2011 spring SURGERY III

2011 spring SURGERY III BY ismail Past papers question and answere

Pyogenic infection of clinical manifestation and treatment of the TB?SYMPTOMS :Onset of symptoms of tuberculosis spondilitis is typical more insidious than pyogenic infection Constitutional symptoms Chronic illness Malaise Night sweats Back pain Often a late symptoms that only occurs after significant boney destruction and deformity Signs kyphotic deformity neurologic deficit(present in 10-47% of patients with potts disease for joints subluxution and dislocation treatment nonoperative isoniazid,rifampin and pyrazanamide therapy

indicantions of surgical intervention of duodenal alcer? 1 accompanied by sever complications:acute perforation,massive hemorrhage and scarring pylorus obstruction 2 failure after three course of formal internal medical therapy 3 operation method:subtotal gastrectomy or vagotomy.

Indications of surgical intervention of gasric ulcer?1 non-healing after 8-12 weeks internal medical therapy2 recurrence 3 accompanied by complications:perforation, hemorrhage and scarring pylorus obstruction 3 duodenal ulcer 4 huge ulcer (>2.5cm) or malignancy suspected

Whate is the surgical indication for removal of simple goiter and Whate are the complications of thyroidectomy?*****Part1:1. Symptom of pressure (dyspnea, dysphagia)2. Substernal extension 3. Large goiter4. Nodular goiter secondary hyperthyroidism5. Suspicon of malignant.Part21. Dyspnea and stridor2. Reccurent laryngeal nerve injury3. Superior laryngeal nerve injury4. Parathyroid glang injury5. Cramping of extremities6. Thyrotoxic crisis( thyroid storm)

Extracorporeal circulation**?Most open heart surgery through sternotomy. At the beginning of the operation, heparin is infused (3mg/Kg). The arterial cannula is placed in the ascending aorta. Venous cannula is inserted into either cava or the right atrium. Extracorporeal circulation starts. Please describe the normal value of intracranial pressuse?

Multiple rib fracture: Flail chest**? Ventilation is severely impaired in these patients. paradoxical respiratory . Flail chest move in and out following respiration movement paradoxically. The flail chest moves in while inspiration and move out while expiration. This will bring to mediastinal flutter which lead to anoxia and carbon dioxide accumulation, et al.

indications for strangulated intestinal obstruction***?1 Shock2 Failure in conservative treatment3 Severe pain, continuous pain4 Peritonitis5 Bloody ascites (paracentesis)6 Asymmetric distention (closed-loop ileus) 7 Xray single dilated loop .

The signs of the pancreatic head cancer**?Jaundice Palpable liverPalpable gallbladderTenderness Acites Abdominal mass.

What is the early complications of bone fractures****?1. shock2.Fat embolism syndrome 3.Injuries of internal organs4.injury of blood vessels and nerve.5.Osteofacial compartment syndrome.

Please briefly state the therapeutic mthod for lumber intervertebral disc protrusion?*****

1. Disk bulge - Annular fibers intact.2. Disk protrusion - Localized bulging with damage of some annular fibers 3. Disk extrusion - Extended bulge with loss of annular fibers, but disk remains intact 4. Disk sequestration - Fragment of disk broken off from the nucleus pulposus.5. The types of urinary stone by the composition**?Calcium-Containing Stones Calcium oxalate calculus Phosphate calculus NonCalcium-Containing Stones Uric acid and urate calculi Struvite Cystine calculiXanthine calculi Paraneoplastic syndrome**?Elevated erythrocyte sedimentation rateHypertensionAnemiaCachexia and weight lossPyrexiaAbnormal liver functionHypercalcemia Polycythemia3.5NeuromyopathyAmyloidosis

What is the common CABG bypass conduits**?Internal Thoracic Artery Radial arteryGastroepiploic arterInferior epigastric artey Greater saphenous vein Complications of postgastrectomy**?hemorrhage duodenal stump rupturerupture of the anastomosis postoperative vomiting (gastric paralysis )postoperative obstruction (stoma, afferent and efferent loop)

Standars of functional reduction****? Rotation and separate dislocation: should be completed rectified.Overlap: adultarea. 1cm, children2cm Angulation: lateral angulation should be completed rectified.Lateral dislocation: the shaft of the long bone should be contacted at least 1/3 area, metaphysis contacted at least 3/4

What is the seze different and constancy of colon cancer**?The size different and the consistency of luminal contents make tumors produce obstruction in the left side more often than in the right side tumors in the right side become so large that patients develop superfacial necrosis from ischemia and then chronic bleeding and anemia occurs

Criteria of clinical union?****** A No direct or indirect tenderness.B No motion of the pseudoarthrosis.C On x-ray film there is continuous callus across the fracture line, and the fracture line is not clear.1/ Cervical spondylosis is commonly seen in outpatient department. Please state its classification and main symptom of each type***. Cervical spondylotic radiculopathy; Symptom:Pain or numbness of neck and shoulder, radiating to the the upper limb Cervical spondylotic myelopathy; Symptom:weakness of limbsinstability when moving or holding sth. Paralysis from upper motor neuron disease Sympathetic type; Symptom:* Excitement of sympathetic nerve headachevertigo, nausea, vomiting Blurring of visionchange of pupilIncreasing of pulses, arrhythmia ,elevated blood pressureSweating ,tinnitusdescending of hearingdisorder of vocal sound* Inhibition of sympathetic nerveVertigo, eyes blurred, tearing, blocked nose, bradycardia, descending of blood pressure, gassiness of bowel Vertebral artery type; Symptom: Vertigo, headache, dysfunction of vision, cataplexy.

Presentation?*Symptoms, which occur at the site of the bunion, may include: Pain or soreness Inflammation and redness A burning sensation Possible numbness. Soft Tissue***? Muscle Ligament Bursa Tendon sheath Tendon Mixed (Shoulder)

2/ What are the surgical indications of the lumbar disc protrusion?*** The nonsurgical treatment is invalid or recurrence, Symptoms affect job and living; Nerve damage symptoms obvious; The central type prolapse of lumbar intervertebral disc has urine dysfunction; With obvious lumbar spinal stenosis disease. 3/ Please state the therapeutic principle for chronic injuries of motor system. *Distributing of the centralized-attentions; improve the strength of muscles, restrict the actions of induced injury, correct the malposture, keep the unbearing movement, *Physiotherapy and massage; *Local injection of hydrocortisone acetate suspension; Definite diagnosestrictly aseptic techniqueaccurate location*Non-steroid anti-inflammatory drugs (NSAID); *Operation;stenosing tenosynovitiscompression of peripheral nerve syndrome

What are symptoms and signs of acute appendicitis and differential diagnosis**? Symptoms 1: 1)Pain in the epigastrium 2:Anorexia ,nausea ,or vomiting 3) Other symptoms include low-grade fever and constipation 4) Infants with appendicitis are lethargic ,irritable and anorexic Signs 1: 1) Localized tenderness in the right lower quadrant is the most important2) Other signs include fever ,muscular rigidity ,rebound tenderness ,referred tenderness Differential diagnosis

1)gastroenteritis2).mesenteric lymphadenitis3) gynecological diseas: 1)Acute salpingitis 2)mittelschmerz. 3)Ruptured ectopic pregnancy.4)Twisted ovarian cyst. 4 urinary tract disease: 1)Ureteral colic.2)Acute pyelonephritis.

Local manifestations**1.General signs pain, tendernese, swelling , dysfuction, ecchymosis 2. special signs******* Deformity Abnormal movement Fricative sound or sensation , must not be routinely examined.

Fracture Healing (three stages)*****

1 hematoma organization (Inflammation);2weeks2callus formation (Repair);12-24weeks3callus remoulding ( Remodeling);1-2yearsFactors on Displacement*1, the size and direction of the violence 2, weight of distal limb segment 3, traction of muscle 4, improper transportation

Systemicfactors*****Agechild the elderGeneral conditions: malnutrition obesity, diabetes, alcohol abuse, nicotine abuse

local conditions*********type of fracture:Blood supplyInfectionDegree of soft tissues injuries Soft tissues lying between the two bone ends

Closed reduction Percutaneous screw fixation****

1Gustilo Type I Open Fracture2. Gustilo Type II Open Fracture3. Gustilo Type III Open Fracture

Three principles of fracture treatment*********1. Reduction 2. Immobilization3Fuctional exercise

b. There are three components within the skull****(1)80% brain tissue and water (2)10% cerebrospinal fluid (CSF)

(3) 10% blood: Cerebral blood flow (CBF). ICP**: Intracranial pressure or ICP is the pressure or force exerted on the skull by the brain and fluid inside the skull cavity.d. Normal range of ICP***: adult:70-200mm H2O(0.7-2.0kPa) child:50-100mm H2O(0.5-1.okPa)2. The concept of intracranial hypertension(IH*****: adult: ICP>200 mm H2O child: ICP>100 mm H2O

3. Common causes of ICH******

a. Brain tissue:brain edema b. CBF: cerebral venous obstruction c. CSF: obstruction of CBF pathway d. Intracranial space-occupied lesions e. Decrease of intracranial volume: cranio- synostosis, large depressed skull fracture. 4 Factors influencing the clinical progress of IH a. Age: Infant: Separation of skull sutures, compensatory volume increase Senile: Atropy of brain tissue compensatory volume increase b. Expansion of lesions: Pressure-volume exponential curve( langfitt curve) If critical volume is reached, dditional volume increase produces prominent increase of ICP. The outcome of ICP elevation******

a. ICP CBF b. Brain herniation c. Brain edema e. G-I tract disturbances f. Cushings response g. Pulmonary edema6.Clinical features of IH******: a. Headache b. Vomiting Triad c. Papilloedema e. Cushings response: Cushing's triad involves an increased systolic blood pressure, a widened pulse pressure, bradycardia, and an abnormal respiratory pattern d. abducent nerve paresis, Epilepsia f. coma, Incontinenceg.Child:circumstance of head increase 7. Diagnosis: a. clinical features b. X-ray c. CT/MRI etc..2.Classification a. Transtentorial herniation: b. Tonsillar herniation:3.Clinical manifestations: (please write the mechanism of Transtentorial herniation)******. a. Trans-tentorial H: (1)Triad (2)Loss of consciousness (3)Ipsilateral mydriasis (4)Contralateral hemiparesis (5)Vital signs change b. Tonsillar H: (1)nuchal rigidity, neck pain, cough reflex (2)respiratory failure early stage (3)loss of consciousness late stage

e. Compensatory Mechanism****** The skull is rigid and does not allow much expansion of the brain, so increases in ICP is a critical medical condition that can lead to brain damage. An increase in one should cause a decrease in one or both of the remaining two. Cranio-cerebral trauma can involve scalp, skull, and brain or in any combination.Craniocerebral Trauma Cranio-cerebral trauma can involve scalp, skull, and brain or in any combination..Scalp: a. hematoma:(1)subcutaneous H:lower in center (2)subgaleal H:diffuse (3)subperiosteal H:bony suture b. laceration: bleeding shock suture debridement within 24hrs with antibiotics. complications:1)Fracture 2)Open injury c. avulsion: detached from the skull , skin graft.Skull fracture a. Vault skull fracture: (1)linear, non displaced: no specific T. (2)depressed indications for operation: 1)large depressed fracture ICH 2)deficit of Neurological system :paraplegia, epilepsy. 3)depth>1.0cm 4)open injury5)near sagital sinus:comtraindication 2) Clinical manifestatiions : ICH herniation death* 1)Epidural 2) SubduralMechanism: acceleration deceleration Location: coup injury contrecoup injury bleeding: middle meningeal A. coriical A, bridging V.Lucid interval: obvious atypical CT: convex mirror semilunar Combination: less more Prognosis: good bad 3)Interacerebral H: mainly secondary to brain laceration, may occur in any part of the brain. 4)Delayed traumatic intracranial hematomaBrain Injury: Primary, Secondary Close, Open. a. Mechanism: acceleration injury: coup injury deceleration injury: contrecoup injury b. Primary brain injury: (1)Concussion: 1) loss of consciousness 2) recovery within 30mins 3) no positive neurological findings2)Cerebral contussion and laceration . Organic damage to the brain tissue (grey and white matter) accompanying laceration of blood vessels which results in intracerebral hemorrhage. Clinical manifestations** 1). disturbance of consciousness:>30min 2). local symptoms and signs 3). ICH herniation (3)Diffuse axon injury(DAI) pathological diagnosis: rupture of the axon axonal retraction ball severe brain injury with high mortality. Primary brain stem injury is nothing but a special type of brain injury .3.Essential Diagnosis:(1) Evidence of SAH : abrupt onset of headache, stiff neck, impairment of consciousness, seizures, etc.(2) Evidence of an expanding intracranial mass: progressive cranial nerve. (3) Demonstration of an aneurysmal sac by angiography, CT scan, or MRI.1.Classification Spontaneous SAH Traumatic SAH2.Concept: Spontaneous subarachnoid haemorrhage is caused by arterial bleeding into the subarachnoid space.3.Causes of SAH.Aneurysm rupture accounts for more than 60% of all spontaneous subarachnoid hemorrhageArteriovenous malformations(AVM)-10%Hypertensive hemorrhageNot defined-20%.

acute abdomen: is the term used for an episode of severe abdominal pain that lasts for several hours or longer and requires medical attention.prompt pyonephritis**: The kidney is converted into a multilocular sac containing pus or purulent urine, pyonephrosis can result from infection of hydronephrosis, follow acute pyelonephritis or, most commonly, arise as a complication of renal calculus disease. Pyonephrosis is usually unilateral.

Stress incontinence**sudden leakage of urine with cough, sneeze, exercise or other activities that increase intra-abdominal pressure. Galeazzi fracture*** Fracture of the distal third radius and subluxation or dislocation of the distal radioulnar articulationColles fracture**: A fracture of the distal radius with dorsal displacement and associated ulnar styloid fractureMost common type of wrist fracture in adults.Monteggia fracture: Fracture of the proximal ulna and dislocation of the radial headRadial nerve is easily injuried Callots triangle** Its bounded by the common bile duct on the left, the cyst duct inferiorly,and the cyst artery superiorly.it arterial blood reaches via the cystic artery, It originates from right hepatic arteryChacots traid**also know as Reynolds pentadJaundiceFeverAbdominal painMental obtundationHypotensionCommon channel Variations in the relation between the intra pancreatic portion of the common bile duct and the main pancreatic duct at the ampula of Vater. A short common channel contain flow from both secretary system.

Indirect hernia**: Through inguinal canal Internal ring and external ring Lateral to inferior epigastric arteryMost common Closed-loop intestinal obstruction** outlet and inlet obstructedto strangulate Emergent operation neededExamples:internal hernia volvulus colonic obstruction

Direct force** Fracture occurs at the same site where the force is applied to. The fracture line may be comminuted or transverse, and it is accompanied by severe soft tissue injury. In leg or forearm fractures the fracture line of two bones are at the same level.Indirect force The fracture site is far away from where the force is applied to. For example, when one has a fall with his palm hits the ground, fracture may occur at the humeral neck, not at the palm its soft tissue injury may be mild(slight). In leg or forearm fractures the fracture lines of two bones are at different level.