Intro Flashcards

Question

1.ABRASION:

Answer 1

It is destruction of the surface epithelium of the skin without loss of dermis integrity (Fig 1). • It is caused by friction against rough surface e.g., roll-over trauma

Answer 2

• Cleaning of the area with liberal amounts of normal saline and antiseptic solution to remove all debris. • Application of topical antibiotic and Vaseline gauze for 7 to 10 days when re-epithelialization becomes complete.

Answer 3

• Infection leads to deep tissue destruction and may leave raw area. • Pigmentation or tattooing of the area by embedded debris.

Answer 4

These wounds are caused by sharp objects such as knives and broken glass. Surgical wounds belong to this type.

Answer 5

Incised wounds are cleanly cut, have regular edges, bleed profusely and may be accompanied by cut of deeper structures such as muscles, tendons, nerves, and blood vessels

Answer 6

• Management should entail resuscitation of the patient if the wound is a big one and bleeds too much. • Management of the wound itself includes: o Cleaning the wound by washing it liberally with normal saline and antiseptic solution o Repair of cut important structures such as tendons, nerves if ends are close and re-anastomosis of important nourishing blood vessels. o Wound is closed primarily by simple suture without drainage if clean not contaminated or with drainage if contaminated or potentially infected.

Answer 7

These are severely damaged wounds caused by traffic road accidents or rollover trauma.

Answer 8

• Tissues are compressed and devitalized by severity of trauma. • Skin has irregular edges with scanty bleeding and dirty ischemic margins (Fig 3). • Devitalization may occur in deeper structures such as muscles, nerves, tendons, and blood vessels. Dirties and debris are usually found in these wounds. • There may be significant skin loss or degloved skin (degloving wounds)

Answer 9

o Management should start by trauma life support in patients with big wounds or polytraumatized. o Under general anesthesia, the wound is cleaned with liberal amounts of normal saline and antiseptic solution. o All devitalized tissues and muscles should be excised until the tissues look good vascularized and bleed freshly. o Deep important structures are repaired according to their conditions, tendons and big vessels are repaired, nerves if they can approximate easily are repaired, otherwise marked for later repair. o Skin is closed with drainage, if possible, if there is significant loss of skin and approximation of skin edges is difficult, local skin flaps or skin grafts are used. o In some circumstances the wound is left open for later reconstruction.

Answer 10

• These are wounds caused by sharp pointed objects penetrating deeply into the body. • Such wounds may penetrate the visceral cavities (peritoneum, pleura or pericardium) and cause serious injuries to vital organs such as the liver, spleen, bowel, lungs or heart.

Answer 11

o Patients may become shocked shortly after injury due to internal hemorrhage. The wound itself may look trivial and does not bleed

Answer 12

o Management of the patient on traumatic life support bases. o With any suspicion that the wound is extending into the visceral cavities, the patient should be explored by laparotomy or thoracotomy according to the site of wound. o Arrest of bleeding and repair of damaged vital organs according to the nature of injury, liver repair, splenectomy, bowel repair…etc.

Answer 13

• These are wounds which penetrate the body and have an inlet and an exit. The commonest example is gunshot injuries (Fig 5). • Such wound usually has great damage to internal organ, partly by the penetrating object and the damage of the surrounding tissue caused by evacuation effect and propagated extensive heat.

Answer 14

o The patient may become shocked, hemodynamically unstable and require emergency resuscitation and very early surgical exploration to stop bleeding and removal of injurious objects or foreign body if possible.

Answer 15

• It is reddish swelling caused by extravasations of blood into the tissue spaces. It is usually caused by hitting by blunt object as blow or heavy stick. Due to disintegration of extravasated blood, the area is at first red then within few, it becomes yellow days and later becomes greenish and lastly fades out

Answer 16

o In the first 24 hours cold compresses are applied to the area to induce vasoconstriction and stop further blood extravasation o After 24 hours, warm compresses are applied to induce vasodilation and enhance absorption of extravasated blood.

Answer 17

• It is a collection of blood in the tissue spaces caused by extravasation from injured sizable vessel. • Blood is at first fluid and then becomes clotted within 3-4 days and after one week it turns fluid again

Answer 18

o Large rapidly increasing hematoma is treated by exploring the area or re-opening the wound, washing out the hematoma and ligating the bleeding vessel. o Moderate-sized hematoma may resolve by repeated aspiration under aseptic conditions. o Small hematoma may be left to resolve spontaneously.

Answer 19

1. Infection leading to abscess formation. 2. Calcification forming calcified hematoma. 3. Pressure on neighboring structures 4. Opening into the nearby vein leading to traumatic arteriovenous fistula

Answer 20

• Thoroughly clean the wound with normal saline or antiseptic solution. • Use a large syringe for irrigation. Attach a 16- or 19-gauge needle or soft IV catheter to generate pressure. • Control residual bleeding with compression, ligation, and cautery • Dead or devitalized muscle is dark in color, soft, easily damaged; does not contract when pinched. Dead tissue does not bleed when cut. • Prep skin with antiseptic.

Answer 21

• Patient vaccinated: give booster dose if needed. • Patient not vaccinated: give antitetanic serum and start dose of tetanus toxoid vaccine (separate syringes, separate sites) • Tetanus immunoglobulin (human) 250 units IM.

Answer 22

• Contaminated wounds • Penetrating wounds • Abdominal trauma • Compound fractures • Lacerations greater than 5 cm • Wounds with devitalized tissue • High risk anatomical sites—hand, foot

Answer 23

• Less than 6 hours from injury, cleaned properly: primary closure. • Greater than 24 hours, contaminated or animal bite: do not close. • Wounds not closed primarily should be packed lightly with damp gauze. • If clean after 48 hours, delayed primary closure. • If wound infected, pack lightly, heal by secondary intention.

Answer 24

• Easy fatigue • Anginal pain • Dizziness & ggiddiness • Syncopal attack

Answer 25

1-Co-existing disease 2-Site of the surgery 3-Age of the patient 4-Preference of the patient 5-Body position of the patient during the surgery 6-Elective or emergency surgery 7-Likelihood of increased amounts or gastric contents (as in pregnancy)

Answer 26

❖ Extreme anxiety and fear ❖ Patient with mental or physical disability or disoriented ❖ Age (Infants and children) ❖ Prolonged procedure

Answer 27

❖ Lack of adequate training by the doctor ❖ Lack of adequate equipment ❖ Lack of adequate facilities ❖ Compromised patient

Answer 28

1-ECG 2-Blood pressure 3-Tempreture 4-Respiratory rate 5-Capnogram for end tidal CO2 6-Pulse oximeter for O2 saturation and pulse 7-Train of four for neuromuscular monitoring

Answer 29

➢ Anaphylaxis Epinephrine (Adrenaline) is the only recommended medication for treating anaphylaxis, antihistamines and steroids may also alleviate symptoms. ➢ Hypothermia Passive rewarming with heated blankets and warm fluids. ➢ Nerve injury -Physical therapy -Medication as Gabapentin, Pregabalin and Ibuprofen ➢ Nausea and vomiting -Ensure good oxygenation and normal blood pressure -IV fluids if dehydrated -Medication as zofran ➢ Cardiovascular collapse -Anticholinergic drugs for bradycardia -Increase the venous return using gravity -IV fluid -Sympathomimetic drugs ➢ Respiratory depression -Oxygen therapy -Relieve pain -Mechanical ventilation ➢ Sore throat -Most cases resolve spontaneously ➢ Pain control - Nonsteroidal anti-inflammatory drugs (NSAIDs) - Opioids - Acetaminophen - Alpha-2 agonist - Antidepressants - Anticonvulsant - Corticosteroids - Lidocaine

Answer 30

(1) Bone of the lower limb operations. (2) Obstetric, gynecological operations. (3) Urologic and rectal operations (pills and fissures). (4) Operation of lower abdomen (appendix).

Answer 31

Absolute contraindications: (1) Patient refusal. (2) Allergy to local anesthetics. (3) Skin infection at the injection site. (4) Severe hypovolemia (shock). (5) Coagulopathy and the use of therapeutic anticoagulant. (6) Increased intracranial pressure (may predispose to brainstem herniation) . Relative contraindications: (1) Neurological disorders. (2) Prior spine surgery and back pain. (3) Uncooperative patient. (4) Psychosis, dementia or emotional instability. (5) Certain cardiac lesions e.g., Aortic stenosis

Answer 32

*History: Exclude history of back problems. *Physical examination: Especially examination of the back for dermatologic conditions, kyphoscoliosis or surgical scar. Palpation of lumbar interspaces *Investigation: Especially bleeding time, clotting time, Prothrombin Time (PT) and Partial Thromboplastin Time (PTT). *Premedication: Preoperative visit may allay fear, and pharmacologic premedication can allow smooth block.

Answer 33

(1) Hypotension: (especially with spinal anesthesia): Reflect venodilatation with decreased venous return and cardiac output Prophylaxis: Adequate hydration (10-15 ml/kg of crystalloid) before induction of spinal and epidural anesthesia. Treatment: - Rapid I.V fluid. -Head down tilt 5-10 degrees after fixation of local anesthetic level. -Vassopressor: as Ephedrine (α and ß agonist) 5-10 mg i.v. in incremental doses. (2) High spinal anesthesia: Occur with spinal anesthesia manifested by severe hypotension, bradycardia and respiratory insufficiency or apnea. Treatment: 1-Support of the airway: -100% oxygen by simple face mask. - Intubation and mechanical ventilation may be needed. 2-Support of circulation: - Head down positioning - I.V fluid - Ephedrine (5-10 mg i.v) to treat hypotension. - Atropine i.v to treat bradycardia. - Inotropes as adrenaline (5-10 µg) in hypotension.

Answer 34

(3) Nerve injury: During placement of a needle, it can come in direct contact with the nerve roots. The nerve injuries lead to persistent paresthesia that resolve without treatment within weeks or months. (4) Vascular injury: Injury to blood vessels result in hematoma due to continued bleeding from the epidural venous plexus. This complication is reported in patients with coagulopathy or has been taking anticoagulants, but it may occur in patients with no apparent risk factors. (5) Meningitis: The incidence of meningitis has fallen dramatically with the use of disposable needles and trays. 6) Urinary retention: Blockade of S2-S4 is associated with loss of bladder tone and inhibition of the voiding reflex. It may require intermittent catheterization. (7) Backache: Needle penetration can cause hyperemia, local tissue irritation, and reflex spasm of muscles. Backache may be also reflecting ligament strain due to profound skeletal muscle relaxation and surgical positioning. (8) Headache (postdural puncture headache): It is believed to be due to decreased CSF pressure resulting from leakage of CSF through the needle hole in the dura. This exerts downward traction on the structures of the central nervous system and on the blood vessels that are attached to both the dura and the brainstem. Risk factors: -Young females - Using large gauge needle

Answer 35

-It is frontal or occipital. -Associated with nausea and vomiting. -The headache is postural in nature, worse in the upright position. -Beginning within 6-12 hours after lumbar puncture. -Associated with diplopia and tinnitus.

Answer 36

-Aggressive hydration. -Soft diet and stool softeners. -Analgesics and bed rest. -Caffeine (300-500mg) oral once or twice daily.

Answer 37

1-Subcutaneous infiltration (IV placement, superficial biopsy, suturing). 2-Submucosal infiltration (dental procedures, laceration repairs). 3-Wound infiltration (postoperative pain control at incision site). 4-Intraarticular injections (postsurgical pain control, arthritic joint pain control). 5-Infiltrative nerve blocks (ankle block, scalp block, digit block).

Answer 38

Drug Onset Maximum dose Duration Lidocaine Rapid 4.5 mg/kg 120 min Bupivacaine Slow 2.5 mg/kg 4 hours

Answer 39

1- Pain on injection: Can be due to aggressive insertion of the needle, damaging soft tissues, blood vessels, nerves. To prevent: use topical anesthetic application and using a smaller-gauge needle. 2- Needle fracture: In most cases, needle fracture happened due to unexpected motion of the patient or assistants. 3- Lack of effect: may be due to anatomical variants, pathological and psychological factors, and poor technique. 4-Prolongation of anesthesia and various sensory disorders: paresthesia, or neuralgia. Avoiding high concentration of anesthetic agent is recommended. 5-Hematoma: due to venous or arterial laceration. To prevent hematoma formation : aspiration before injection , using a short needle and a minimum number of needle penetrations into tissues. When swelling forms immediately after injection, localized pressure should be applied. 6-Edema: Swelling of tissues can be due to trauma during injection, infection, allergy, hemorrhage, and injection of irritating solutions. It`s managed as a hematoma. 7-Infection: is rare since the usage of disposable needles. To prevent infection: The area to be penetrated should be cleaned with a topical antiseptic prior to insertion of the needle. The local anesthetic should not be injected through the infected area. Antibiotics should be prescribed.

Answer 40

A. Catgut: natural absorbable suture material (made from the submucosa of bovine intestine) is absorbable suture material, but the resorption time is highly variable. It stimulates a considerable inflammatory reaction and tends to potentiate infections. B. Silk: a natural nonabsorbable suture material and is an animal protein but is relatively inert in human tissue and is a non-absorbable suture material. • It has a favorable handling characteristic. • It is unsuitable for suturing arteries to plastic grafts or for insertion of prosthetic cardiac valves. • Silk sutures are multifilament, providing mechanical immune barriers for bacteria.

Answer 41

generally inert polymers that retain strength. However, their handling characteristics are not as good as those of silk, and they must usually be knotted at least four times, resulting in increased amounts of retained foreign material. • Multifilament plastic sutures may also become infected and migrate to the surface like silk sutures. • Monofilament plastics will not harbor bacteria. Nylon monofilament is extremely nonreactive, but it is difficult to tie. Monofilament polypropylene is intermediate in these propertie. Vascular anastomoses rely indefinitely on the strength of sutures; therefore, use of absorbable sutures may lead to aneurysm formation.

Answer 42

strong, have predictable rates of loss of tensile strength, incite a minimal inflammatory reaction, and have special usefulness in gastrointestinal, urologic, and gynecologic operations that are contaminated. • Polyglycolic acid and polyglactin retain tensile strength longer in gastrointestinal anastomoses. • Polydioxanone sulfate and polyglycolate are monofilament and lose about half their strength in 50 days, thus solving the problem of premature breakage in fascial closures. • Poliglecaprone monofilament synthetic sutures have faster reabsorption, retaining 50% tensile strength at 7 days and 0% at 21 days. This suture is suitable for low-load soft tissue approximation but is not intended for fascial closure.

Answer 43

wire is inert and maintains strength for a long time. It is difficult to tie and may have to be removed late postoperatively because of pain. It does not harbor bacteria, and it can be left in granulating wounds, when necessary, and will be covered by granulation tissue without causing abscesses.

Answer 44

1. Staples, whether for internal use or skin closure, are mainly steel-tantalum alloys that incite a minimal tissue reaction. The technique of staple placement is different from that of sutures, but the same basic rules pertain. • There are no real differences in the healing that follows sutured or stapled closures. Stapling devices tend to minimize errors in technique (Fig 17). 2. Surgical glues or tissue adhesives are now established as safe and effective for the repair of small skin incisions. The most common forms are cyanoacrylate-based glues. 3. Tissue adhesives (Steri-strips) are often less painful than sutures or staples, and the seal can serve as the wound dressing as well (Fig 18). • Size of suture “bite” and interval between bites should be equal in length, proportional to thickness of tissue being approximated. • Suture is a foreign body: use minimal size, amount of suture necessary to close wound.

Answer 45

1. Good approximation of wound edges is important to proper wound closure technique (Fig 19). 2. The placement of deep sutures subcutaneously to approximate the skin edges. • When placing deep sutures, absorbables (e.g., gut, Dexon, Vicryl, Monocryl) are typically used. The knot is buried. • All deep sutures serve to eliminate the dead space and relieve tension from the wound surface (Fig 20). 1. Achieve hemostasis prior to wound closure to avoid future complications such as hematoma. 2. Use atraumatic skin-handling technique with instruments such as skin hooks and small forceps. Typically, a cutting needle is the needle of choice. 3. For wound closure in the head and neck region, small 5-0 or 6-0 sutures of nonabsorbable Prolene. 4. Take great care to avoid tension during closure. 5. Ensure that wound edges are not only aligned but are also everted (Fig 21). Eversion of all skin edges avoids unnecessary depression of the resultant scar.

Answer 46

o Surgical suture material o Needle holder (Fig 22) o Tissue forceps (Fig 23) o Stitch scissor (Fig 24) o Drapes o Antiseptics o Anesthetics o Artery forceps

Answer 47

Non-absorbable – Use when possible – Braided suture not ideal for contaminated wounds Absorbable – Degrades, loses tensile strength within 60 days – Option when not possible for patient to return or for children for whom suture removal may be difficult

Answer 48

1. Interrupted sutures 2. Simple running suture 3. Vertical mattress suture 4. Horizontal mattress suture 5. Subcuticular suture 6. Purse string suture

Answer 49

is a term used to describe the entire span of surgery, including what occurs before, during, and after the actual operation.

Answer 50

1. Preoperative: begins with the decision to perform surgery and continues until the client has reached the operating area. 2 .Intraoperative: includes the entire duration of the surgical procedure, until transfer of the client to the recovery area. 3. Postoperative: begins with admission to the recovery area and continues until the client receives a follow up evaluation at home, or is discharged to a rehabilitation unit.

Answer 51

1. Assess the fitness for anesthesia. 2. Optimizing patient physical condition for anesthesia and surgery. 3. Arrange further investigations, consultations and treatments for patients not yet optimized 4. Allay fear and anxiety. 5. Establishment of preoperative fasting. 6. Premedication. 7. Provide appropriate information to the patient and obtain consent.

Answer 52

• History of present illness and reason for surgery • Past medical history • Medical conditions (acute and chronic) • Previous hospitalization and surgeries • History of any past problem with anesthesia • Allergies • Substance use: alcohol, tobacco, street drugs • Family history: Hereditary diseases and Anesthetic history. • Review of system • Drug history

Answer 53

Antihypertensive ACEI May be associated with severe hypotension during induction. B blocker -ve inotropic effect additive with anesthetic agents. Ca blocker Decrease AV conduction and excitability. Digoxin Toxicity enhanced by hypokalemia (should be corrected) pre Diuretics Can cause hypokalemia may potentiate Ms Relaxant Anticonvulsant MAOIs React with opioid (pethidine) causing coma or convulsion Tricyclic A.D Inhibit metabolism of catech. Increase likehood of arrhythmia Antibiotics Aminoglycoside Potentiate effect of NM Blockers

Answer 54

• Vascular disease of peripheral, coronary and cerebral circulation • lung carcinoma. • Effect of nicotine ..tachycardia and HPT • Increase in CO hemoglobin decrease O2 delivery to the tissues. • Six fold increase in postoperative respiratory morbidity • Should be stopped 6 weeks or at least 12 hrs before surgery

Answer 55

• Nutritional state • Fluid balance. • Condition of skin and mucus m.(anaemia –perfusion-jaundice ) • Temperature

Answer 56

• Presence of dyspnea, fatigue, chest pain. • Peripheral pulse (rate, rhythm, volume). • Neck veins • Carotid bruits • Heart sounds • Lower Limb edema

Answer 57

• Presence of cyanosis ( peripheral or central). • Presence of cough • Presence of tachypnoea • Tracheal shift • Auscultation of all the lung fields

Answer 58

• Documentation of the level of consciousness • Documentation of any cranial or peripheral nerve lesions

Answer 59

• Documentation of any skeletal muscles dysfunction or syndromes

Answer 60

• Teeth exam. ( dentures, loose teeth, protruding upper incisors) • Prediction of difficult airway (for ventilation or endotracheal intubation)

Answer 61

• Major surgery requiring group and screen or cross and match • Male>50 years. • All adult female. • Bloody surgery. •History of anemia. •Haemoglobinopathy. • CVD

Answer 62

• Routine for all patients

Answer 63

•History of diabetes, •Patients on steroid therapy

Answer 64

•All pts > 65 years • +ve urinalysis •Patient with renal or liver diseases • Diabetic patients • Malnutrition • Dehydrated patients •Patients on diuretics •Antihypertensive •Steroid drugs •Pituitary or adrenal disease •Vascular disease •Digoxin , diuretic, or other drug therapies affecting electrolytes

Answer 65

•History of liver disease •Previous hepatitis • Malnutrition •Alcoholism

Answer 66

•History of bleeding disorder •Liver disease •Drug abuse •Anticoagulant therapy

Answer 67

•All patients > 50 years •Smoker>45 years •History of CVD and DM •History of Pulmonary disease •History of medication active on CVS or diuretics

Answer 68

•All patients > 60 years •Any possibility of cardiovascular and/or pulmonary disease •Thyroid enlargement (thoracic inlet x-ray)

Answer 69

•All COPD and asthmatic pts •Patients scheduled for elective thoracotomy.

Answer 70

•Women of reproductive age

Answer 71

•Pt is fit for anesthesia. •Pt is in the optimal physical condition. •Pt is in the almost possible Correction. •Pt is in high emergency Situation. •There is a legal consent. •Pt is not fit for anesthesia. •Pt is not in the optimal physical condition. •Pt is not in the almost possible Correction. •Pt is not in high emergency Situation. •There is no legal consent.=== Determine the degree of fitness and the anesthetic risk by ASA grading

Answer 72

•Pt is not fit for anesthesia. •Pt is not in the optimal physical condition. •Pt is not in the almost possible Correction. •Pt is not in high emergency Situation. •There is no legal consent. Determine the degree of fitness and the anesthetic risk by ASA grading=== Cardiac, pulmonary consultation Or any other measures to optimize Physical condition of the pt

Answer 73

Pre -operative medications to consider Pre -operative medications to stop Pre -operative medications to adjust

Answer 74

• Hypertension • Coronary Artery Disease • Respiratory Diseases • Aspiration • Fasting Guidelines • Hematological Disorders • Endocrine Disorders • Obesity and Obstructive Sleep Apnea

Answer 75

• Risk of GE reflux: sodium citrate and/or ranitidine and/or metoclopramide 30 min-1 h prior to surgery • Risk of infective endocarditis: antibiotics • Risk of adrenal suppression: steroid coverage • Anxiety: consider benzodiazepines • COPD, asthma: bronchodilators • Coronary artery disease risk factors: nitroglycerin and -blockers

Answer 76

❖Oral antihyperglycemics: do not take on morning of surgery ❖ACEI and angiotensin receptor blockers: do not take on the day of surgery (controversial – they increase the risk of hypotension postinduction but have not been shown to increase mortality or adverse outcomes; therefore, some people hold and some do not) ❖Warfarin : (consider bridging with heparin). ❖ASA and NSAIDs : In patients undergoing non-cardiac surgery, starting or continuing low-dose ASA in the perioperative period does not appear to protect against post-operative MI or death, but increases the risk of major bleeding ❖Herbal supplements: stop one week prior to elective surgery .

Answer 77

Insulin (consider insulin/dextrose infusion or holding dose) Prednisone Bronchodilators

Answer 78

• BP <180/110 is not an independent risk factor for perioperative cardiovascular complications • Target systolic blood pressure <180 mmhg, diastolic blood pressure <110 mmhg • Assess for end-organ damage and treat accordingly

Answer 79

➢At least 60 day should elapse after a MI before a noncardiac surgery in the absence of a coronary intervention • This period carries an increased risk of re-infarction/death ➢Mortality with perioperative MI is 20-50% ➢Perioperative -blockers • May decrease cardiac events and mortality (but increases risk of perioperative strokes) • Continue -blocker if patient is routinely taking it prior to surgery • Consider initiation of -blocker in: • Patients with CAD or indication for -blocker • Intermediate or high risk surgery, especially vascular surgery

Answer 80

Higher >>• Emergent major operations, especially elderly • Aortic and other noncarotid major vascular surgery (endovascular and nonendovascular) • Prolonged surgery associated with large fluid shift and/or blood loss Intermediate>> • Major thoracic surgery • Major abdominal surgery • Carotid endarterectomy surgery • Head/neck surgery • Orthopedic surgery • Prostate surgery Lower>> • Eye, skin, and superficial surgery • Endoscopic procedures

Answer 81

• Adverse effects: altered mucus secretion and clearance, decreased small airway calibre, altered oxygen carrying capacity, increased airway reactivity, and altered immune response • Abstain at least 8 wk pre-operatively if possible • If unable, abstaining even 24 h pre-operatively has been shown to increase oxygen availability to tissues

Answer 82

Asthma • Increased risk of bronchospasm from intubation • Administration of short course (up to 1 wk) pre-operative corticosteroids and inhaled 2-agonists decreases the risk of bronchospasm and does not increase the risk of infection or delay wound healing • Avoid non-selective -blockers due to risk of bronchospasm (cardioselective - blockers (metoprolol, Atenolol) do not increase risk in the short-term) • Delay elective surgery for poorly controlled asthma (increased cough or sputum production, active Wheezing) • Ideally, delay elective surgery by a minimum of 6 wk if patient develops URTI

Answer 83

• Anesthesia, surgery (especially abdominal surgery, in particular upper abdominal surgery) and pain Predispose the patient to atelectasis, bronchospasm, pneumonia, prolonged need for mechanical Ventilation, and respiratory failure • Pre-operative ABG is needed for all COPD stage II and III patients to assess baseline respiratory Acidosis and plan post-operative management of hypercapnea • Cancel/delay elective surgery for acute exacerbation

Answer 84

1. Upper respiratory tract infection: cough, dyspnea 2. Age >60 years 3. COPD 4. American Society of Anesthesiologists Class 2 5. Functionally dependent 6. Congestive heart failure 7. Serum albumin <3.5 g/dL 8. FEV1<2 L 9. MVV <50% of predicted 10. PEF <100 L or 50% predicted value 11. PCO245 mmHg 12. PO250 mmHg

Answer 85

•Decreased level of conscious (drugs/alcohol, head injury, CNS pathology, trauma/shock) •Delayed gastric emptying (non-fasted within 8 h, diabetes, narcotics) •Decreased sphincter competence (GERD, hiatus hernia, nasogastric tube, pregnancy, obesity) •Increased abdominal pressure (pregnancy, obesity, bowel obstruction, acute abdomen) •Unprotected airway (laryngeal mask vs. endotracheal tube )

Answer 86

• Manage risk factors if possible • Utilize protected airway (i.e. Endotracheal tube) • Reduce gastric volume and acidity • Delay inhibiting airway reflexes with muscular relaxants • Employ rapid sequence induction

Answer 87

Fasting Guidelines Prior to Surgery : Before elective procedures, the minimum duration of fasting should be: • 8 h after a meal that includes meat, fried or fatty foods • 6 h after a light meal (such as toast or crackers) or after ingestion of infant formula or non-human milk • 4 h after ingestion of breast milk • 2 h after clear fluids (water, black coffee, tea, carbonated beverages, juice without pulp)

Answer 88

deficiency, ITP, liver disease) ➢Evaluate hemoglobin, hematocrit and coagulation proles when indicated . ➢Anemia: Pre -operative treatments to increase hemoglobin (PO or IV iron supplementation, erythropoietin or pre-admission blood collection in certain populations) ➢Coagulopathies • Discontinue or modify anticoagulation therapies (warfarin, clopidogrel, ASA, apixaban, dabigatran) in advance of elective surgeries • Administration of reversal agents if necessary: vitamin K, FFP, prothrombin complex concentrate, recombinant activated factor VII

Answer 89

• Clarify type 1 vs. Type 2 • Clarify treatment – oral anti-hyperglycemics and/or insulin • Assess glucose control with history and Hba1c; well controlled diabetics have more stable glucose levels intraoperatively • End organ damage: be aware of damage to cardiovascular, renal, and central, peripheral and autonomic nervous systems • Preoperative guidelines for DM: 1. Verify target blood glucose concentration with frequent glucose monitoring: <180 mg/dl in critical patients, <140 mg/dl in stable patients) 2. Use insulin therapy to maintain glycemic goals 3. Hold biguanides, -glucosidase inhibitors, thiazolidinediones, sulfonylureas and GLP1 agonists on the morning of surgery 4. Consider cancelling nonemergency procedures if patient presents with metabolic abnormalities (DKA, HHS, etc.) Or glucose reading above 400 mg/dl

Answer 90

Hyperthyroidism and hypothyroidism Hyperthyroidism : can experience sudden release of thyroid hormone (thyroid storm) if not treated or well-controlled pre-operatively. Treatment : -blockers and pre-operative prophylaxis Adrenocortical insufficiency (Addison’s, exogenous steroid use) Consider intraoperative steroid supp

Answer 91

• Severity of OSA may be determined from sleep studies and level of pressure prescribed for home CPAP device • Both obesity and OSA independently increase risk of difficult ventilation, intubation and post-operative respiratory complications

Answer 92

It is a set of steps of laboratory testing, beginning from the test requested by the clinician to the interpretation of the results.

Answer 93

I)Pre-analytical • Selection of tests • Test request • Patient identification & preparation • Specimen identification • Sample collection and labeling procedures • Sample transportation • Sample receipt and preparation for analysis II) Analytical • Selection of analytical method and device. • Quality control • Performance of analysis. III) Post analytical - Result transcription & reporting - Interpretation of results.

Answer 94

selection of the appropriate investigation for each patient is a must so as to provide the patient with the best possible medical service, with minimal side-effects on the patient and at an appropriate cost to the health

Answer 95

The communication link between the clinician and clinical laboratory is the laboratory request form (LRF)

Answer 96

1) At least 2 unique patient identifiers (full name, date of birth, national ID number, hospital file number...) 2) Sex 3) Date and time of collection (where supplied) 4) Date and time of receipt in Laboratory 5) Type of Specimen (e.g., blood, urine, body fluid) 6) Person collecting the sample. 7) Clinical status of patient (e.g., fasting), where required. 8) Specimen characteristics which may provide information relevant to interpretation of results (e.g., hemolysis) 9) Informed consent where required by legislation. 10) The name of the requesting clinician. 11) Adequate clinical information, which is essential for proper result interpretation (e.g., clinical diagnosis, cause of admission,.)

Answer 97

-Cardiac enzymes (CKMB, troponins) -Electrolytes: Na, K, Cl. -Complete Blood picture (CBC)

Answer 98

Confirmed positive identification of a patient is a must before sampling. Failure of proper patient identification may results in mix up of lab results with grave medical consequences.

Answer 99

1) Blood specimens: • Venous: the easiest sample to obtain. The commonest site is the veins of antecubital fossa. Phlebotomy is a technique to acquire a venous blood sample. • Arterial: arterial blood is used to measure arterial blood gases, like oxygen, CO2, and pH. • Capillary: capillary blood is mostly used in the pediatric patient’s group and for bedside tests where there is no need for a large amount of blood. The common sites are the fingertips and heel. 2) Urine, stool, sputum, nasal discharge. 3) Ascitic, synovial, pleural, and cerebrospinal fluids. 4) Seminal and prostatic fluids. 5) Bronchoalveolar lavage, tissues for culture. 6) Swabs for nasopharynx, oral cavity, vagina, and wounds. 7) Any unknown collection of fluid and abscess. 8) Bone marrow

Answer 100

1) The appropriate container is ready: tube, urine collection container, heparinized syringe for blood gases, etc. 2) Proper labelling of the sample container with full patient data (full name, hospital number, ward, ….), type of sample (blood, body fluid,…), and the required tests. In clinical laboratories, where information system is applied, barcoded label with the previous date in addition to unique sample number is used for labelling the samples. 3) The clinician/nurses must ensure proper patient preparation prerequisites before sampling (e.g., fasting patient, 2 hours after drug therapy in case of therapeutic drug monitoring, etc.). Clinical pathologists provide the clinician with these data. 4) The appropriate transport container is available: ice on a chilled container, and courier to transport the sample promptly, etc.

Answer 101

• Light blue capped tubes: contain Na citrate as an anticoagulant. Used for coagulation testing (PT, PTT and coagulation factor assay). • Red capped tubes: empty tubes without adding any anticoagulant material which are used in serology and some routine samples. • Yellow capped tubes: contain a clot activator which cause blood to clot quickly and serum gel separator that separates blood cells from serum, allowing the clear serum to be removed easily for testing after centrifugation. Used for the same purposes as the red capped tubes but not for PCR testing. • Green capped tubes: contain Na or lithium heparin. Used for cytogenetic analysis sampling. • Purple capped tubes: contain EDTA as an anticoagulant. Used for CBC, reticulocyte counting, and for HbA1c estimation. • Grey capped tubes: contain K oxalate as an anticoagulant and Na fluoride, which acts as sample preservative, that preserve glucose in whole blood by inhibition of glycolysis by the red cells, which would subsequently cause false-low glucose level. Used for glucose testing (figure 3)

Answer 102

3. Ensure proper patient preparation (e.g., fasting before sampling; 8 hours for fasting blood glucose and 12 hours for serum lipid profile). 4. Put on gloves. 5. Position the patient properly. 6. Apply a tourniquet just above the venipuncture site and ask the patient to make a fist without vigorous hand pumping. Select a suitable vein for puncture. 7. Clean the skin with 70% alcohol and allowed to dry spontaneously. 8. Withdraw blood from an antecubital vein or other visible veins in the forearm. 9. Enter the skin with the needle at approximately a 20-30-degree angle or less to the arm, with the bevel of the needle up. Insert the needle smoothly and fairly rapid to minimize patient discomfort. 10. Venipuncture is done by means of either an evacuated tube or a syringe. ▪ If evacuated tube is used for blood collection, the vacuum controls the amount of blood which enters the tube. ▪ If a syringe is used for blood collection, the piston of the syringe should be withdrawn slowly and no attempt made to withdraw blood faster than the vein is filling. Haemolysis can be avoided or minimized by withdrawing the blood slowly. 11. Release it as soon as the blood begins to flow into the syringe / vacutainer tube. 12. After obtaining the blood, remove the needle and then press a sterile swab over the puncture site for a minute or two. Then cover the puncture site with a small adhesive dressing. 13. Anticoagulated specimens must be mixed gently by inverting the containers several times. 14. Needle disposal: place needle, together with the used swab and any other dressings, in a puncture-resistant container, for disposal. Don’t try to recover the needle.

Answer 103

• Check the patient’s identity and sample barcoded label again and make sure that it corresponds to the details on the LRF. • The specimen tubes must be set upright in a holder or rack and placed - in a carrier together with the request forms for transport to the laboratory.

Answer 104

• Failure to adhere to proper patient preparation according to the requested test (e.g., fasting blood glucose is requested but dietary supplement was administrated within 8 hours). • Failure to adhere to proper timing in sampling (e.g., cortisol AM/PM, therapeutic drug monitoring, and fertility hormones) • Vigorous activity before sample collection affect results of some tests (e.g., CK, protein in urine)

Answer 105

• Prolonged tourniquet pressure results in haemo-concentration. • Excessive negative pressure when drawing blood into syringe results in hemolysis. • Using incorrect type of tube for blood collection ( e.g., EDTA tube for liver enzymes test

Answer 106

• Insufficient or excess anticoagulant • Inadequate mixing of blood with anticoagulant. • Error in patient and/or specimen identification results in mix up of results • Inadequate specimen storage conditions affect the result of some tests (e.g., light cause breakdown of bilirubin) • Delay in transport to laboratory affects the result of some tests (e.g., culture of fastidious organisms)

Answer 107

Specimens should always be placed upright in the plastic biohazard transport container. LRFs are transported separate from samples (don’t place them in the same container with samples so as not to be contaminated by any possible sample spills).

Answer 108

1) Microbiology: Urine culture, culture for tuberculosis. 2) Immunology: Anti-Nuclear anti body testing, Epstein Barr virus serology. 3) Chemistry: kidney & liver function tests, and hormones testing. 4) Hematology: Complete blood counts, and prothrombin time.

Answer 109

Test panels are groups of tests that are routinely ordered to determine the status of a major body organs. The tests are usually performed on a blood sample

Answer 110

1- Liver Panel (also called Hepatic Function tests) – used to screen, detect, evaluate, and monitor acute and chronic liver inflammation (hepatitis), liver disease and/or damage. It includes Total ,direct bilirubin, total protein, albumin, and liver enzymes [AST, ALT, and Alkaline phosphatase enzyme ( ALP)]. 2- Renal Panel (also called Kidney Function tests) – contains tests such as creatinine, urea, uric acid , estimated glomerular filtration rate (eGFR) to evaluate kidney function. 3- Thyroid Function Panel – used to evaluate thyroid gland function, diagnose thyroid disorders, and follow up of treatment. It includes TSH, FreeT4, Free T3, T4, T3.

Answer 111

• Patient identifiers (full name, age, sex, hospital number). • Requester name • Date and time of analysis. • Test name, result, measuring unite, and reference interval. • Result interpretation (where required and appropriate). • Name of Clinical pathologist who released the report and date of release.

Answer 112

1) Is it normal? 2) Is it significantly different from any previous results? 3) Is it consistent with the clinical findings?

Answer 113

Comparison of a patient’s laboratory test result versus a reference or “normal” range is an important aspect of medical decision making.

Answer 114

- White blood cell count (WBCs) <2 x109 /L & >30 x109 /L. - Platelets <20 x109 /L & >1000 x109 /L. - Hemoglobin <5 g/dl & >20 g/dl - Bilirubin (newborn) >15 mg/dl. - Sodium < 120 mmol/L & ˃150 mmol/L.

Answer 115

Pre-analytical phase issues are related to patient’s interaction, specimen collection, sample receiving and its transport. It includes the following ethical issues: A) Respect for persons: - Consent must be understood by the patient. - The patient’s right to refuse to get tests done should be appreciated. - Confidentiality B) Beneficence: - All tests performed/referred must benefit to patient. - Collection of samples should be done as per universally recommended precautions so as to protect the patient and the healthcare worker. - The additional samples should not be drawn from the patient without informing and getting the permission from Institutional ethics committee. - The specimens should be well-labeled with minimum two unique identifiers. - Transportation of samples should be done to protect the integrity of the sample. C) Justice: No preference should be given to some patients in order to facilitate or accelerate the collection procedure at the cost of others.

Answer 116

A) Respect for persons: - After collection, patients have the right to refuse to have their specimens examined. - Confidential information B) Beneficence: The aim is to provide the best possible result to the patients. This is accomplished via good laboratory practices which should involve the establishment of quality assurance program including quality control analysis, proficiency testing and accreditation of laboratory. C) Justice: - All patient samples are treated equally. - Develop operating procedures for STAT samples. - All specimens are analyzed accurately and in a timely manner.

Answer 117

A) Respect for persons: - Specimens will not be used beyond the testing prescribed by a clinician. - Maintain the confidentiality of results. B) Beneficence: - Reporting of results by qualified persons - Reports should be understandable and interpretable. - Notifying for errors and correction C) Justice: - Consistent reporting for all patients. - Avoid withholding of results because of financial causes

Answer 118

We must respect patient and their self-respect. It is an obligation to respect the decisions made by people concerning their own samples.

Answer 119

The goal is to maximize benefits and minimize harms, Everyone must be fair and correct in all their actions to prevent harm.

Answer 120

Basically, we have an obligation to treat all people equally, fairly

Answer 121

good technical practice accompanied by proper attitudes and behavior. In deciding what is proper, reference is often made to moral values adhered to the community and to standards of professional practice.

Answer 122

Scintigraphy, also known as a gamma scan, is a diagnostic test in nuclear medicine, where radioisotopes attached to drugs that travel to a specific organ or tissue (radiopharmaceuticals) and taken internally then the emitted gamma radiation is captured by external detectors (gamma cameras) to form two-dimensional images in a similar process to the capture of x-ray images.

Answer 123

1- Pregnancy (suspected or confirmed). If the patient is known or suspected to be pregnant, a clinical decision is necessary to weigh the benefits against the possible harm of carrying out any procedure. 2-Breast –feeding: The patient should stop and milk expressed and discarded when possible for 24 h and at least for 4 h post radiopharmaceutical administration.

Answer 124

**High sensitivity **Functional information is provided as well as anatomical information.

Answer 125

• Use of ionizing radiation • Cost of equipment • Extra care required in handling radioactive materials and long period required for isolation of patient after examination.

Answer 126

-solid, liquid, or gases.

Answer 127

plants, animals, minerals, and synthetics.

Answer 128

a) Poisons that have local action: Corrosives (act only when come in contact with tissue). b) Poisons that have remote action: most poisons (act only after being absorption). c) Poisons that have both local & remote action: heavy metals.

Answer 129

hepato toxin, nephro toxin, cardiac toxin.

Answer 130

It may be suicidal, accidental or homicidal. Ideal homicidal poison should be tasteless, odorless, colorless, highly and rapidly fatal. Suicidal patients need psychiatric evaluation.

Answer 131

1)Dose: ↑ Dose →↑ toxic effect except with vomiting. 2) State of the poisons: ➢ Increased concentration →↑ effect. ➢ Form: gas > liquid >fine powder > coarse powder in their effect and rapidity of the onset of action. ➢ Increased solubility →↑ effect. ➢ Route: IV > inhalation >IM >SC >oral >MM >intact skin in the rapidity of the onset of action. 3) State of the stomach: ➢ Empty or full stomach: • Empty stomach → more rapid & serious action. • Full stomach → delayed absorption & action. ➢ Nature of food: • Fatty food → delay absorption except in fat soluble substances such as phosphorus. ➢ Gastric acidity: • In cases of achlorhydria → cyanide salt is not fatal. 4) Age of the patient: Extremes of age are more affected than adults. 5) Health of the patient: ➢ ↑ Health → ↓ the effect of the poison. ➢ Liver & /or kidney diseases → ↓ metabolism & /or absorption of the poison → prolonged & serious effect.

Answer 132

6) Tolerance & habit: Patient with addicting drugs (opium, cocaine, alcohol) can withstand high doses without serious effect. 7) Abnormal response to the drug: ➢ Hypersensitivity: (immunological response) in which severe allergic reactions can result from a small harmless dose of a certain drug to certain individuals (e.g., anaphylaxis occurred with penicillin). ➢ Personal idiosyncrasy: It may be of genetic origin in which an abnormal response occurs to the usual therapeutic dose of a certain drug (e.g., liver damage that occurs in persons received valproic acid, hemolysis that occur in patients with G6PD deficiency when they receive any oxidant as fava beans). ➢ Drug abuse: It is the use of a drug for non-medical purposes, or persistent or sporadic drug use inconsistent with acceptable medical practice. ➢ Drug Dependence includes: A. Drug addiction (physical & psychological dependence) B. Drug habituation (psychological dependence)

Answer 133

Definition: It is a state of chronic intoxication produced by repeated use of the drug which affects the individual`s psychological, mental, and physical state and characterized by: 1. Tolerance: a tendency to increase the dose frequently to produce the same effect as there is progressive diminish effect on repetition of the same dose. 2. Physical & psychological dependence: An overpowering desire (craving) or compulsion to continue taking the drug and to obtain it by any mean in order to reach personal satisfaction (psychological dependence) and prevent a characteristic and specific group of symptoms termed withdrawal or abstinence syndrome. 3. Withdrawal syndrome (abstinence syndrome): A serious characteristic and specific group of symptoms occur on withdrawal of the drug and disappear immediately on administration of the drug. 4. Detrimental effects on both addict and society.

Answer 134

A. General physical characters: • Moral & Mood changes: Mood swings, Anger and Depression, Lying, stealing, cheating. • Mental changes: Poor judgment, Lapses in memory and amnesia. • Loss of appetite & weight loss except cannabis (bulimia & craving for sweets) • Infection due to unsterile injection (e.g., Infective endocarditis, septic emboli to lungs & organs, Tetanus, malaria, TB, Hepatitis, Nephritis, AIDS, Bacterial & fungal pneumonia) B. Others: • In opiates addiction: Pulmonary edema (Heroin), Cerebral edema, transverse myelitis, CVS, and marrow depression. • In cocaine addiction: sexual perversion & nymphomania in females. • In amphetamine addiction: hallucinations, irritability, mood swings, paranoia.

Answer 135

➢ Definition: A desire but without compulsion to take the drug to produce pleasure or to avoid discomfort. ➢ There is no tolerance, physical dependence, withdrawal syndrome or detrimental effects (e.g., tea, coffee).

Answer 136

Definition: an interaction between a drug and another substance that prevents the drug from performing as expected.

Answer 137

a) Synergistic: it is of two types: • Summation: drugs are full agonists act at the same receptor (e.g., barbiturate with benzodiazepine). • Potentiation: one drug makes the other drug/s more potent (e.g., barbiturates or benzodiazepines with a muscle relaxant → more CNS depression). b) Antagonistic: when one drug diminishes or completely abolishes the action of another drug (e.g., the action of morphine is abolished by its competitive antagonist naloxone).

Answer 138

a) At the sites of absorption: Drug interaction may ↓ or ↑ absorption (e.g., prolonged use of antibiotics → ↓ absorption of digitalis as they kill bacterial flora which enhance digitalis absorption). b) Distribution: Drugs with plasma protein binding sites (e.g., warfarin and salicylates can compete with each other). Competition at receptor sites (e.g., naloxone and morphine). c) Metabolism: It is mainly by P450 enzyme system. Induction or inhibition of this enzyme can shorten or lengthen the duration of action of drugs metabolized by this enzyme system. d) Excretion: Alkalization of urine enhances excretion of salicylates.

Answer 139

It may be one of the followings: ➢ Metabolism then excretion as a metabolite. ➢ Excretion as a parent drug via the kidney.

Answer 140

I) Emergency stabilization. By maintaining vital signs ABCD Airway, Breathing, Circulation, and CNS Depression. II) Proper clinical evaluation. History, clinical examination, laboratory tests, and differential diagnosis. III) Reduction of further absorption (Decontamination) GIT, skin, Eyes IV) Elimination of the absorbed poison • Repeated dose activated charcoal. • Alteration of urine pH & diuresis. • Hemodialysis. • Hemoperfusion. V) Antidotal therapy. VI) Supportive & symptomatic therapy.

Answer 141

• Toxic coma: may cause posterior displacement of the tongue (1st cause of death in impaired conscious level) • Foreign bodies aspiration (e.g., Button batteries, seeds as nut meg, castor oil seeds) • Mucosal swelling: hypersensitivity or corrosive irritation, or smoke inhalation • ↑↑ Secretions: organophosphorus insecticides.

Answer 142

• Dyspnea • Dysphonia • Air hunger • Hoarseness of voice • Cyanosis • Tachypnea • Intercostal retraction

Answer 143

• Prevent the tongue from falling back by pulling the tongue forward, supporting the jaw or oropharyngeal or nasopharyngeal airway. • Frequent suction of secretions. • Removal of any foreign body. • Cuffed endotracheal tube in comatose patient with lost gag reflex to prevent aspiration. • Tracheostomy in acute upper airway obstruction as angioneurotic edema.

Answer 144

• O2 inhalation by nasal cannula or mask. • Artificial ventilation if failure of spontaneous respiration is present as in cases of respiratory muscle paralysis (e.g., botulism) or continuous fits (strychnine), or sustained spasm (antipsychotics).

Answer 145

• Excessive fluid loss: arsenic. • Depression of myocardial contractility: tricyclic antidepressants. • Post- arteriolar dilatation: iron. • Hypoxia: carbon monoxide, cyanide.

Answer 146

• It depends on central venous pressure (CVP): • Normal values vary between 4 and 12 cmH2O (CVP is 2 to 6 mm Hg). If low • Fluid replacement therapy. • Vasopressor drugs as dopamine and noradrenaline. • Cardiotonic as digoxin. • Treatment of the cause and correction of complications as metabolic acidosis.

Answer 147

digitalis, theophylline, phenytoin, antiarrhythmics, electrolyte imbalance.

Answer 148

• Qualitative abnormality: decreased content of consciousness: confusion, delirium, dementia, psychosis. • Quantitative abnormality: decreased level of consciousness: lethargy, stupor and coma

Answer 149

1. Anticholinergics as atropine. 2. Withdrawal syndromes as with alcohol and sedative hypnotics. 3. Drugs causing encephalopathy as lead and arsenic. 4. Hallucinogenic and designer drugs

Answer 150

1. In- alertness: the patient can't repeat 5 digits. 2. Disorientation of persons, time and place. 3. Loss of short-term memory. 4. Delusions, illusions or hallucinations. 5. Dementia: 1, 2 are usually not present.

Answer 151

Treatment of the cause. 2. Benzodiazepines &/ or major tranquilizers in severe cases.

Answer 152

• Traumatic. (concussion &compression) • Medical as diabetic comas, cerebrovascular accidents, hepatic encephalopathy. • Toxic causes as: ❖ CNS depressants as alcohol and sedative- hypnotics. ❖ Hypoxic causes as carbon monoxide, organophosphates. ❖ Heavy metals. ❖ Narcotics. ❖ Causes of hypoglycemia as oral hypoglycemic toxicity. ❖ Causes of acid- base disorders as iron and salicylates.

Answer 153

• Stabilization, patent airway, O2 therapy, i.v line. • All comatose patients should be given a triad of naloxone, Dextrose 50 or 25% & thiamine (Coma Cocktail) due to: 1) Most of the toxicological comas are due to opiate overdose, hypoglycemia or Wernicke's encephalopathy of alcoholics 2) This triad is highly diagnostic as no response to any of them can exclude their causes, while, the response to one of them is extremely diagnostic. Single dose of any of them is not harmful to the patient not responding to the triad. ➢ Dose: Naloxone: 0.4 – 2 mg IV. Dextrose: 100 ml of 50% solution in adults or 1gm /kg of 25% solution in children. Thiamine: 100 mg IV. • Treatment of the cause. • Supportive measures are very important to minimize complications in comatose (see symptomatic & supportive therapy).

Answer 154

Personal history, complaint, analysis of the complaint (including name of the toxic substance, amount, route of exposure, time of ingestion, symptoms following ingestion) and past history (See toxicological sheet).

Answer 155

• Assessment of the patient’s level of consciousness using Reed's classification. • Assessment of the patients' vital signs: pulse, blood pressure, respiratory rate, temperature. • Examination of other systems: a) Auscultation of the chest &heart b) Proper neurological examination c) Palpation of the abdomen

Answer 156

• Routine investigations: [complete blood count, liver function tests, renal function tests, arterial blood gases (ABG), electrocardiogram (ECG), random blood sugar (RBS)]. • Specific investigations: a) Qualitative: toxicological drug screen in urine (e.g., drug abuse kits), confirmed by HPLC & GCMS in legal situations. b) Quantitative: drug level in the blood (e.g., paracetamol, pseudocholinesterase enzyme in organophosphorus insecticide). • Others: a) Abdominal erect x-ray: e.g., Body packer. b) Chest x-ray: e.g., kerosene toxicity.

Answer 157

To differentiate the toxicological case from other medical cases (e.g., differentiate the toxic coma from traumatic coma or medical coma as hypoglycemic coma, renal or hepatic coma).

Answer 158

gait, behavior, and movements in moving child.

Answer 159

A. Clinical assessment as 1. Alert and oriented about time, place and person in older child or active and playing in small infants OR 2. The child either delirious, confused, stuporous or comatose B. The Glasgow Coma Scale has been adapted to assess the level of consciousness for children.

Answer 160

three areas of brain function should be considered: speech (4 scores), eye opining (5 scores), and motor response (6 scores)

Answer 161

normal (average), underbuilt, or overbuilt.

Answer 162

► Fascial expression ► Position in bed (Decubitus) ► Colors (Complexions) ► Odors ► Sounds.

Answer 163

• Toxic, dehydrated, wasted or edematous. • Mongol in Dawn syndrome • Mongoloid features as in thalassemia and racial. • Wiseman face: As in marasmus o In which there is loss of buccal pad of fat which is the last one to disappear as it is brown fat (not easily dissolved). • Cretin face: in congenital hypothyroidism in which coarse fascial features

Answer 164

Mongoloid features

Answer 165

Wiseman face

Answer 166

Cretin face

Answer 167

• Orthopneic position: o In heart failure: o Due to lung congestion with defective gas exchange • Opisthotonos position: o In meningitis → There is hyperextended neck, arching of the back & flexion of the lower limbs to relax paravertebral muscle & relieve the back pain. • Squatting position: o In Fallot tetralogy and most cases of CCHD with ↓↓ pulmonary blood flow o An acquired condition to ↑↑ VR to the lungs for more oxygenation • Tripod position: o In bronchial asthma, and acute epiglottitis o The child is sitting on three part of the body and leaning forwards to increase work of accessory muscles of respiration.

Answer 168

• Orthopneic position:

Answer 169

• Opisthotonos position:

Answer 170

• Squatting position:

Answer 171

• Tripod position:

Answer 172

breath, urine, stool, sputum, vomitus, skin, or vagina.

Answer 173

Of the body ▪ Acetone odor due to ketones in DKA ▪ Fishy smell due to toxic chemicals as in CRF ▪ Kerosene smell in kerosene poisoning Of the mouth ▪ Bad odor (halitosis): due to: o Gingivitis & dental caries o Chronic tonsilitis o Suppurative lung diseases. ▪ Rotten apple (fetor hepaticus): in hepatic failure Of urine ▪ Acetone odor: in DKA. ▪ Bad odor in UTI

Answer 174

Acetone odor

Answer 175

Fishy smell

Answer 176

Kerosene smell

Answer 177

▪ Bad odor (halitosis):

Answer 178

▪ Rotten apple

Answer 179

Snoring/// Inspiratory, low pitched, irregular ==Oropharyngeal obstruction Stridor //Inspiratory, sometimes an expiratory component=== Larynx/ trachea obstruction Rattling //Insp. / Exp., may be felt by placing hands over the chest == Secretions in the airways Wheezing// Whistling or musical sound, predominantly expiratory == Lower airway obstruction Grunting// Expiratory, expiration against a partially closed glottis== Lung consolidation

Answer 180

❖ Pallor ❖ Cyanosis ❖ Jaundice:

Answer 181

Def,: is an unusual paleness of the skin and mucous membrane.

Answer 182

o Mucous membranes of the mouth, tongue & inner sides of the lips by gentle pressure. o Inner membranes of the lower eye lids o Hands→ palms, palm creases (become evident on stretching of the fingers) and fingernails.

Answer 183

pallor may be graded as mild to moderate and severe. o In mild to moderate pallor, there is paleness of the mucosae but pink palmar creases. o In severe pallor, the palmar creases become faint and pale.

Answer 184

o ↓↓ in RBCs number: anemic causes…….. o ↓↓ in blood flow and oxygen: shock, hypoxia, vagal stimulation, hypothermia, or fear o ↑↑ skin’s thickness: as in edema and myxedema o Abnormal amount of melanin in the skin: normally pale or so dark.

Answer 185

• Definition: bluish discoloration of the skin and mucous membrane due to the presence of reduced Hb in the blood (at least 5 gm/dl of reduced hemoglobin)

Answer 186

Central cyanosis: cyanosis of mucosae and extremities. ▪ Impaired pulmonary function: o Alveolar hypoventilation, ▪ Cardiac shunts: o Cyanotic congenital heart diseases ……. o Pulmonary AV fistulas ▪ CNS causes: o Central respiratory failure ▪ Hemoglobin abnormalities o Methemoglobinemia o Carboxy-hemoglobinemia ➢ Peripheral cyanosis: cyanosis in extremities but not the mucosae. Due to poor peripheral circulation resulting in increased 02 extraction from blood as in: ▪ Cold exposure, congestive heart failure ▪ Arterial obstruction (Raynaud phenomenon, emboli)

Answer 187

▪ Impaired pulmonary function: o Alveolar hypoventilation, ▪ Cardiac shunts: o Cyanotic congenital heart diseases ……. o Pulmonary AV fistulas ▪ CNS causes: o Central respiratory failure ▪ Hemoglobin abnormalities o Methemoglobinemia o Carboxy-hemoglobinemia

Answer 188

cyanosis in extremities but not the mucosae. Due to poor peripheral circulation resulting in increased 02 extraction from blood as in: ▪ Cold exposure, congestive heart failure ▪ Arterial obstruction (Raynaud phenomenon, emboli)

Answer 189

1. The hands are blue, but feet are pink. (Coarctation of aorta with TGA) 2. Alternatively, the hands are pink, but the feet are blue. (PDA with reversed shunt due to pulmonary hypertension)

Answer 190

• Definition: is the yellowish discoloration of skin and mucosal membranes.

Answer 191

o Jaundice is clinically apparent at serum bilirubin levels > 2 mg/dl in older children and > 5 mg/dL in neonates.

Answer 192

blanching of the skin.

Answer 193

o Sclera o Mouth: in the palate and under surface of tongue o Skin especially tip of nose, palms, and soles (in neonates)

Answer 194

(Kramer’s index) depending on the clinical scoring system: 1. Face and neck: around 5 mg/dL 2. Upper trunk: 6 - 10 mg/dL 3. Lower trunk and thighs: 10 - 15 mg/dL 4. Legs: 15 – 18 (< 20) mg/dL 5. Palms and soles: ≥ 20 mg/dL

Answer 195

Size Shape Sutures Swellings Fontanels Craniotabes Hair examination

Answer 196

microcephaly or macrocephaly

Answer 197

o Caput succedaneum (crosses the suture lines) or o Cephalohematoma (does not cross suture lines) or o Subgaleal hematoma: loose fluctuating swelling cover all the skull. o Others as: abscess, hemangioma, encephalocele, tumor

Answer 198

• Premature closure (craniosynostosis) or • Widely separated may occur in: – Mongol – Achondroplasia – Cretinism - Rickets – Osteogenesis imperfecta. - Hydrocephalus, Prematurity

Answer 199

o Microcephaly: due to premature closure of all sutures or o Macrocephaly due to ….. o Trigonocephaly: Pointed skull due to closure of metopic suture. o Brachycephaly: Anterior-posterior flattened skull (square and short) due to premature closure of coronal suture e.g., Down syndrome. o Plagiocephaly: Skewing of skull due to premature unilateral fusion of coronal or lambdoid suture. It may be a flattened occiput which is postural in infancy. o Scaphocephaly: Anteroposterior elongated skull due to premature fusion of sagittal suture. The parietal eminences are usually absent. o Oxycephaly (tower skull): Elongation of the skull like a tower due to premature closure of multiple sutures.

Answer 200

Trigonocephaly:

Answer 201

Brachycephaly:

Answer 202

Plagiocephaly:

Answer 203

Scaphocephaly:

Answer 204

Oxycephaly (tower skull):

Answer 205

the areas in between 3-4 skull bones meetings

Answer 206

inspection and palpation while the infant is calm and held in both supine and upright positions.

Answer 207

✓ One posterior. ✓ Two sphenoids. ✓ Two mastoids. ✓ One anterior.

Answer 208

✓ Located at the junction of the occipital and two parietal bones. ✓ Its size at birth equal to the tip of the baby little finger (0.5 cm). ✓ Closes at age of 6 - 8 weeks (2 months).

Answer 209

✓ Located at the junction of the two parietal and two frontal bones. ✓ It is the most prominent and important fontanel. ✓ It measures 2.5 x 2.5 cm at birth in a full-term baby. ✓ Closes gradually at the age of 18 ± 6 months (12 - 24 month) o Palpate to decide: ✓ If the fontanel is bulging or depressed (without crying) or ✓ Pulsatile (as in meningitis, encephalitis or hydrocephalus) o Causes of delayed closure of anterior fontanelles: MACRO ✓ Mongol ✓ Achondroplasia ✓ Cretinism ✓ Rickets ✓ Osteogenesis imperfecta – Hydrocephalus

Answer 210

o Skull bones yield under pressure like ping - pong or egg shell crackling sensations due to thinning of both layers of the skull and weakness of the trabeculae in-between → weak support → yield under pressure. o May be normal in new-born especially premature. o Detected by pressing over occipital or parietal bone while putting the 2 thumbs over the forehead and the other fingers are fanned over the skull. o Disappear by the end of 1st year esp. in rickets.

Answer 211

✓ Rickets (parietal bone mainly) ✓ Osteogenesis imperfecta (frontal bone mainly) ✓ Hydrocephalus (all bones of skull)

Answer 212

• Fine silky hair as in Dawn syndrome. • Blond hair: in phenylketonuria • Coarse: brittle, and easily removable as in kwashiorkor. • Flag sign: means alternating horizontal bands of normal coloration with: o Hypopigmentation of the hair (in kwashiorkor) or o Hyperpigmentation: in high dose methotrexate cycles. • Low anterior hair line: o An apparently ↓↓ distance between the hairline and the glabella = low by 3.5 cm than normal as in cretinism • Low posterior hair line means that the posterior hair line is below 5th cervical spinous process as in turner syndrome.

Answer 213

1. Eye ball size: 2. Placement of the eye: 3. Eye slant: ▪ Upward eye 4. Eyelid/ eye lash: 5. Eye brow and eye lashes 6. Conjunctiva/ Cornea/ Sclera

Answer 214

o Prominent (exophthalmos) ✓ Unilateral proptosis: as in orbital cellulitis (most common) ✓ Bilateral proptosis: as in neuroblastoma, leukemia, thyrotoxicosis. ✓ Can be measured by Ophthalmometer or by a ruler. o Sunken (enophthalmos) an in Horner syndrome, dehydration o Small (microphthalmos) as in TORCH infection.

Answer 215

✓ Unilateral proptosis

Answer 216

Bilateral proptosis:

Answer 217

Sunken (enophthalmos)

Answer 218

Small (microphthalmos)

Answer 219

▪ Hypotelorism: the eyes too closely placed may be seen in trisomy 13 and holoprosencephaly (even single eye). ▪ Hypertelorism: too widely spaced eye may be seen in Down syndrome, cretinism, thalassemia, Turner.

Answer 220

Hypotelorism:

Answer 221

Hypertelorism:

Answer 222

▪ Upward eye slant (mongoloid): o The outer canthus is higher than the inner canthus. o As in Dawn syndrome. ▪ Antimongoloid slant: o The inner canthus is higher than the outer canthus. o As in Turner, Noonan syndrome, … ▪ Epicanthic folds: o Are folds of skin which project from the upper lid over the medial epicanthus. o fo example: Down syndrome or racial.

Answer 223

Upward eye slant (mongoloid):

Answer 224

Antimongoloid slant:

Answer 225

Epicanthic folds:

Answer 226

▪ Oedema or swollen eye lid: as in o Allergic (red, itchy, and usually without discharge) o Acute nephritis, nephrotic syndrome, … o Pertussis or IMN in which there is puffy eye lids. o Conjunctivitis (pink eye) (painful and tender ± yellowish discharge o Chalazion or stye • Position: Normally, the upper eyelids cover 1-2 mm of upper corneoscleral junction. o Ptosis of the eyelids can be congenital or acquired. o May be unilateral or bilateral. It may be partial or complete. o As in Horner syndrome, botulism, myasthenia gravis

Answer 227

Oedema or swollen eye lid

Answer 228

• Thinning and loss of the outer 1/3 of eye brow as o Familial or artificial. o Vitamin & mineral deficiency (esp. vitamin A and zinc) o Hypothyroidism • Fused eye brow (Unibrow or Synophrys) as in Cornea de Lange syndrome • Long and curly eyelashes: o Familial, single gene mutation or as a part of syndrome o Acquired as severe malnutrition, TB, …

Answer 229

Thinning and loss of the outer 1/3 of eye brow

Answer 230

Fused eye brow

Answer 231

Long and curly eyelashes:

Answer 232

• Pallor • Jaundice • Hemorrhages: trauma, scurvy, pertussis, or hemorrhagic disorders.

Answer 233

o As in IDA, Marfan syndrome, Osteogenesis imperfecta, & Congenital glaucoma. o Due to thinning and transparency of the collagen fibers of the sclera that allow visualization of the underlying uvea

Answer 234

(keratomalacia) as in vitamin A Def.

Answer 235

is a brownish ring around the cornea (Wilson dis.)

Answer 236

assess the pupil size, symmetry, and reaction of the pupil to light.

Answer 237

1- Slight or simple wound: not serious, heals in less than 20 days, no permanent infirmity. 2- Dangerous wound: wound is serious, heals in more than 20 days, and may leave permanent infirmity. 3- Fatal wound: causes death immediately or sometime after injury.

Answer 238

1- Blunt trauma: - Abrasions - Bruises (Contusions). - Contused (Lacerated) wounds. 2- Sharp trauma: - Cut (Incised) wounds. - Stab wounds

Answer 239

Destruction of superficial layers of skin

Answer 240

Rough blunt object e.g., fingernail, teeth, tire of car

Answer 241

1- Sliding abrasions: classified into: a- Scratches: due to blunt object with pointed end passing across the skin and moving the surface layers in front of it e.g., fingernail, fork…etc. b- Grazes: when a rough object comes in contact with a wider surface of skin. e.g., dragging abrasion after motor car accident. 2- Pressure abrasions: they occur when an object is stamped on the skin e.g., ligature mark, motor car tire, teeth marks (bite).

Answer 242

Scratches:

Answer 243

Pressure abrasions:

Answer 244

1- Sign of resistance or struggle. 2- Type of crime: a) Throttling: semilunar fingernail abrasions on skin of victim’s neck. b) Strangulation & hanging: ligature mark on skin of neck. c) Smothering: semilunar fingernail abrasions around mouth & nostrils. d) Rape: semilunar fingernail abrasions on the skin of inner aspect of thigh, on her wrists to prevent her from defensing, around mouth to prevent her from shouting. 3- Identification of assailant a) Fingernail abrasions tell if assailant is right or left-handed or if he had a missing finger. b) In case of hanging or strangulation, we can identify a suspected rope from the pattern of ligature marks. c) We can identify assailant’s teeth from a human bite on the body of the victim. 4- Age of abrasion (time passed between infliction of wound and death) abrasion is covered with soft scab for 2 days then covered with dry scab for 3 days then the scab separates after 7 days leaving red surface. 5- Differentiation between contusion & hypostasis: Abrasions are present around contusion only. 6- Differentiation between incised and contused wounds: abrasions are usually present at the edges of contused wound only. 7- Site: abrasions always occur at the same site of injury.

Answer 245

Throttling: Abrasions

Answer 246

Strangulation & hanging Abrasions

Answer 247

Smothering: Abrasions

Answer 248

Rape: Abrasions

Answer 249

abrasion is covered with soft scab for 2 days then covered with dry scab for 3 days then the scab separates after 7 days leaving red surface.

Answer 250

abrasions always occur at the same site of injury

Answer 251

a) Fingernail abrasions tell if assailant is right or left-handed or if he had a missing finger. b) In case of hanging or strangulation, we can identify a suspected rope from the pattern of ligature marks. c) We can identify assailant’s teeth from a human bite on the body of the victim.

Answer 252

It is an extravasation of blood into the tissues due to rupture of blood vessels

Answer 253

Blunt object e.g., stick or big stone

Answer 254

1- Sign of resistance or struggle. 2- Type of crime: a) Throttling: subcutaneous bruises are found in the neck. b) Strangulation & hanging: bruises are present in the deeper tissue of neck. c) Smothering: bruises are found around mouth and nostrils. d) Rape: bruises are present around mouth, on the wrists and on the inner aspect of thighs. 3-Identification of causal instrument: bruise usually takes the shape of causal instrument e.g. 1) Stick → elongated bruise. 2) Human bite → two curved rows of abrasions in an elliptical form with underlying bruises. 3) Animal bite → two parallel rows of abrasions not meeting each other. 4-Age of bruises (time passed between infliction of wound and death): recent bruise is red in color due to (oxy Hb) then changed into blue due to (reduced Hb), then to green due to (biliverdin), then changed to yellow due to (bilirubin) each change takes 2-3 days, then color disappears after 2 weeks. 5- Differentiation between incised wound and contused wound: bruises are present at edges of contused wound only. 6- Site: bruises usually occur at the site of injury, but it may shift under the effect of gravity e.g. bruises in temple may sink down over cheek.

Answer 255

1) Type of tissue: bruises develop more easily in soft, vascular, lax tissue e.g., eye lid but if the skin is strongly supported by fibrous tissue or if the muscle tone is good, bruising is less or even absent. 2) Age: infants (delicate skin) & old people (poorly supported blood vessels) bruise more easily than adults. 3) Sex: female bruises more easily (because they have more subcutaneous fat). 4) Color of skin: white person shows bruises more obviously than dark person. 5) Natural disease: persons suffering from hypertension, vitamins deficiency, liver damage → blood vessels become unhealthy and show more bruises. 6) Shape: usually take the shape of causal instrument 7) Site: bruises shift down under the effect of gravity e.g., deep bruise in the hip fasciae may sink down and appears at the knee

Answer 256

▪ Red in color ▪ Underlying bruise ▪ Healing or sepsis ▪ Vital reaction e.g.: - Small hemorrhage - Fibrin threads - Infiltration with polymorpho-nuclear leucocytes

Answer 257

Vice versa

Answer 258

▪ May be of any size. ▪ Accompanied by swelling. ▪ May show color changes. ▪ Blood is clotted in tissues.

Answer 259

▪ Small ▪ No swelling ▪ No color changes. ▪ Amount of blood in meshes of tissue is very slight.

Answer 260

Tearing or splitting of tissue

Answer 261

Heavy blunt object e.g., heavy stick or big stone

Answer 262

Drawing edge of sharp instrument along surface of skin

Answer 263

Sharp object e.g., knife or broken glass

Answer 264

Irregular & lacerated

Answer 265

Slight because blood Vessels are crushed

Answer 266

Common: because more tissue damage at edges and causal instrument is usually infected

Answer 267

Usually present at edges

Answer 268

Take longer time to heal & leaving extensive scar

Answer 269

Sharp & regular

Answer 270

Sharply cut

Answer 271

Free because blood vessels are sharply cut

Answer 272

Unusual: minimal tissue damage at edges and bleeding washes out any bacteria carried into the wound

Answer 273

Linear or spindle shaped

Answer 274

Leave thin scar

Answer 275

Forcing sharp pointed instrument into the body

Answer 276

Sharply cut & regular

Answer 277

Sharply cut

Answer 278

Depth > length

Answer 279

Very dangerous because may injure deep organs and introduce sepsis

Answer 280

1) Wound has one sharppointed angle → in case of single sharp bladed instrument C > 2) wound has two sharppointed angles → in case of double sharp bladed instrument < > 3) length of wound is little smaller than breadth of blade because skin is elastic. But it may be larger if the weapon is withdrawing or by its lateral movement. 4) Broken tip of weapon may be present inside wound → help identification of weapon

Answer 281

- May be a desire for revenge. - Self-inflicted wound, not suicidal. - In areas within the reach of hand e.g., in case of right-handed people occur in left arm. - Harmless, superficial, parallel cuts. - No corresponding tear or blood stain in clothes.

Answer 282

- Gaping edges. - Swollen and hyperemic edges. Blood clot (bruise) infiltrates the edges (not washable under the tap and may show color changes). - Vital reactions (healing or sepsis). - Microscopical examination will show infiltration by polymorphnuclear leucocytes and fibrin threads. In the postmortem wound, the above-mentioned characters are absent.

Answer 283

1. Neurogenic shock due to reflex vagal cardiac inhibition. 2. Hemorrhage from carotid arteries and jugular veins. 3. Chocking: trachea is opened, and blood may be inhaled. 4. Mechanical asphyxia: - in cases of complete division of trachea, the soft parts of the neck fall in and close the air way to cause death from mechanical asphyxia. 5. Venous air embolism 6. Delayed death - Sepsis - Infection of larynx, oedema of glottis - Bronchopneumonia

Answer 284

Liver is bulky and friable organ; blow on abdomen may cause lacerations of liver. These lacerations may be shallow & split capsule especially over right lobe of liver or severe & separate right and left lobes of liver with severe bleeding inside peritoneal cavity.

Answer 285

Malaria and schistosomiasis render the spleen larger and more friable. The minimal trauma in these cases may cause severe rupture of spleen.

Answer 286

The injury of kidney is uncommon because they are protected in their situation alongside the spine. They may be penetrated by stab wound or may be lacerated after running over accident that may cause partial or complete rupture of renal artery

Answer 287

to differentiate between traumatic rupture and pathological rupture of the intestine

Answer 288

• The tumor may date since birth or may appear immediately after. It is purple in color birth mark or port wine nevus. • Although it may appear anywhere in the skin, the commonest sites are the face and neck. The tumor is flat and not raised above the surface (Fig 1). • Spontaneous regression may occur, and the tumor may disappear within months or years. • X-ray therapy or C02 snow applied to the nevus every month may cause partial or complete cure.

Answer 289

X-ray therapy or C02 snow applied to the nevus every month may cause partial or complete cure.

Answer 290

the face and neck

Answer 291

• The tumor consists of dilated vascular spaces and thus it bleeds easily on injury. The face, lips and tongue are common sites of affection. It may occur in the internal organs such as the liver and intestine where it may cause anemia, thrombocytopenia or it may rupture giving internal hemorrhage. • The tumor is raised above the surface, soft and compressible and may be lobulated It is usually bluish in color, but the center may be red (Fig 2). • Surgical excision if possible is the best line of treatment. • X-ray therapy, surface or interstitial irradiation by radium and repeated electrocoagulation by diathermy may lead to a cure.

Answer 292

• Surgical excision if possible is the best line of treatment. • X-ray therapy, surface or interstitial irradiation by radium and repeated electrocoagulation by diathermy may lead to a cure.

Answer 293

The face, lips and tongue and others the liver and intestine

Answer 294

the scalp, the face, the neck and the scrotum #Multiple cysts are common in the scalp and the scrotum.

Answer 295

• The cyst is not usually tense; it is attached to the skin in the center, where the mouth of the gland may be seen as a punctum. • It is freely mobile over the underlying structures. • The cyst contains a greasy, thick, greyish material with a characteristic odor, but it does not contain hair. On pressure the contents may come out and the cyst evacuates, to fill again in a short period (Fig 3).

Answer 296

1) Infection to form an abscess. 2) Rarely ulceration and fungation (sometimes it resembles a carcinoma and is then called Cock’s peculiar tumor. 4) Malignant change is rare. 5) Multiple sebaceous cysts of the scalp may by pressure effects lead to baldness

Answer 297

• Complete surgical excision. If any part of the wall is left the cyst recurs. If infected it is drained first and when the inflammation subsides, complete excision is performed.

Answer 298

Lipoma is a common tumour composed of adult fat cells. It has a well-formed (Fig 4), capsule, from which it can be easily shelled out at operation. Strands of fibrous tissue passing from the capsule divide the tumour into lobules.

Answer 299

fibrolipoma.

Answer 300

angiolipoma,

Answer 301

Cushing’s syndrome, cretinism and alcoholics.

Answer 302

painful false lipomas are found in fatty women near the menopause (lipoma dolorosa). The thighs are usually affected.

Answer 303

o Calcification. o Infection. o Malignant changes into a liposarcoma (Common in lipomas of the shoulder region and retroperitoneal). o A submucus lipoma of the intestine may predispose to intussusception. o A subthecal lipoma, although rare may compress the cord causing paraplegia.

Answer 304

in consistency, pseudocystic and pseudofluctuant. Its surface is lobulated, and it has a slippery margin. It is freely mobile over the deep fascia and due to its attachment to the skin by multiple fibrous strands, when it is moved it is dimpled at many points.

Answer 305

May feel firm in consistency and it is not usually lobulated therefore it is difficult to diagnose.

Answer 306

may be intermuscular, subperiosteal, subserous, submucous and retroperotonial. Subsynovial lipoma (lipoma arborescens) occurs in joints. A subperiosteal lipoma is usually seen in the skull and it causes depression of the bone underlying it.

Answer 307

Excision by incising the capsule and shelling it out. A retroperitoneal lipoma is liable to recur and it is considered by some to be a liposarcoma from the start.

Answer 308

A dermoid cyst is a benign cutaneous developmental anomaly that arises from the entrapment of ectodermal elements along the lines of embryonic closure.

Answer 309

• Dermoid cysts are true hamartomas. They occur due to the abnormal sequestration and inclusion of the surface ectoderm along the lines of skin fusion during embryologic development.

Answer 310

• Dermoid cyst on histology shows a well-defined wall lined by stratified squamous epithelium and a lumen that may be filled with mature adnexal structures of mesodermal origin, such as hair follicles and shafts, sebaceous and eccrine glands.

Answer 311

• In the majority of cases, dermoid cysts occur in the head and neck region, although they may be found anywhere on the body. • In the head and neck region, dermoid cysts can most commonly be seen in the frontal, occipital, and supraorbital areas, with the outer third of the eyebrow being the most frequently affected region (Fig 5). • A lower lid dermoid cyst may be evident as a painless, gradually enlarging swelling of the lower lid. Dermoid cysts in the medial canthal area may present as masses adherent to lacrimal canaliculi. • Dermoid cysts are typically present as a pale, flesh-colored, pearly, dome-shaped, firm, deep-seated, subcutaneous nodule. They are usually asymptomatic, non-pulsatile, and noncompressible.

Answer 312

1. Ultrasound will show a well-defined homogenous and hypoechoic cystic lesion. 2. Fistulography was done preoperatively in some cases to rule out the involvement of a deep tract in a dermoid cyst. 3. Consultation with a neurosurgeon is highly recommended for dermoid cyst complicated by intracranial or intraspinal extension.

Answer 313

1. Epidermoid cyst 2. Encephalocele 3. Lipoma 4. Meningioma 5. Neurofibroma 6. Teratoma 7. Lymphoma 8. Subcutaneous abscess 9. Lymphatic malformation 10.Thyroglossal duct cyst

Answer 314

• Dermoid cysts usually tend to grow slowly, further having the potential to cause bony deformities, intracranial extension, or intraspinal extension. • The presence of intracranial extension or intraspinal extension can further lead to meningitis or develop into an abscess. Because most dermoid cysts grow over time, complete surgical excision without disruption of the cyst wall by an experienced surgeon is recommended before the development of such complications.

Answer 315

Dermoid cysts that have intracranial or intraspinal extension may lead to meningitis, abscess, or cause local mass effect. Aspiration and biopsies of dermoid cysts have the potential to cause infection, further leading to osteomyelitis, meningitis, or cerebral abscess.

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