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General Surgical Scheme


1. Swellings  Differential Diagnosis of swelling case
y If the Pt. told you that it was after trauma y If the swelling has an expansile pulse y If the swelling has a transmitted pulse artery. Haemangioma. Aneurysm. Swelling over an Hernia

y The swelling is reducible & shows expansile impulse on cough or Saphena varix. y The swelling moves up and down with deglutition thyroglossal cyst. y The swelling moves with protrusion of the tongue cyst. y The swelling increase in size in very short period y Not one of these so by exclusion

Thyroid enlargement or Thyroglossal

A tumor.

Lipoma or Sebaceous cyst.

 How to diagnose a swelling?


a. Anatomically: organ involved. b. Etio-pathological diagnosis:
Traumatic, Inflammatory (F.H.M.A), Neoplastic.

c. Functional

diagnosis "compensated or not".

 Examples
I.
State True or False:

"Examine the Back".

1. The swelling has slippery edges. 2. The swelling is sub muscular. 3. The most common complication is malignant transformation.
What is your diagnosis?
Subcutaneous lipoma of the back.

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2.
 A Swelling shows

Hernia

- Expansile impulse on cough. - Reducible, and .. Near linea alba, so the hernia may be Umbilical "it is rounded; usually there is absence of the shape of umbilicus". Para umbilical "it is cresenteric, usually presence shape of the umbilicus" Other with no incision Epigasteric. Any where at a site of an incision, the hernia may be Incisional "A scar of previous operation other than hernia". Recurrent hernia "A scar of previous hernia operation". At the inguinal region & above the inguinal ligament, hernia may be Direct "At Hassel Bach's triangle, Reduced backwards & don't descend to scrotum". Indirect "Hernia reduced upwards, backwards and laterally & may descend to scrotum".

 Saphena varix:
Site: at femoral triangle. With Trendlenberg test junction. incompetent sapheno-femoral

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 Examples
I.
State True or False:

"Examine both Groins".

1. The swelling doesn't reach the scrotum. 2. This is a direct hernia. 3. Internal ring test is negative.
What is your diagnosis?
Right indirect inguinal hernia in a male patient, non complicated, enterocele, fit for surgery.

II.
State True or False:

"Examine both Groins".

Rt. Indirect inguinal hernia.

1. 2. 3. 4.

The patient has oblique inguinal hernia. The patient has left femoral hernia. The hernia is irreducible. This is a case of recurrent hernia. III.

"Examine both Groins".

Rt. indirect inguinal hernia.

State True or False:

1. 2. 3. 4. 5.

There is a scar in left groin. It shows malgaigne bulging. It is downward & lateral to pubic tubercle. It is strangulated. There is sliding bladder.

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IV.
State True or False:

"Examine Right Groins".

Rt. indirect inguinal hernia.

1. 2. 3. 4. 5.

This is oblique uncomplicated hernia. It is partially irreducible. It shows transmitted impulse. The patient is kept in the hospital for herniotomy. Internal ring test is positive. V.

"Examine the Abdomen".

State True or False:

1. The abdomen is distended. 2. The swelling is not completely reducible. 3. The most urgent complication is strangulation.
What is your diagnosis?
Supraumblical hernia, non complicated, in a female patient.

VI.
State True or False:

"Examine the Abdomen".

1. The hernia is reducible. 2. The hernia is obstructed. 3. There is Gurgling sensation on palpation.
What is your diagnosis?
Epigastric hernia in a male patient, non complicated, omentocele.

VII.
State True or False:

"Examine the Abdomen".

Incisional & Para umbilical hernia.

1. 2. 3. 4. 5.

There is only Para umbilical hernia. Mid line previous incision. It is tender. It shows an expansile impulse on cough. Appears more on contraction of abdominal muscles.
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VIII.

"Examine the Abdomen".

Para umbilical, Incisional hernias & 2 scars "one above the umbilicus & the other at inguinal region".

State True or False:

1. 2. 3. 4. 5.

There is Para umbilical hernia. There is incisional hernia. More than one scar. Both hernias are reducible. Malgaigne bulge is seen. IX.
Umbilical hernia.

"Examine the Abdomen".

State True or False:

1. 2. 3. 4. 5.

It is a paraumblical hernia. There are signs of inflammation. There is an ulcer. The swelling shows impulse on cough. There is a scar of previous operation. X. "Examine the Abdomen".
Umbilical hernia.

State True or False:

1. 2. 3. 4. 5.

The mass has an expansile impulse in cough. Occupation is important to be asked in this case. It is not complicated. Abdominal & pelvic sonar is important. Strangulation could occur due to twisting of 2 loops of intestine.

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3.
Neck

Thyroid
Neck lumps

Enlarged lymph node, thyroid enlargement, thyroglossal cyst, and


tumour. Thyroid Simple goitre, solitary nodule, 1ry thyrotoxicosis or 2ry thyrotoxicosis autonomous toxic nodule. What are the suggestive of malignant goitre?? 1. 2. 3. 4. 5. 6. Recent rapid increase in size. Hard consistency. Fixation to the surroundings. Local pain referred to the ear. Fixed hard cervical lymph nodes. Signs of distant metastasis.

 Examples
I.
State True or False:

"Examine the Neck".

1. The Pulse is less than 80/min. 2. The patient has +ve stellwag sign. 3. The patient has no fine tremors on extremities.
What is your diagnosis? Primary toxic goiter.

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II.
State True or False:

"Examine the Neck".

1. The patient pulse is more than 100/min. 2. The swelling moves up and down with deglutition and with protrusion of the tongue. 3. The swelling has nodular surface.
What is your diagnosis? Simple nodular goiter.

III.
1ry toxic goiter. State True or False:

"Examine the Neck".

1. There is pretibial myxedema. 2. +ve Vongrafe sign. 3. Moves up & down with deglutition and with protrusion of tongue. IV.
Simple nodular goiter. State True or False:

"Examine the Neck".

1. It is in posterior triangle. 2. Superficial to sternomastoid. 3. There is a retrosternal extension. V.

"Examine the thyroid".

There may be a Stethoscope near the patient, so take care.


State True or False:

1. 2. 3. 4. 5.

There is thrill over upper pole. The swelling is pulsating. The skin shows a scar. The right lobe is enlarged. There is a retrosternal extension.

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VI.
2ry toxic goiter. State True or False:

"Examine the Neck".

1. 2. 3. 4.

The trachea is central. There are nodules in both lobes. There are visible pulsations over the superior pole of thyroid. There is audible bruit over the thyroid. VII.

"Examine the Neck".

1ry toxic goiter. State True or False:

1. 2. 3. 4. 5.

There is thrill on upper pole. The Berry's sign is +ve. The pemperton sign is -ve. There is a dull sternum. The swelling moves up & down with deglutition. VIII.

"Examine the Thyroid".

State True or False:

1. 2. 3. 4. 5.

This is a case of secondary toxic goiter. The gland is nodular asymmetrical. There is retrosternal dullness. The best line for treatment of this case is surgery. The gland moves upwards with deglutition and protrusion of the tongue. IX.

"Examine the Thyroid".

State True or False:

1. 2. 3. 4. 5.

There is thyroid enlargement. There is scar of previous operation. The swelling is completely covered with sternomastoid. RT supraclavicular LN is enlarged. The swelling moves with protrusion of tongue.
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X.

"Examine the Thyroid".

Simple nodular goiter. State True or False:

1. 2. 3. 4. 5.

The swelling moves with deglutition. The swelling is hard. The swelling moves with protrusion of tongue. The swelling is bilateral. The swelling is attached to skin. XI.

"Examine the Neck".

2ry thyrotoxicosis. State True or False:

1. 2. 3. 4.

It is a case of 1rythyrotoxicosis. The patient has a fine tremor. The pulse > 100. The only line of ttt is surgical.

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4.
a. b. c. d.

Ulcers

Vascular venous ulcer, ischemic ulcer, lymphoma ulcer. Traumatic direct trauma or bed sore. Infection chronic osteomylitis, T.B & syphilis. Neoplastic:
Primary skin ulcer "epithelioma, melanoma, basal cell carcinoma". Marjolin's ulcer "epithelioma on top of ulcer, burn". Ulcerative deep malignancy "bone tumours".

e.

Others: neuropathy & rheumatoid ulcer.

y Venous Ask about history of DVT. y Ischemia Ask about history of Claudication pain, Color change & Atrophic tissue. y Neuropathy y

y Malignant . y Others From the shape of the edge. The most common is venous ulcer. course

Complication of thrombophlebitic limb or


complication of 2ry varicose veins.

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 Examples
I.
State True or False:

"Examine the Face".

1. The condition is related to sun exposure. 2. The safety margin of excision is more than 5 mm. 3. Distant metastasis is the most common complication.
What is your diagnosis?
Basal cell carcinoma of the nose "Rodent Ulcer".

II.
State True or False:

"Examine the Face".

Squamous cell carcinoma at angle of mouth.

1. Safety margin is less than 5mm. 2. It is related to nicotine.

SOME OTHER CASES


I.
State True or False:

"Examine Both Lower Limbs".

1. The patient has +ve Fagan test. 2. The condition is unilateral. 3. There is Saphenofemoral incompetence.
What is your diagnosis? Bilateral 1ry varicose veins non complicated.

II.
State True or False:

"Examine Both Lower Limbs".

1. There is competent Saphenofemoral junction. 2. There is no thrill on Saphenous opening. 3. The condition is bilateral.
What is your diagnosis? 2ry varicose veins in left limb & complicated. WWW.MEDICAWY.COM

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III.
State True or False:

"Examine

Left Leg".

1ry unilateral varicose veins.

1. 2. 3. 4.

There is Saphenofemoral incompetence. There is affection of the short Saphenous vein. There is venous ulcer. There is no pigmentation. IV.

"Examine Both Lower Limbs".

State True or False:

1. 2. 3. 4.

Dorsalis pedis pulse is present. 2ry to incompetent right Saphenofemoral junction. Right leg is longer than left. There is atrophy blanche. V. "Examine Both Lower Limbs". Short saphenous vein is palpable. Venous refill takes longer than 10 min. There is evidence of lipodermatosclerosis. There is evidence of haemosiderosis. VI. "Examine Both Lower Limbs".
Old obese female.

State True or False:

1. 2. 3. 4.

State True or False:

1. 2. 3. 4.
5.

This is a case of secondary varicose. Varicosities appear along the course of short saphenous. Veins are pulsating. There is incompetent Saphenofemoral junction. Modified Perth's test is positive for this case.

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VII.
State True or False:

"Examine Both Lower Limbs".

Unilateral 2ry varicose veins.

1. 2. 3. 4. 5.

The prominent system affected is short saphenous. The long saphenous is pulsating. There is apparent sahena varix. There is pigmentation. This is a case of 2ry varicose veins.

VIII.
State True or False:

"Examine Both Lower Limbs".

2ry varicose veins.

1. 2. 3. 4. 5. 6.

A case of 1ry varicose veins. There is an incompetent perforator. The ulcer is healed. It is not complicated. The treatment is surgical. Venograhy is the best investigation to be done.

IX.
State True or False:

"Examine Both Lower Limbs".

1ry varicose veins in right side.

1. 2. 3. 4. 5.

The dilated veins are bilateral. There is an ulcer in the right side. There is a scar in the right side. The shape of dilatations is saccular. There are dilatations in sapheno femoral junction.

X.
State True or False:

"Examine the Neck".

Lymphadenopathy following sore throat.

1. 2. 3. 4. 5.

This is anatomical site for lymph node. It is related to throat condition. Submental LN is palpable. It is soft in consistency. Pagets test is +ve.

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OSCE Exam Questions


These are a group of questions from the previous end round exams. In the OSCE exam you are asked to examine a Case, and then you answer on those questions & just to state if these sentences are true or false.

End Round
" o Case 1 "

"Examine the Right Elbow".

Cystic Swelling in the elbow.


State True or False:

1. 2. 3. 4. 5.

The skin is abnormal. The swelling is deep to the muscle. The swelling is solid. The skin over the swelling showed dimpling on movement. Paget test is a fluctuation test for large swelling.

o Case 2
Hernia (indirect)

"Examine Both Groins".

"patient above 40 years".

State True or False:

1. This is oblique uncomplicated hernia. 2. It is partially irreducible. 3. It shows transmitted impulse. 4. The patient is kept in the hospital for herniotomy. 5. Internal ring test is positive.
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o Case 3 "Examine the Neck". 2ry toxic goiter "Female 33 years".


State True or False:

1. 2. 3. 4. 5.

This is a case of secondary toxic goiter. The gland is nodular asymmetrical. There is retrosternal dullness. The best line for treatment of this case is surgery. The gland moves upwards with deglutition and protrusion of the tongue. o Case 4 "Examine Left Leg". 1ry varicose veins "Old obese female".

State True or False:

1. 2. 3. 4. 5.

This is a case of secondary varicose. Varicosities appear along the course of short saphenous. Veins are pulsating. There is incompetent Saphenofemoral junction. Modified Perth's test is positive for this case. o Case 5

"Examine the Abdomen".


one above the umbilicus &

Para umbilical, Incisional hernias & 2 scars "

the other at inguinal region".


State True or False:

1. 2. 3. 4. 5.

There is paraumbilical hernia. There is incisional hernia. More than one scar. Both hernias are reducible. Malgaigne bulge is seen.

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o Case 6
Simple nodular goiter.

"Examine the Neck".

State True or False:

1. 2. 3. 4. 5.

There is thyroid enlargement. There is scar of previous operation. The swelling is completely covered with sternomastoid. Rt. supraclavicular LN is enlarged. The swelling moves with protrusion of tongue. o Case 7

"Examine Both Legs".

Unilateral 2ry Varicose Veins.

State True or False:

1. 2. 3. 4. 5.

The prominent system affected is short saphenous. The long saphenous is pulsating. There is apparent sahena varix. There is pigmentation. This is a case of 2ry varicose veins. o Case 8
Sebaceous cyst.

"Examine the Scapula".

State True or False:

1. 2. 3. 4. 5.

The swelling is tender. The swelling is pulsating. The swelling is attached to skin. It has a well defined edge. The draining LN is enlarged.

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" o
Dermoid cyst.

" "Examine the Neck & Face".

Case 1

State True or False:

1. 2. 3. 4. 5.

The swelling is cystic. The swelling has slippery edges. The swelling is attached to skin. There is a scar. It is a sebaceous cyst.

o
State True or False:

Case 2

"Examine Both Legs".

Primary varicose vein in right side.

1. 2. 3. 4. 5.

The dilated veins are bilateral. There is an ulcer in the right side. There is a scar in the right side. The shape of dilatations is saccular. There are dilatations in Saphenofemoral junction.

o
State True or False:

Case 3

"Examine the Abdomen".

Umbilical hernia.

1. 2. 3. 4. 5.

It is a paraumbilical hernia. There are signs of inflammation. There is an ulcer. The swelling shows impulse on cough. There is a scar of previous operation. o Case 4 "Examine
Simple nodular goiter.

the Neck".

State True or False:

1. 2. 3. 4. 5.

The swelling moves with deglutition. The swelling is hard. The swelling moves with protrusion of tongue. The swelling is bilateral. The swelling is attached to skin. WWW.MEDICAWY.COM

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" o Case 1
2ry thyrotoxicosis.

"

"Examine the Neck".

State Yes or No:

1. 2. 3. 4. 5. 6. 7. 8. 9.

Is the swelling hard? Is the swelling attached to the skin? Is the ttt conservative? FNAC is an essential of diagnosis? Is the swelling present in the digastric triangle? Is the swelling nodular? Cancer in this case is more common in males than females? Does the swelling move up &down with protrusion of the tongue? Does the swelling arise embriologically from the tongue? o Case 2

"Examine the Back".

Lipoma at the left side of the back.

State Yes or No:

1. 2. 3. 4. 5.

Is the swelling compressible? Are the edges well defined? The main line of ttt is excision? This swelling usually turns malignant? Does this swelling have impulse on cough o Case 3

"Examine Both Groins".

Right inguino-scrotal hernia.

State True or False:

1. 2. 3. 4.

This hernia may contain urinary bladder? This hernia may contain intestine? This hernia may be obstructed? The main line of ttt is essentially surgical?
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5. 6. 7. 8.

The hernia is more common in elderly? The hernia is bilateral in 60% of cases? Does the hernia have impulse on cough? Is this hernia reducible? o Case 4

"Examine Both Groins".

Left inguinal hernia "indirect".

State True or False:

1. 2. 3. 4. 5. 6. 7. 8.

This hernia has +ve cross fluctuation? This hernia may contain sigmoid colon? This hernia protruded through the superficial inguinal ring? This hernia is common in elderly? This hernia is bilateral in 60% of cases? This hernia has expansile pulsations? This hernia occurred due to direct trauma? The direction of this hernia is forwards? " o Case 1
Incisional hernia.

"

"Examine the Abdomen".

State True or False:

1. 2. 3. 4.

The mass is seen on cough and standing and disappear on lying down. Treatment is herniotomy only. It is not complicated now. Complications don't occur in this type of hernia. o Case 2 "Examine the Neck".
2ry thyrotoxicosis.

State True or False:

1. It is a case of 1ry thyrotoxicosis. 2. The patient has a fine tremor. 3. The pulse > 100.
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4. The only line of ttt is surgical. o Case 3


Umbilical hernia.

"Examine the Abdomen".

State True or False:

1. 2. 3. 4. 5.

The mass has an expansile impulse in cough. Occupation is important to be asked in this case. It is not complicated. Abdominal & pelvic sonar is important. Strangulation could occur due to twisting of 2 loops of intestine o Case 4
2ry Varicose veins.

"Examine Both Legs".

State True or False:

1. 2. 3. 4. 5. 6.

A case of 1ry varicose veins. There is an incompetent perforator. The ulcer is healed. It is not complicated. ttt is surgical. Venograhy is the best investigation to be done. o Case 5
Inguinal hernia.

"Examine Both Groins".

State True or False:

1. This case may be complicated. 2. There is a scar for an operation. 3. Hernia is partially reducible. o Case 6
Thyroid Case.

"Examine the Neck".

State True or False:

1. There is a thrill. 2. The gland superficial to sternomastoid muscle.


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3. Carotid pulse can be felt. 4. Surface is " o Case 1


Lipoma.

irregular. "

"Examine the Swelling".

State True or False:

1. 2. 3. 4. 5.

The swelling has slippery edges. It is pseudo fluctuant. It is translucent. It is partially attached to the skin. Its consistency is soft. o Case 2 "Examine the Neck".
A thyroid case.

State True or False:

1. 2. 3. 4.

Enlargement in the Rt. lobe only. There is retrosternal extension. Trachea is central. Pretracheal lymph node palpable. o Case 3 "Examine the Neck".
A thyroid case.

State True or False:

1. 5. 2. 3.

Carotid pulse on both sides can be felt. Left deep cervical LN can be palpable. Swelling in the submandibular region. There is sinus in the skin. o Case 4 "Examine the Back".
Sebaceous cyst.

State True or False:

1. The swelling has slippery edges. 2. It is soft in consistency. 3. It is Pseudo fluctuant.


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4. It is translucent. 5. It is partially attached to the skin. o Case 5 "Examine Both Groins".


Hernia Case.

State True or False:

1. It is idiopathic hydrocele. 2. Inguinal LN are impalpable. 3. There is left oblique inguinal hernia. o Case 6 "Examine Both Legs".
An ulcer in the leg.

State True or False:

1. 2. 3. 4.

The base is indurated. Unhealthy granulation tissue present. There is everted edge at one side. There are varicose veins. o Case 7 "Examine Both Groins".
Hernia case.

State True or False:

1. 2. 3. 4. 5.

There is Rt. direct inguinal hernia. There is infantile hydrocele. There is enlarged epididymis. There is enlarged spermatic cord. There is loss of Rt. testicular sensation. o Case 8 "Examine the Neck".
A case of lymphadenopathy.

State True or False:

1. 2. 3. 4.

Swelling seen in the left side of neck. The swelling is in the carotid triangle. There is intra oral ulcer. Supraclavicular LN is palpable.

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" o Case 1
State True or False:

"

"Examine the Abdomen".

Incisional & paraumbilical hernias.

1. 2. 3. 4. 5.

Patient has 2 scars. Incisional hernia over Cesarean section produced. Both hernias are reducible. Patient has paraumbilical hernia. It shows malgaigne sign.

o Case 2
Thyroid case "No

"Examine the Neck".

thyrotoxicosis or malignant symptoms".

State True or False:

1. 2. 3. 4. 5.

The thyroid gland is enlarged. Rt. supraclavicular LN is enlarged. There is previous scar in the neck. The swelling is covered by sternomastoid muscle. It moves up & down with protrusion of tongue.

o Case 3
Varicose veins case.

"Examine Left Leg".

State True or False:

1. 2. 3. 4. 5.

The prominent system affected is short saphenous. Saphena varix is present. The varicosity is secondary. There is pigmentation around medial malleoulus. The affected veins pulsate.

o Case 4
A swelling in the Rt. Lid.

"Examine the Swelling".

State True or False:

1. The swelling is attaching to the skin.


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2. There is enlarged LN. 3. It has a well defined edge.

2009/2010
" o Case 1
State True or False:

"

"Examine Both Groins".

oblique inguinal scrotal hernia

1. 2. 3. 4. 5.

There is an expansible impulse on cough 4 cm below and lateral to the pubic tubercle. The swelling reaches the bottom of the scrotum. The swelling lies below the groin crease lateral to the inferior epigastric vessels. After reduction pressure on the internal ring doesn't prevent the appearance of the swelling. There are local signs of strangulation

o Case 2
ulcer in the left leg

"Examine Both Legs".

State True or False:

1. 2. 3. 4. 5.

There are 2ulcer Margin show pigmentation Edge is raised and everted Floor show dried out tissue There is ascar of previos operation

o Case 3
epigastric hernia

"Examine the Abdomen".

State True or False:

1. 2. 3. 4. 5.

There is expansible impulse on cough Defect is in the semi lunar line There is erythema in the overlying skin Scar healing by primary intention is present There are local signs of strangulation WWW.MEDICAWY.COM

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o Case 4
thyroid on the left side

"Examine the Neck".

State True or False:

1. 2. 3. 4.

Enlargement in the left lobe Berry sign is positive Attached to sternomastoid muscle There is retrosternal extension

"

"

o Case1 "Examine the neck "


Simple nodular goiter

State True or False:

1. 2. 3. 4. 5.

Patient present with hard swelling in thyroid gland No retrosternal extension of neck swelling Palpable pretracheal lymph nodes No palpable right cervical lymph node Carotid pulses are palpable on both sides

o Case 2
Paraumbilical hernia

"Examine the Swelling".

State True or False:

1. 2. 3. 4. 5.

Swelling is tender It is reducible It has well defined edge One of its complication is obstruction Mesh hernioplasty is the main surgical ttt

o Case 3
venouse ulcer

"Examine Both Legs".

State True or False:

1. Visible varicose veins are noted


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2. 3. 4. 5.

It is ischemic ulcer It has sloping edge No palpable inguinal lymph node Healthy granulation is covering floor

o Case 4
sebaceous cyst

"Examine the Swelling".

State True or False: 1. It is benign lesion 2. It is cystic 3. It has well defined edge 4. Treatment is essential medical 5. It has a frequent malignant potentially

" o Case 1

"

" Inspect the abdomin & the scrotum".

Left inguino-scrotal hernia

1. 2. 3. 4. 5.

State True or False: There is right scrotal swelling The swelling is tender There is a scar below the umbilicus There is small paraumbilical hernia There are dilated veins around the umbilicus

o Case 2
State True or False: 1. 2. 3. 4. 5. The swelling is hard The swelling is severly painful It is attached to the muscle It has well defined edges It is attached to the muscle

"Palpate the Left axilla ".

Lipoma in the left axilla

o Case 3
Incisional hernia

" Inspect the Abdomen".

State True or False: 1. The swelling extends below the umbilicus WWW.MEDICAWY.COM

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Presented by Medicawy . 2. 3. 4. 5. The swelling shows expansile impulses on cough The skin is red denoting inflammation There is a scar overlying the swelling There is healing with 2ry intention

" ONE VISION ONE MISSION "

o Case 3

" Inspect the front of the neck ".

Simple nodular goiter right lobe

1. 2. 3. 4. 5.

State True or False: The swelling is more prominent on the left side There are large dilated veins The swelling moves up & down with deglutition The skin is red & hot denoting inflamation The swelling is deep to sternomastoid muscle

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Full detailed lectures of Prof.Dr. Hussein Khairy. Hints from notes of Dr. Wael Metwaly. Hints from notes of Dr.Amr El Shayeb. Our curriculum from Oral book.

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