الProblem solving للوحده ال8

موضوع: الProblem solving للوحده ال8 4/25/2007, 9:46 am

السلام عليكم و رحمة الله و بركاته

إن شاء الله يكون الموضوع ده مفيد للناس اللي ماحضرتش ال seminar من أول ال roundأو الناس اللي فاتتها حاجات...
أنا مش كاتبه ال cases بالظبط بس تفهموا منها الgeneral ideaHernia
Female with umbalical hernia that's reducible
she underwent hystrectomy
then she complained of vomiting,pain & abd. distension

what caused her those symptoms

the correct answer is Insicional hernia

موضوع: رد: الProblem solving للوحده ال8 4/25/2007, 10:03 am

thyroid cases
38
yrs. old female pt. complained of nodular goiter ass. with sever clinical thyrotoxicity & confirmed by hormonal assay major complaint CVS & CNS pt. was treated surgically

medical ttt.: was 5 mg carbimazole oraly with porpranolol 10 mg oral both were given twice daily for 14 days,lugol's iodine was give for 10 days preoperative total thyroidectomy was then performed
during operation there was excessive bleeding but at the end heamostasis was satisfactory

the pt. recovered from ansrhesia
at the end of the operation
pulse : 92 bpm
Bl.pr : 140 over 80
Temp.: 37.6
two hrs. later temp. was 40 R.R : 28 pulse : 130 bpm
the pt. was agitated,apprehensive talking non sense

Q: Immediate Proper management
a) ca gluconate slowly IV
b) atropine IV
c) Dopamine cont. infusion under ECG monitoring
d) Propranolol IV

the correct answer is
D
propranolol alone without carbimazole bcs. hte case is of TOTAL thyroidectomy

موضوع: رد: الProblem solving للوحده ال8 4/25/2007, 10:11 am

Breast cases
female 42 yrs. old with Rt. axillary swelling
mild pain during menestrual cycle
swelling was mild tender

D.D

accessory breast
hypertrophied or palpable axillary tail
L.N swelling
Skin Swelling for eg. Lipoma
hydradenitis supurative

Imp. pionts in history

onset,course,f.h,other swellings

Imp. points in clinical eamination
ccc. of swelling

Value of investigation
Mammography in encrouchment on axillary tail

موضوع: رد: الProblem solving للوحده ال8 4/25/2007, 10:14 am

that's for now
to be continued isa
waiting for your feedbacks:roll:
salamz

موضوع: رد: الProblem solving للوحده ال8 4/27/2007, 10:09 pm

السلام عليكم
آسفه للتأخير
نكمل باقي ال breast cases
female 50 yrs. old,with lt. breat mass,discovered during bathing 2 m. ago,
with history of truma to the same breast 1 wk. ago
On examination, the mass is firm,fixed
teathered(fixed) to the overlying skin
with enlarged mobile axillary L.N

what's ur possible diagnosis
1) malignant
2)traumatic fat necrosis

what's the most important investegation

Biopsy FNAC
Mammography

do you need to interfere surgically in this case
Yes, in the from of frozen section and excision

موضوع: رد: الProblem solving للوحده ال8 4/27/2007, 10:17 pm

آخر case في ال breast
lactating female c/o breast edema,skin ulceration,mastalgia,nipple retraction,L.N enlargement,inflamatory mass in lt. breast
few weeks later there were redness & hotness
she started to complain of back pain( which indecated metastases in this case)

what's your D.D
1)duct ectasia
2) chronic inflamatory lesion
3) breast abscess
4) mastaitis carcinomatosis
5) periductal mastitis

what are the invest. needed & why
mammography
FNAC
bcs. it's mostly mastitis carcinomatosis

what are the lines of ttt
simple mastectomy & follow up
with chemotherapy and radiotherapy

موضوع: رد: الProblem solving للوحده ال8 4/28/2007, 7:39 am

جزاكى الله خيرا على المجهود ده

ربنا يجعله فى ميزان حسناتك

موضوع: رد: الProblem solving للوحده ال8 5/4/2007, 11:25 am

cases of post operative fever

by Dr/Hisham el 3akkad

Case 1

58 yrs old male

during preoperative evaluation b4 open

cholecyctectomy

he was found to have

well controlled HTN

hyperlipidemia & osteoartheritis

u determined that he is optimized for surgery

he complaied of moderate knee pain

controlled by medication

new medications was added

as cefazolin for prophylaxis

on physical examination

the pt is normal except for small amount of serosanguineous wetting of abd wound dressings

temp. 37,9

bl. pr. 130/72 mmHg

laboratory results

WBCs 11,000/mm3

Which of the following diagnosis& ttt options do u recommend

the answer is

observation only

موضوع: رد: الProblem solving للوحده ال8 5/4/2007, 11:34 am

Case 2

61 yrs. old pt

female with RA

medications: methotrexate & hydroxychloroquine

she under goes Lf total hip replacement

Foley's catheter is placed during surgery

she begins to ambulate the day following surgery

a fever of 38 is noted on the 1st day PO

fley's catheter removed on D#2 PO

her temp fall

but on D#4 PO

her temp was 38,5

what is the most likely diagnosis

the answer is

UTI

fever of UTI appearing on the 4th day after surgery

ttt

ciprofloxacin

for 10 to 14 days

then reculture urine

موضوع: رد: الProblem solving للوحده ال8 5/4/2007, 11:41 am

Case 3

48 yrs old female

under went abdominal hysterectomy

D#1 PO

Temp. 38.7

febrile till D#4 PO

some pain at the incision

she looks comfortable

& is haemodynamically stable

O/E. Nr. except for mild bibasilar crackles heard in the lung feilds

chest X-ray is Nr

Lab. results : WBCs 10.500/mm3

what is the most likely to cause fever

Atelexacis

ttt

chest physiotherapy

موضوع: رد: الProblem solving للوحده ال8 5/4/2007, 11:56 am

Case 4

49 yrs.old male

with dry gangrene of left foot

Not infective type

with coronary ds.

history of lower extremity AS

Hyperlipidemia

Gout

HTN

smoker of 60 packs/day

medications : hydrochlorothiazide

lisinopril

atorvastin

asprin

he under went Lt. tansmetatarsal amputation

rcved piperacillin & tazobactam PO

opiates for pain

& indomethacin was recently ineroduced for gout

the pt. was well over the 1st 2 days

however on the 3rd day he develops fever of 38,5

& Rt. knee pain

what is the next step

knee aspiration

would be a reasinaple option for determining wether gout or infection is the cause of this episode

But

if the fever was on D#7 PO

with no apparant infection

the correct answer will be

discont. indomethacin

موضوع: رد: الProblem solving للوحده ال8 5/19/2007, 7:39 am

[b

]السلام عليكم و رحمة الله و بركاته
فين يا جميل باقي ال cases
الامتحان قرب و احنا علي باب الله
جزاكي الله خيرا

[/b]

موضوع: رد: الProblem solving للوحده ال8 5/19/2007, 9:50 am

و عليكم السلام و رحمة الله و بركاته

آسفه على التأخير و التقصير

إن شاء الله ح كمل باقي ال cases

بس المشكله إني آخر محاضره

سجلتها على الموبايل

ح رفعها إن شاء الله

و أنزلها على النهارده بليل

موضوع: رد: الProblem solving للوحده ال8 5/20/2007, 12:47 am

السلام عليكم و رحة الله و بركاته

يا جماعه انا آسفه جدا

حاولت أرفع الملفات لكن لقيتها ح تاخد وقت طويل

و حيبقى أطول عشانحد يحملها

فإن شاء الله ح جيبها من حد موثوق فيه

و أكتبها هنا على المنتدى

و لو كانت موجوده فعلا عند حد من أعضاء المنتدى يا ريت يضيفها

موضوع: رد: الProblem solving للوحده ال8 5/21/2007, 12:13 am

case 5

a healthy 58 yrs. old male farmer

developed crushed wound of the lt. thigh after blunt trauma

lacerated crushed femoral A. was managed operatively

P.O temp. 37.6

Bl. pr. 110/70

pulse 86/m

!1 one hr. P.O pt. was ill and anxious

temp.39.9

Bl.pr. 88/40

pulse 122 bpm

which of the following is unlikely to be the cause of the pt. condition؟

A.malignant hyperthermia

B.colistridia wound infection

C.pulmonary embolism

D.acute adrenal insuffiency

the right answer is A

malignant hyperthermia presents very early

generaly becomes apparant IO

although rarely it may presents as long as several hours after surgery

موضوع: رد: الProblem solving للوحده ال8 5/21/2007, 12:32 am

GIT bleeding

case 1

male pt. 55 yrs. old presenting with bleeding per rectum in the form of haematochazia starting 2 hrs, previously for 3 times

each time an amount of about 400 ml. was passed no previous similar attacks

positive history of hypertension

but the pt.does not take his medications regularly

pulse 96 bpm

Bl. pr. 110/70

RR 24/m

pallor & sweaty face

abdominal examination showing mild distension

no tenderness or rigidity

scar of appendectomy done 20 yrs. ago

P/R including anoscopy

no anal pathology detcted

resuscitation started

lab samples taken

ECG done

showing 6-7 ectopic beats/min

NGT placedand 100 ml colourless water like gastric fluid aspirated

the most appropriate diagnostic invest. to start with is

A. upper endoscopy

B.barium meak follow through

C. lower endoscopy

D. abdominopelvic CT scan

the right answer is

A

موضوع: رد: الProblem solving للوحده ال8 5/21/2007, 12:58 am

case 2

32 yrs. old male complains of painless passage of fresh blood per rectum at time of defecation 2 month

the bleeding stops spontaneously

the pt. is generally good and has no other complaints

he is used to spicy food & snack meals

appropriate initial evaluation includes

A. barium enema

B.per rectal examination including anoscopy

C.colonoscopic examination

D.occult blood is stools

the right answer is

B

anoscopy was done and revealed second degree haemorrhoids

covered by blood clot

futher mamangement should be

A.emergance haemorrhoidectomy

B. elective haemorrhiodectomy

C. screening for coagulopathy

D. conservative ttt for the haemorrhiods

E.colonoscopy to exclude haemotthiods 2ry to tumors

the right answer is

D

conservative ttt was followed by stopage of bleeding

five years later bleeding recurred

in the form of musoud and cotted blood

with tenesmus and small caliper stool

what is the further managment

colonoscopy

colonoscopy was doneand a tumor mass was found at 18 cm from anal verge

the next step will be

A. colonoscopic biopsy and further assesment

B.prepare for elective resction of the recto sigmoid segment

C. emergancy operation

the right answer is

A

موضوع: رد: الProblem solving للوحده ال8 5/22/2007, 7:41 am

السلام عليكم و رحمة الله و بركاته

د/مصطفى عدلي في seminar الوحده الثامنه إمبارح قال

إن الوحده ال8 أ ح تمتحن يوم الخميس إن شاء الله الموافق 31/5

أما الوحده ال8 ب ف ح تمتحن في ميعادها عادي الأربعاء 30/5

و ده سببه العدد الكبير طبعا

و وضح إن نظام الإمتحان ح يكون مختلف شويه عن 8 ب

ح يكون 4 حالات

3 منهم حالات عملي

short clinical cases

و حاله واحده من ال word round

و بعدين أسئلة mcqs

على موضوعات ال seminar

ربنا يوفق الجميع إن شاء

على العموم إحنا فاضلنا إن شاء الله

3 problem solving

ح كملهم على النهارده بليل

موضوع: رد: الProblem solving للوحده ال8 5/22/2007, 9:46 am

ربنا ما يحرمنا منك و لا من خدماتك
معلش تعبينك معانا
نرودهولك يا رب في الدكتوراه

موضوع: رد: الProblem solving للوحده ال8 5/26/2007, 8:38 am

case 3

45 yrs. old male presenting with haematemesis of fresh blood

of 4 hours duration and pt. become dizzy 1 hr. ago

there is no history of similar attacks

long standing medications for hyperacidity pt. pale

pulse 120/min bl/pr. 100/80

next step to do?

ressucetation

pt. should be addmited,IV fluids

blood samples for cross matching was taken

lab samples taken

urine catheter intreduced

what is the next step?

NGT introduced and gastric lavage with cold saline started

pt. is stabilized

what is the next step?

upper endoscopy was done and revealed a bleeding ulcer with spurting vesselat the base of the ulcer

what is the next step?

injection of adrenaline around the spurting vessel was done and the vessel was seen to have stopped bleeding

the pt. was observed in the surgical ward

12 hours later haematemesis recurred and the pt. rcved another 2 units of blood

and pressure was maitained at 100/80

and gastric wash through the NGT become less bloody

what is the next step?

emergancy operation and underrunning of the bleeder was done

pt. was started on extensive anti-ulcer ttt

no recurrance of heamatemesis post operatively

and the pt. was heamodynamically stable

but the 1st motion after 24 hours was in the form of melena

what is the next step?

i'm not sure of the answer mostly endoscopy

موضوع: رد: الProblem solving للوحده ال8 5/26/2007, 8:40 am

to be contiued isa

only 2 cases left

good luck for all

موضوع: رد: الProblem solving للوحده ال8 5/27/2007, 4:23 pm

ياريت يا جماعة ... تنزلولنا اي جديد ... انا علينا امتحان الاسبوع ده ... جزاكم الله خيرا

موضوع: رد: الProblem solving للوحده ال8 5/28/2007, 6:09 am

فين باقي ال prpblems اللي فاضلة يا دكتورة ؟؟؟؟؟
علينا امتحان احنا كمان
و لا ايه؟؟

موضوع: رد: الProblem solving للوحده ال8 5/28/2007, 5:32 pm

case 1

38 yrs. old female

underwent laparotomy 5 yrs. ago for torsion overian cyst

since then the pt. is complaing of attacks of intestinal ocolics

for few ms. 3-4 days ago associated with some andomenal distension and conistepation

pt. noticed that certain bulky food are more likely to cuase this

2 days ago pt. got semilar colics but this time associated with repeated vomiting of grenish fluid marked distension later on absolute conistepation

pt. reports that urine become scanty and dark yellow

o/E

pulse 86

Bl. pr. 100 over 60

temp. 37.3

dry mouth

mild tenderness all over

exaggerated intestinal sounds and empty rectum

what's next step?

NGT

IV fluids

labs CBC createnine electrolytes ABG

plain x_ray erect and supine

diagnosis simple obstruction

what fluids to start with?

saline bcs. of oliguria to avoid prerenal failure

lab invest. is done

pcv is high

WBCS 8.7

Na 134

K 3.2

HCO3 21

PCO2 30

creatinine 2.1

NGT 200 ml green since addmision 1 hr. ago

U/S gaseous distension

X-ray

distension jejenum loops

what is next?

continue observation and conservative ttt

fixed tenderness at the Rt. iliac fossa

and supra pupic region temp 38

WBCS 11.5

urine 30 ml per hr

.

what's next step

immediate laparotomy

at exploration loop of ileum was entrapped in pelvis

among adhesions which was lysed

itrapted segment was dusky color

NGT was advanced to jejnum and used to deflate the bowl

what to do operatively?

no resection of part of ileum

what r signs of viability?

luster

pulsating

peristalsis

pink color

better to detect pulsation by pluse oximeter

موضوع: رد: الProblem solving للوحده ال8 5/28/2007, 7:05 pm

case 2

59 yr. old male c/o abd. distension

of 2 days followed by increased R.R,dysnea,no vomiting,pt. suffer long standing COPD & rcved br.dilators on demand

pt. on regular antiHTN ttt

O/E pulse 94,bl.pr.190/120,R.R 26/m with effort

mouth dry

abdominal distension allover with audible intestinal sounds

no tenderness or shifting dullness P/R empty rectum

with ballooning

what's priority?

control HTN by sublingual or parentral ttt

NGT---->minimal greenish

IV fluids------>isotonic saline

urine catheter----->120 ml dark yellow

whta are the invest.?

tou have time

10cxray,ECG

2.cbc,pt,pttt

3.ABG electrolytes

4.specific

What's 1st specific invest.?

plain abdominal X-ray

D.D

cancer colon

volvulos

divertculosis

intusseption

strangulated hernia

what's your plan for magaement?

repeated enema for 24 hrs.,NPO,IV fluids

what's preparation you need preoperative?

arrange for ICU bed

start AB IVE

consult internist

prepare 2 units blood

sigmoid colon was found

what are 3 surgical points?

1.lt.colectomy

tr. colostomy

rt.colectomy

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