIC LNs
III, M
RADIOTHERAPY
t
MANTLE THERAPY
l)
Cgclophosphamide
g g
Lowers Hgpercalcemia in late slages Relieve itching Raises lhe mood lmproves CBC, appetite
EI Biopsg EI Laparolomg
lnleslinal Obslruction
M Jaundice
INFRA.DIAPHRAGMATIC
X.E+:IW{r, A'.W;fN,VXf.#I
ARTERIAL SYSTEM
. . . . . . r .
lnlermittent claudication Mag be an indication for bgpass surgerg if it interfere which the palient normal life. Sensorg loss mag be reversible after revascularization. ln diabetic fool infeclion drainage through a small incision over lhe pointing area is enough in most patient and debridement should be avoided especiallg in presence of good vascularizafion lo avoid excessive
bleeding.
of small bones of the foot might be indicalion for ampulalion in Septic fool infection in diabeiics. Allen lesl is done lo detecl Dominant blood supplg of the hand.
The presence of osteomgelitis
an
VENOUS SYSTEM
Acule severe deep venous lhrombosis can present bg the limb A-Warm, swollen with tur$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
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
*fer,,U ailqolstt/
1e,q*Twt5 ww/J.t71Rqw
?hqvtw
ioN
aa
f,2@Z 2@4,2M2ob,
Azhar rl/,
2M, 2mL/)
-
Acute ischernia
(Kasn
6i/ siafils,2W
Uh
sfiart/s,
(
2@5,2fu)
r Eiio-pathologg of lgrnphederna
Ailar f,2@7)
( Kasn
2d/ )
t60
il
ao