ORTHO NUGGETS>>>
ORTHO NUGGETS>>>
1) Newborn with uneven
1) Newborn with uneven gluteal folds; limitation in abduction; limp;gluteal folds; limitation in abduction; limp; positive barlow and ortolani est = DDH= more
positive barlow and ortolani est = DDH= more common in females; Docommon in females; Do ultrasound and xray = Treat with lexion!"bduction splinting with
ultrasound and xray = Treat with lexion!"bduction splinting with #alvlic$ harness%%%% after 1 year =
#alvlic$ harness%%%% after 1 year = open reduction with bony re&alignmentopen reduction with bony re&alignment by spica cast%
by spica cast% ') (' years child
') (' years child with imp and pain in groin*$nee*thigh; abnormal gait;with imp and pain in groin*$nee*thigh; abnormal gait; = egg&#erthes disease = Do "# + lateral x&ray for diagnosis=shows small = egg&#erthes disease = Do "# + lateral x&ray for diagnosis=shows small and dense femur head; ,#D is avascular
and dense femur head; ,#D is avascular necrosis of epiphysis of femur)necrosis of epiphysis of femur) -) "dolescent with imp and pain in groin*$nee*thigh; legs showing
-) "dolescent with imp and pain in groin*$nee*thigh; legs showing external rotation=.lipp
external rotation=.lipped capital ed capital femoral epiphysis ,dislocation b*wfemoral epiphysis ,dislocation b*w epiphysis and metaphysis) = do x&ray
epiphysis and metaphysis) = do x&ray and do immediate emergency repair and do immediate emergency repair /) young child after respiratory tract infection ; decreased leg
/) young child after respiratory tract infection ; decreased leg movements; painful leg and flexed0
movements; painful leg and flexed0 abducted and externally rotated =abducted and externally rotated = .eptic arthritis
.eptic arthritis
) racture where one side of
) racture where one side of bone is bent and other side fractured =bone is bent and other side fractured = 2reenstic$ fracture
2reenstic$ fracture 3) "bdu
3) "bducted arm; cted arm; prominent acromian; externally rotated ,4ust li$eprominent acromian; externally rotated ,4ust li$e sha$ing hand position); after in4ury to
sha$ing hand position); after in4ury to shoulder; = "NT567shoulder; = "NT5678686 D7.89"T78N
D7.89"T78N
8 .H8:D56= do lateral and "# 6"<= Treat after "T. and proper 8 .H8:D56= do lateral and "# 6"<= Treat after "T. and proper analgesia do 98.5D 65D:9T78N by
analgesia do 98.5D 65D:9T78N by i) >ocher method of T5"6 ii)i) >ocher method of T5"6 ii) Hanging
Hanging
arm*gravitation
arm*gravitational al method iii) method iii) Hippocrite method%%%%%%%%%%%%Hippocrite method%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
9omplications i) Nerve damage "xillary0 brachial plexus ii) ?uscle 9omplications i) Nerve damage "xillary0 brachial plexus ii) ?uscle in4ury .upra&spinatus iii) 6ecurrent dislocation iv) @one
in4ury .upra&spinatus iii) 6ecurrent dislocation iv) @one damagedamage 9ompression fracture of humerus v) 9artilage in4ury 7n4ury to glenoid 9ompression fracture of humerus v) 9artilage in4ury 7n4ury to glenoid labrum ,ban$art lesion)
labrum ,ban$art lesion)
A) "dducted arm; internally rotated after attac$ of 5#75#.< = A) "dducted arm; internally rotated after attac$ of 5#75#.< = #8.T56786
#8.T56786
D7.89"T78N 8 .H8:D56 D7.89"T78N 8 .H8:D56
B) <oung child fall on outstretched hand = .:#6"98ND<"6 B) <oung child fall on outstretched hand = .:#6"98ND<"6 6"9T:65= CA
6"9T:65= CA
5T5N.78N; - 578N%%%%%% type -= complete dissplacement = Do 5T5N.78N; - 578N%%%%%% type -= complete dissplacement = Do closed
closed
reduction%%%
reduction%%%%%% but if fails* %%% but if fails* vascular in4ury = 867 ,open reduction andvascular in4ury = 867 ,open reduction and int%fixation) by
int%fixation) by >&wires%%%%%% 9omplications>&wires%%%%%% 9omplications ") 5"6
,@rachial artery; Eol$man ischemic contracture)0 compartment syndrome0 soft tissue in4ury0 wound infection0
heamarthrosis%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
@) D5"<5D Non&union0 mal&union0 delayed union0 4oint atrophy0 .udeh$ atrophy0 myositis ossificans
C) ?alunion in case of .:#6"98ND<"6 6"9T:65 leads to 9:@7T:. E"6:.
,gun&stoc$ deformity)
1F) "nterior interroseous nerve is most common nerve in4ured in
supracondylar fracture11) Eol$man ischemic contracture is #56?"N5NT 578N 98NT6"9T:65 of hand
and wrist leading to claw hand b*c of compromise of @6"9H7" "6T56< leading to muscle fibrosis
1') 8ld aged; osteoporotic women fall on outstretched hand = Dinner for$ deformity = 985G. 6"9T:65= extra&articular fracture of lower part of radius within '%cm%%%%%%%%Do &ray ap and lateral%%%%%%%%%%%%%%after
"T. and analgesia%%%%%%%%%
") N8N&8#56"T7E5 volar forearm splint temporarily0 close reduction&&& (apply cast%%%%( place arm in palmar flexion and ulnar deviation
@) 8#56"T7E5 if above fails ,internal fixation) 9) #56&9:T"N58:. wires may also be placed 1-) old age and fall on flexed hand = smith fracture
1/) <oung age ; fall on outstretched hand%%%%%% wrist pain and tenderness over "N"T8?79" .N:@8 = .9"#H87D 6"9T:65%%%%%%%%%%%do & 6"< 6"<
will be absolutely normal b*c the fracture is obvious after '&wee$s%%%%%%6x%%%%%%%%i) Thumb spica cast%%%%ii) 6epeat x&ray after -wee$s%%%%%%%% if un&displaced = apply plaster; if displaced =
867%%%%%%%%%%%%%%%%9omplications i) High rate of N8N&:N78N ii) "E".9:"6 N5968.7. of proximal pole
1) &6"< does not show any finding in .9"#H87D 6"9T:65 so repeat should
be done after - wee$s%%%%%,v%imp)
13) #687?" :N" 6"9T:65 with D7.89"T78N 8 6"D7:. = ?ontegia fractue
1A) 6"9T:65 8 6"D7:. with D7.89"T78N 8 :N" = 2ellai fracture
1B) @oth mottegia and gellai fracture need 867
avascular necrosis of femoral head%%%%%%%%%%%%%%%%%%%%%% 7f it is :ndisplaced 7NT56N" 7"T78N!D<N"?79 H7#
.965I%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% if Displaced "6T7797" H5"D*TH6 by prosthesis%%%%% but do DH6 in young pts%%%%%% old patients if immbolied
are increased ris$ of DET %%%% .8 27E5 #8.T&8# anticoagulation as welll 'F) .mith peterson nail is used for fixation of fracture of nec$ of femur '1) racture of femoral shaft
i) 7nfant = :se 2alow traction ii) 9hild = balanced traction
iii) "dult= 7ntramedullary nail fixation
'') emoral shaft fracture leads to extensive blood loos so 65.:97T"T78N is the $ey element in management
'-) lexion and rapid rotation e%g during $ic$ing football; normal x&ray; 9lic$ sound in $nee when $nee is extended = ?edial meniscus tear%%%%D8 ?67%%%%%%% "6TH68.98#79 65#"76* ?enisectomy'/) ootball in4ury; severe $nee pain; pain on ?5D7" aspect; "@D:9T78N
more than normal ,valgus stress test) = 7NJ:6< T8 ?5D7" 98"T56"
72"?5NT
') ootball in4ury; severe $nee pain; pain on "T56" aspect; "DD:9T78N
more than normal ,varus stress test) = 7NJ:6< T8 "T56" 98"T56"
72"?5NT%%%%%%%%%%%%%% use H7N25D 9".T for both these ligament in4uries '3) ootball in4ury; $nee pain and swelling; on $nee flexion leg at CF o is pulled anteriorly ,"nterior drawer sign)%%%%%%% and also on fixation
of $nee at 'F o pulls anteriorly ,achman test) = "NT56786 96:97"T5 72"?5NT T5"6%%%%%% do ?67%%%% 7mmobilie the patient* arthroscopic reconstruction
'A) or bone tumors%%%%%%%from epiphysis; metaphysis; diaphysis ,285) i) 5piphysis = 2iant cell tumor soap bubble appearence on x&ray%%% do surgery
ii) ?etaphysis = 8steosarcoma sun&burst* codman triangle on xray%%% surgery; chemo; radio
iii) Diaphysis = 5wing sarcoma 8nion peel appearence on xray%%% chemo; radio; surgery."7E"6< 2"ND. N:225T.
1) There are /F minor salivary glands and contribute 1F saliva% They are histologically similar to ma4or salivary glands and may be found on lip mucosa% Their tumors are more li$ely to be malignant,CF) as
compared
to ma4or salivary glands%
') 7f any salivary gland tumor is K1cm and benign = do 597.78N" @78#.<
-).ublingual gland lies on mylohyoid muscle% 7t is paired and each of the part has more than one duct% B of .ublingual gland tumors are
?alignant
and treated by Iide excision with nec$ dissection%
/) ?ucus retention cyst of sublingual gland = 6anula%%%%translucent swelling on floor of mouth ,4ust li$e frog belly); brilliantly trans&
illument%%%%%%% 6x excision of cyst and sublingual gland ) T:?86.
i) CF minor salivary glands = ?alignant ii) B sublingual gland = ?alignant
iii) F submandibular gland = ?alignant
iv) very low #"68T7D tumors are malignant and mostly are benign ?eans smaller the gland = more li$ely the chance of malignancy
3) 7nflammation of submandibular gland = .ial&adenitis= leads to radio& opaLue stone formation
A) .tone in salivary gland = .ialo&lithiasis = .I57Ng precipitated by eating and relieved 1&' hrs after meal
i) .ubmandibular stone= 6"D78&8#"M:5; Dx by 6"<; remove by longitudinal
incision%%% most common stone in salivary gland .:@?"ND7@:"6 ii) #arotid stone = 6"D78:95NT; d by .ialography ,:.2) remove along
with parotid gland%%%%% Do not do .ialography in acute suppurative parotitis
B) #arotid gland lies on ?"..5T56%%%%%%%% 7t contains i) acial nerve ii) 5xternal carotid artery iii) 6etromendibular vein
C) ?ost common benign tumor of parotid = #58?86#H79 "D5N8?" = mostly
involves the superficial lobe of gland= if long standing&transform into malignancy%%%%Dx N"c%%%%%%%%%%%6x .uperficial parotidectomy%%%%,Never do 4ust
enucleation b*c of ris$ of recurrence)%%%%%%%%%%%%%%%%%%7f deep lobe involved so that
tonsils are pushed medially = total parotidectomy
iii) acial nerve palsy iv) 9ervical lymphadenopathy
1F) ?ost common malignant tumor of parotid = ?:985#7D56?87D 9"697N8?"%%%%%%%%%%%Dx N"9%%%%%%%%%%%%6x 7f low grade = .uperficial parotidectomy
,pateys operation)%%%%%%%%%%%%%%7f high grade = 6adical parotidectomy "cini cell carcinoma is low grade and exclusively found in parotid
11) 9omplications of parotid surgery Hematoma0 seroma0 frey0 infection0 facial nerve palsy0 great auricular nerve damage1') rey syndrome = gustatory sweating b*c of regeneration of
parasymphatic fibers%%%%%%%%% Dx 7odine starch test %%%%%%%%%%%6x Tympanic neurectomy0 botulinm toxin%%%%%%%% #65E5NT78N #lace muscle flap from .9? b*w
s$in and parotid* facial flap* insert artificial membrane
11) "ll salivary glands tumors are most commonly found in parotid gland except
i) "denoid cystic carcinoma = ?inor salivary gland ii) .Luamous cell carcinoma = .ubmandibular gland
1') ?ost common benign tumor of salivary glnad = pleomorphic
1-) ?ost common malignant tumor of salivary gland = mucoepidermoid 1/) ?ost common malignant tumor of minor salivary gland = adenoid cystic carcinoma
1) ?ost common bening tumor of paotid in children = hemangioma 13) ?ost common radiation induced neoplasm of salivary gland = mucoepidermoid carcinoma
1A) "ll parotid tumors are more common in females except I"6TH7N T:?86
which is most common in males; I"6TH7N T:?86 arise exlusively from parotid gland; mostly found in tail of parotid; 1F bilateral; 6x by
.:#56797" #"68T7D59T8?<
1B) "denoid cystic carcinoma is most common malignant tumor of minor salivary glands; it is low grade ; and shows #567&N5:6" 7NE".78N%
THYROID NUGGETS...
1) or thyrotoxicosis if K/ years = do surgery%%%%%%%%%%%%%% (/ years = 6adioiodine ablation
') 7f 2oiter and thyrotoxicosis appear simultaneously = primary thyrotoxicosis
-) 7f goiter appears early and thyrotoxicosis late = secondary thyrotoxicosis
/) 9ardiac signs are more pronounced in .econdary whereas eye signs are
more pronounced in primary thyrotoxicosis
) 7nvestigation of choice for T8797T< with N8D:"67T< = Thyroid scan 3) Treatment of choice for solitary thyroid nodule =
obectomy*Hemithyroidectomy
A) #apillary carcinoma radiation exposure is a ris$ factor; 7t is
bilateral and ?ultifocal in origin; spreads through lymphatics; has best prognosis; diangnosed easily by N"9; treated by T8T"
TH<687D59T8?< with
nec$ dissection% + post op radio&iodine
B) ollicular carcinoma endemic goiter is a ris$ factor; unifocal; more aggresive than papilllary; hematogenous spread; poor prognosis
andgreater recurrence rate; canGnot be diagnosed with N"9; treat by T8T"
TH<687D59T8?< with nec$ dissection + post&op radio&iodine
C) ?edullary carcinoma 65T proto&oncogene mutation; associated with ?5N&'; mulcentric c&cell hyperplasia; spreads to lymphnodes; high levels of 95" and 9"97T8N7N%%%%%%% Treat with T8T" TH<687D59T8?< with nec$
dissection%% but there is N8 685 8 #8.T&8# 6"D78&78D7N5%%% 7f at any
time in patient life 65T oncogene is found in screening%%%%%%%% do
prophylactic thyroidectomy even if there is no evidence of medullary carcinoma
1F) "naplastic carcinoma Iorst tumor; diagnosed by T6:&9:T biopsy%%%%% treat with radiotherapy %%% but if T6"9H5" [email protected]:9T78N= do
7.TH?:.59T8?<%%%%%%%%% remember never to tracheostomy if emergency tracheal obstruction has happend b*c of anaplastic ca%% always do
11) ymphoma associated with autoimmune thyroiditis; diagnosed by N"9
but needs futher confirmation by T6:9:T%%%% for early stage = radiotherapy00 for late = chemo
1') The most common cause of respiratory distress after thyroidectomy is T5N.78N H5?"T8?"* 6eactionary hemorrhage leading to aryngeal edema%%%%%%%% 6x Do wound exploration and secure airway
1-) "fter papillary and follicular carcinoma of thyroid%%%% to prevent recurrence of thyroid ; .:#65..7E5 D8.5 8 TH<687D is given
,'FFug)%%%%%%%%% but after medullary carcinoma%%%% 65#"95?5NT D8.5 7. 27E5N ,1Fug)%:6825N7T" N:225T.%%%%
1) >idney fusion at lower poles in front of / = Horseshoe $idney %%%%%%% increased ris$ of infection and stone formation
') 7ntermittent and moderate hematuria is a feature of "#>D
-) 9ystic dilation of intra&mural portion of ureter is called :65T568955 and it gives O"DD56 H5"DO D586?7T< on urography%%% patients are increased ris$ for stone formation%%% Treat by endoscopic diathermy /) The most common cause of ureteric in4ury is 7"T6825N79
,hysterectomy +
gut surgery)%%%%% and the best way to prevent this is to place #65& 8#56"T7E5 .T5NT in the ureter to enable better palpation of ureter during
surgery%%%%%%%%%%%%%%%%% if it gets in4ured i) either do end to end
anastomosis%%%%%%%%%% if in4ury is large so that tension will happen on ureter if anastomosed then u can do ii) ?obilie the $idney iii) Ta$e flap from bladder ,@oari flap) iv) lap from appendix v) 7nsert ureter into opposite ureter vi) :reterosigmoidostomy
) #elviureteric 4unction obstruction ,#:J) leads to unilateral hydronehprosis%%%%%%%% treatment is #<58#".T<
3) >idney stones ,9#:)%%%%%%%%%%%%%%%% CF $idney stones are 6"D78& opaLue
i) 9alcium oxalate most common; irregular with sharp pro4ections and give rise to hematuria
ii) #hosphate ,staghorn*struvite)%%%%%%due to proteus or staph%%%%%,in al$aline urine)
iii) :ric acid stones are 6"D78:95NT%%%%%confirmed by 9T
iv) 9ystine stones are resistant to 59.I b*c they are hard ,imp%mcL) A) .tone Kmm passes spontaneously%%% so manage it conservatively B) 7f there are bilateral stones%%%%%the better functioning $idney should
be treated first%%%%%
C) 59.I is indicated for $ideny stones K'cm and for ureteric stones K1cm
1F) :reteric stones produces pain but if it completely obstructs the ureter%%% #"7N .T8#.%%%%% the best treatment of ureteric stones (1cm is
:65T568.98#79 .T8N5 [email protected]:9T78N and it is superior to D86?7" @".>5T%
11) .tones which are formed in $idney ; if they pass and go to bladder they are called #67?"6< @"DD56 .T8N5.%%% whereas .598ND"6< @"DD56
.T8N5. are those which form in bladder b*c of @880 infection or foreign body%%%% bladder stones are treated by 7TH8"#"<%%
1') :rethral stricture0 contracted bladder and large stones are contra& indications of 7TH8"#"<%%%%% so here u can do i) #569:T"N58:.
.:#6"#:@79 7TH8"#"< ii) 59.I1-) #<8N5#H68.7. occurs b*c of i) "cute pyelonephritis ii) 6enal stone
iii) #re&existing hydronephrosis%%%%it should be treated aggrasively b*c sepsis can ta$e place%%%% i) Do N5#H659T8?< if other $idney is
normal%%%%%%%% ii) #569:T"N58:. N5#H68.T8?< if patient is too sic$ for surgery%%%%%%% iii) 7f pus is thic$=8#5N N5#H68.T8?y
1/) lan$ pain; ever; #us cells in urine = "cute pyelonephritis
1) lan$ pain; fever; flan$ mass; pus cells in urine; = #yonephrosis 13) lan$ pain; fever; flan$ mass; 1st no pus cells but later pus cells in urine = 6enal carbuncle ,abscess)%%%%%%%%%% it is caused by
hematogenous spread and 9T is investigation of choice for it%
1A) lan$ pain; fever; flan$ mass; N8 pus cells in urine = #567N5#H679 "@.95..%%% :ltrasound differentiates it from 65N" "@.5.. but
investigation of choice is 9T
1B) T@ of >7DN5< "ND @"DD56 = pain relieved by micturation; sometimes
painless hematuria%%%%%%%sterile pyuria ,no organisms but pus cells are in urine)%%%%%%%% 8n cystoscopy u will find i) inear ulcers ii) Hunner ulcer iii) 2olf hole appearence of ureteric orifice iv) Timble
bladder%%%%%%%%%%%%% for $idney T@%%% give "TT and after that do nephrectomy ,if $idney function lost)%%%%%%%%%%%% if bladder is contracted ,timble) = do "ugmentation cystoplasty%0 instill dimethylsulphoxide
1C) T@ of epidydymitis and and testis is very resistant to "TT%%%%%% so do surgery%
'F) or 699 = in early stage do 6"D79" N5#H659T8?<%%%%% use T6"N.&
#567T8N5" "##68"9H Do not mobilie the $idney until 65N" "6T56< "ND
E57N #5D795 7. T75D%%% also #"#"T5 65N" E57N for any deposit% '1) ?ost effective treatment for .:#56797" @"DD56 9" =
7NT6"E5.79"
9H5?8T56"#< ,@92)
'') @low on distended bladder = 7ntraperitoneal rupture of bladder '-) #elvic fracture = extraperitoneal rupture
'/) "bdominopelvic in4ury; urinary retention; scrotal hematoma; blood at tip of penis = :rethral in4ury%%%%%%%%%%Do ascending urethrogram !
suprapubic cystostomy
') "bdomniopelvic in4ury; no urinary retention; hematuria on folley%%%%%%%%%%%%may be >7DN5< or @"DD56 7NJ:6<%%%%%%%%%%%%%%%%%%%
ascending cystogram will diagnose for @"DD556 6:#T:65 while 7E#0 9T0 :.2
for $idney in4ury%%%%%%%%
'3) #riapism is caused by .79>5 95 D7.5".50 7NJ 8 #"#"E5697N5
'A) ?ost common part of urethra which is ruptured in #5E79 6"9T:65 =
?5?@6"N8:. :65TH6"'B) 9ryptorchidism %%%% mostly unilateral ,on right side)%%%%%do surgery
after 1 year and before the child goes to school%%%%%%%%%%%% complications i) cancer ii) Torsion iii) Trauma iv) "trophy v)
Hernia%%%%%%%%%%%%%%%%%%%%% 8rchidopexy is done but it does not reduce the chance of malignancy in testis%%
'C) .udden onset of testicular pain%%%%%%%% T5.T79:"6 T86.78N%%%%%%%%% differentiate from 5#7D<D7?8&869H7T7. by #65HN .72N%%%%%% Doppler :.2 is
confirmatory but do immediate surgery%%%%%%%%%%% 869H7D8#5< ,by scrotal incision)%%%%%%%%%% other normal testis should also undergo
869H7D8#5<%%%%%%%%%%%%%
-F) or testicular tumors%%%%%%%%%% "I"<. D8 H72H&7N2:7N"
869H7D59T8?<%%% ,not scrotal)%%%%% after histological diagnosis%%%%%%%%%% for .5?7N8?" = 6"D78TH56"#<%%%%%%%%% for T56"T8?" = 9?@E ,cm $i bv)
node dissection can also be done%
-1) 9ongenital hydrocele is the only hydrocele which is treated by
H56N78T8?<; and it communicates with peritoneum%%%%%%%%% it presents with intermittent hydrocele%%%%%%% when patient lies down = hydrocele
disappears%%%%%%%%%% if congenital hydrocele is bilateral = thin$ abt ".97T75.%
-') Hydrocele and 5pidydimal cyst = both are trasilluminant ! %%%%%%%%% but hydrocele is not separated from testis wehreas 5pidydimal cyst is separated from testis; is bilateral mostly and feels li$e bunch of
grapes%
--) or other hydroceles = do either Jobuley repair ,eversion of sac)%%%%%%%*%%%%%ords plication
-/) .permatocele is :N789:"6 retention cysts arising from epidydmis%%%%
fluid resembles @"65< I"T56 and contains spermatooa%%%mostly located on
upper pole
-) in the end%%%%%%%%%%% 65?5?@56= N5E56 5E56 :.5 .968T" "##68"9H 86
869H7D59T8?< 86 T5.T79:"6 9"N956%%%%%%%%%%% J:.T :.5 H72H& 7N2:7N"
"##68"9H%%%%@65".T N:225T.%%%%%
1) ibroadenoma ,1&'cm) most common breast tumor K- years%%% firm rubbery mass ,@reast mouse)%%%%% do triple assesment%%%% 5xcision *
enucleation
') 7f fibroadenoma(cm = 2iant fibroadenoma
-) #hyllodes tumor females (/F years%%% mass (cm%%%%%% arise from proliferation of stroma%%%%%%% have somewhat malignant potential%%% do triple assesment%%%%%% 6x by Iide local excision with rim of normal tissue
/) @loody discharge from nipple without any palpable mass = 7ntra&ductul #"#78?"%%%%% do triple assesment%%%%% 6x by ?icrodiscetomy
) @loody discharge from nipple with palpable mass = @reast cancer 3) 2alactorrhea mil$y discharge from nipple
?ost common physiological cause nipple stimulation* sexual intercourse ?ost common pathological cause #rolactinoma
?ost common non&pituitary pathological cause Hypothyroidism A) 2alactocele is associated with use of 89# = do aspiration
painful sub&areolar mass0 sometimes fistula formation = D:9T
59T".7"*#567D:9T: ?".T7T7.*#".?" 95 ?".T7T7. = Do triple assesment =
6x antibiotics and Hadfield operation ,9one excision) C) @reast cancer K-cm = Do @reast conservation therapy (-cm = ?odified radical mastectomy
1F) @reast conservation therapy includes
i) Iide local excision with 1cm healthy margin ii) "xillary lymph node dissection
iii) #ost&op 6adiotherapy
11) ?odified radical mastectomy Ihole breast along with nipple areola removed; axillary lymph nodes upto level '; #59T86"7. ?7N86 7. ".8
65?8E5D but #59T86"7. ?"J86 N8T 1') #ost op hormonal therapy
premenoupasal = Tamoxifen postmenopausal = "nastraole
1-) Tamoxifen decreases the recurrence and incidence of bone mets %%% also decreases the death rate and should be given for <5"6.%
1/) The most common indication for post&op 6"D78TH56"#< is @65".T 98N.56E"T78N TH56"#<%%%% it decreases the recurrence but not
?5T.%%%%1) "fter radiotherapy and axillary dissection = 9hance of <?#H5D5?" 7N
"6? 7N965".5.%%%%%and this <?#H5D5?"T8:. arm may transform into
?"72N"NT= "N278."698?"* <?#H"N278."698?"%%% ,imp mcL) 13) 7n pregnancy with breast cancer;
No radiotherapy in prengnancy No chemotherapy in 1st trimester
1A) @reast cancer arising in pregnancy are hormone resistant%27T N:225T.
1) 5sophageal perofration most often caused b*c of 7N.T6:?5NT"T78N ,removal of foreign body)%%%%% surgical emphysema of nec$ n upper chest is pathogonomic%%%%%% Dx do &6"<0 gastrograffin contrast study%%%%% if &ve %%%do dilute barium study*9T scan%%%%%%%%
') or perforation of 956E79" 5.8#H"2:. = manage
conservatively%%%%%%%%%%%%% but or "@D8?7N" 5.8#H"2:. = "I"<. D8 .:6256<%%%%%%%%%%%%% other indications of surgery large septic load0
-) 6egarding surgical options for esophageal perforation i) /&3 hours = Do primary repair ,always stitch the ?:98.")
ii) (1' hours = edema develops = so; #687?" 5ND >8 @"H"6 5 ""8 and
D7.T" >8 98.5 >6N" H"%%%%%%%%%%%% + for feeding = eeding
4e4onustomy%%%%%%%%%% $uch din $ baad colon*4e4num $a graft laga dena hai us 4aga pe%%
4is proximal end $o bahar laya ha waha se drain $rna ha by placing T& T:@5
! local drains placement
/) 5arly endoscopy is mandatory for corrosive esophageal in4ury and
regular follow up 5ND8.98#75. are advised to assess the development of
stricture%%%% Do not do N*2 aspiration in acute corrosive in4ury%%% eeding 4e4unostomy can be done
) @arret esophagus is intestinal metaplasia of lower esophagus%%%%%% increased ris$ for adenocarcinoma%%%%%%%%give ##7 and follow up using endscopy
i) 7f 4ust metaplasia = endoscopy every '&- years ii) 7f low grade dysplasia = endoscopy 3&1' months
iii) 7f high grade dysplasia = ablation with endoscopy; photodynamic; argon laser; plasma coagulation; esophagectomy
3) 9omplications of peptic ulcer surgery includes 659:665N95; D:?#7N2
.<ND68?5; ">"7 65:*@75 65:; #8.T&E"28T8?< D7"66H5"; 2".T679 9";
2".T8N5.; N:T67T78N" D57975N9<
A) Dumping syndrome 5arly dumping is due to hypovolemia whereas late dumping is due to hypoglycemia%%%%%%% Dumping will improve with time
B) 7f reflux gastritis happens%%% treat by cholestyramine and metoclopromide00%%%%%%%%if persists%%%%%%%%%%%%% do 68:&5N&< 6598N.T6:9T78N
C) Hepatic adenoma is associated with 89#; found in young women; there are no >upffercells in it; it can cause intra&peritoneal bleeding; it can
predispose malignancy so do biopsy and do surgical resection
1F) ocal nodular hyperplasia is associated with trauma; gives central stellate scars on liver with radiating septa producing mass effect; it
H". >:#56 95. so detected by .:#H:6 9887D N:95"6 .9"N; not
premalignant so no treatment reLuired%11) Dilated intrahepatic ducts b*c of congenital hepatic fibrosis =
9"687 D7.5".5 = may lead to bile stasis and stone formation in the liver%%%%% if infected treat by antibiotics%%%%%%%%%% drain
bile%%%%%%%%segment of liver can be removed or iver transplantation is last resort
1') .plenunculi are accessory spleens in 1F&-F ppl mostly found at splenic hilum but may be found in the ligaments of spleen%%%%%%%%.o in
patients undergoing splenectomy esp for hematologic disease%%%%% always loo$ for .plenunculi and resect them also b*c they can be site for
recurrence
1-) .plenic artery aneurysm more common in females; in pregnancy; if it is symptomatic or ('cm%%%%%%treat by 5mboliation* .plenectomy
1/) .plenic infarction caused by myeloproliferative disease0 sic$le cell0 portal vein thrombosis%%%%% does not always needs surgery but if it gets infected*abscess formation%%% do splenectomy
1) 7n 7T#= splenectomy is done if i) ailure to steroid therapy ii) ' relapses after steroid iii) #ersistant 7T#%%%%%%befor surgery =( if
platelet count is low= transfuse platelets%%%%%%%stop giving platelets
once splenic artery is ligated b*c rebound thrombocytosis is happening now%%%
13) ' wee$s before splectomy = give #neumovax for strep%pneumoniae0; meningococcal vaccine; and also Hib if patient not got in
childhood%%%%%%%%% if splenectomy has been performed in emergency i%e for trauma = give these vaccines as soon after surgery before discharge% 1A) 7n H565D67T< .#H5689<T8.7.= splenectomy is done after 3 years of
age%%%%%%%%%before splenectomy = do ultrasound to rule out gallstones 1B) 9holedocal cyst is dilation of extra*intrahepatic biliary
system%%%%%% i fusiform ii) 9@D diverticulum iii) pancreatic cyst iv) 7ntra!extra v) 8nly intra ,9aroli disease)%%%%%%%%%%%%%%dx do :.2 %%%%%%%%%%% best is ?69#%%%%%%%%% treat with excision of cyst and 6oux& en&< hepatico4e4unostomy
1C) #erforation and abscess in diverticulits are strong indications of surgery%%%%%%%%%%% if "bscess = 1st drain the abscess percutaneously then after some time = do 6esection of segment with end&end
anastomosis%%%%%%%%%%
if perforation = Do hartman procedure * or * 6esection and exterioriation
'F) 7nvestigation of choice for acute diverticulitis = 9T
scan%%%%%%%%%%%% never do barium*colonoscopy in case of acute diverticulitis b*c of ris$ of perforation
'1) 7n diverticulosis%%% barium and 9T can be done%%%% barium shows ."I T88TH "##5"65N95'') 7n case of "mebic liver abscess = give trial of ?etronidaole 1st ;
but in case of #yogenic liver abscess = :.2 guided p*c aspiration is effective in BF&CF%; so do it in addition to antibiotics%%%% but
remember to treat the underlying cause as well%
'-) emoral hernia is the most common hernia; more common in females; has
high incidence of strangulation; @58I "ND "T56" T8 #:@79 T:@5695;
more common on right side; although they have more chances of strangulation but they are mostly asymptomatic and unnoticed as compared
to inguinal hernia; differentiate it from 7nguinal hernia0 sephna varix0 femoral lymph node; lipoma0 femoral aneurysm and psoas
abscess%%%%%%%%%%%%%%%%%Treat by i) oc$wood ,infra&inguinal) ii)
othessian ,trans&inguinal) iii) ?c5verdy ,high inguinal)%%%%%6emember femoral hernia has got more chance of strangulation = so always repair it '/) 7nguinal hernia is mostly found in males; 7ndirect in young and
direct in elderly; %%%% Treatment principle include i) Dissection of sac ii) igation of sac iii) 6eduction of sac iv) ?esh
placement%%%%%%%%%%%%%%; if patient refuses surgery = Truss can be used% ') :mbilical hernia=conical in shape; in children ; rarely strangulate; mostly resolve spontaneously; wait for / years&&&( if not resolve&&&(do herniorapphy
'3) 2astrinomas ,P5.) are mostly malignant%%%% found in gastrinoma triangle%%%%% associated with ?5N&1%%%%%%%%%%%%labs reveal increased
fasting gastrin (1FFFpg*ml%%% confrmd by .5965T7N .T7?:"T78N in which
after secretin ('FFpg*ml rise in gastrin ta$es place
'A) "fter doing left hemicolectomy%%%%%%%% colostomy should be done if gut is not prepared ,e%g if emergency intestinal obstruction b*c of left colon ca= do resection and colostomy b*c gut was not prepared in emergency)%%%%%%%%%but after doing right hemicolectomy%%%%% anastomosis can be effectively done%%%,no need of colostomy*ileostomy)
8?52" .72N= .72?87D E8E8:. = Do rigid sigmoidoscopy and try to reduce
it%%%%%%%%%%%%%if fails%%%% do laprotomy%%%%% if area is dead = resect and do double barral colostomy%%%%%%%%%%%%if viable%%% do sigmoid colectomy and hartman procedure%
'C) ?ost common clinical presentation of ?er$el diverticulum is #"7N5.. @55D7N2 #*6%%%%%%% others Diverticulitis0 intestinal obstruction0
intussusception0 peptic ulcer0 volvolus0 Hernia of
littre%%%%%%%%7nvestigation of choice=Tc&CC scan ,detects gastric mucosa)0 "ngiography ,detects vitellointestinal artery) %%%%%%%6x .egmental resection; ?er$el diverculectomy%%%
-F) 9holangiocarcinoma = "denoca of intra*extrahepatic biliary
apparatus%%%%%%%%%%%%%most common ris$ factors are #.9 + 9H85D89" 9<.T%%%%%%%Dx 569#0 5ndocscopic :.20 #T9 ,esp useful for tumor at confluence)%%%%%%%%Do resection0 bypass0 bilioenteric anastomosis0
stenting-1) ?ost common mesenteric cyst is 9hylolymphatic; it is thin wall; has
independant blood supply; so treat by 5N:95"T78N
-') 8hter mesenteric cyst is 5NT56825N8:.; it is thic$ wall; has common
blood supply with intestine; so "I<". 65.59T 7NT5.T7N5 I7TH 7T --) 7n "chalasia; the constricted portion has normal ganglion cells while the dilated portion has absent*few ganglion cells
-/) 7n Hurschprung disease; the constricted portion is "@.5NT in ganglion cells while dilated portion is N86?"%%%%%%%%%%%%N56E5 T6:N>. :ND5628 H<#56T68#H<%%%%%%%%%%%most common site 659T:?%%%%% 6is$ factor
Down*familial %%%%%%%%%
Neonate Delayed passage of meconium; "bdominal distention; bilious vomiting
9hild 9hronic constipation; abdominal distention; failure to thrive
Dx full thic$ness rectal biopsy0 @arium enema shows coning; "norectal manometry
Tx i) Do colostomy ,imp 1st step)%%%%%%%%%%%%% 9orrect nutritional status%%%%%%%%%% Ihen child is over 1F$g%%%%%%%%%%%%
ii) .wenson ,pull through) iii) .oave ,resection and anastomosis with sleeve mucosectomy of anal canal and rectum) in old iv) Duhamel v) Transanal vi) ?yomectomy
years%%%%%%%%%most
common site cecum%%%%; associated with aortic stenosis and v&wb disease%%%%%%%%%%%%%% Dx "ngiography0 9olonoscopy0 Tc&CC 6@9
scan %%%%%%%%%%%%%%%%% 6x excision* colectomy
-3) ?ost common site of small bowel diverticula = J5JN:?%%%%%%%%%%%% Duodenal
diverticula are on 'nd and -rd part and on ?5.5NT5679 @86D56%%%% Ihile
mer$el diverticulum is on "NT7&?5.5NT5679 @86D56%%
-A) 9olonic diverticula are acLuired disease and the most common site is .72?87D%%%% They never involve 6ectum b*c its muscle layer is complete and
it does not split into tinea%%%%%%%%They may lead to istula formation ,eg E5.798&9879 most common)
7n diverticulosis%%% barium and colonoscopy can be done%%%% barium shows ."I T88TH "##5"6"N95
-B) 7nvestigation of choice for acute diverticulitis = 9T
scan%%%%%%%%%%%% never do barium*colonoscopy in case of acute diverticulitis b*c of ris$ of perforation%%%
or uncomplicated diverticulitis bed rest0 antibiotics0 analgesics and barium enema after acute phase subsides
#erforation and abscess in diverticulits are strong indications of surgery%%%%%%%%%%%
if "bscess = 1st drain the abscess percutaneously then after some time = do 6esection of segment with end&end anastomosis%%%%%%%%%%
if perforation = Do hartman procedure * or * 6esection and exterioriation
