Note: the answers in this file are based on the PYQ, so there is a

possibility of inaccurate answers

 Contents
Topic Slide
Thoracic Surgery 3
Vascular Surgery 15
Genitourinary Tract 47
GI Tract (Esophagus, Stomach, Intestines) 52
Liver, Spleen, Pancreas, Gallbladder & The Adrenals 106
Anorectal Region 149
Bariatric Surgery 163
Salivary Glands 173
Neck & Thyroid 180
Breast 217
Pediatric Surgery 258
Skin 318
Burns 375
General Surgery & Others 391
Tools & Instruments 433
Q: This is a chest X-Ray for a
35-years old female with a
history of breast cancer 3
years ago, who presented to
the clinic with progressive
shortness of breath and
cough.
Q1: What is the Dx?
- Malignant Pleural Effusion

Q2: What is the next step in Mx?

- Tube thoracostomy (Chest tube)
 Q1: What is the Dx?
- Right sided hemothorax

Q2: Name 2 other findings?

1) Absence of diaphragmatic angle
2) Right side multiple rib fractures
3) Right side clavicle fractures

Q3: What are the indication of

needle thoracotomy after chest
tube insertion?
- initial loss >1.5 L of blood
- Continuous blood loss of 200 ml
per hour over 2-4 hour
Q: Hx of motor vehicle
accident (MVA):

Q1: What is the Dx?

- Left sided hemothorax

Q2: What is the Mx?

- Chest tube insertion
 Q: A patient after a motor
vehicle accident?

Q1: What is the Dx?

- left sided hemothorax
(obliterated costophrenic angle)

Q2: What is the rapid initial Mx?

- Needle decompression

Q3: What is the definitive Mx?

- Chest tube
Q: A scuba diver came to ER, his
CXR shows the following:

Q1: What is the immediate MX?

- Needle thoracostomy

Q2: Where to insert the needle?

- 2nd intercostal space

Q3: What is the procedure you

want to do next?
- Pleurodesis
 Q1: What is the Dx?
- Right sided tension pneumothorax
Q2: Mention 2 signs on CXR?
1) Tracheal deviation
2) Left lung compressed or collapsed
Q3: Mention 2 signs on PE?
1) Absent breath sounds in affected side
2) Jugular venous distention
Q4: What is the Mx?
- Needle decompression
- Chest tube
Q: 18 year old male presented
with sudden progressive
shortness of breath and
underwent this investigation:

Q1: What is the Dx?

- Spontaneous Pneumothorax

Q2: What is the Mx?

- Chest tube/needle

Q3: Give 2 indications to do

surgery?
- Failure of decompression
- Hemo-pneumothorax
Tension Pneumothorax : Pneumothorax in the Supine
The most reliable sign of Patient . The ""deep sulcus
tension pneumothorax is sign"" is seen here (arrow) in
depression of a hemidiaphragm. the left lung base.
 right-sided pneumothorax
with a chest tube inserted.

• pneumothorax localizes
more towards the apex of
the lung.
• Notice that the markings are
absent from the apex down
to some degree.
• Notice the white visceral
line.

Chest tube
 Surgical emphysema

• Radiolucent striations
outlining pectoralis major
• It is usually benign, and
treatment is directed at
reversing the underlying
cause.
It is unilateral
diaphragmatic
paralysis.(right)

we can still see the

costodiaphragmatic
angle so it is not
effusion or
hemothorax.
What's A: inferior epigastric artery
What's B: direct inguinal hernia
What's C: indirect inguinal hernia
What's D: femoral hernia
Q: A Question was asking about the following arteries?
1- Left gastroepiploic artery
2- Gastrodudenal artery
3- Short gastric arteries
Q: Patient had hip replacement 5 days ago:
Q1: What is the Dx?
- DVT

Q2: What is the Mx?

- LMWH & Warfarin on discharge

Q3: Mention 4 DDx?

1) DVT
2) Cellulitis
3) Lymphadenopathy, lymphatic obstruction
4) Chronic Deep Vein Insufficiency
5) Rupture of baker’s cyst

Q4: What are the complications:

1) Pulmonary embolism
2) Ulcers
3) Ischemia
 Q1: What is the Dx?
- Varicose veins

Q2: What is the system involved in this

part (name the vessel)?
- Great (long) Saphenous vein
(Superficial Venous System)

Q3: Name 2 modalities of Mx?

1) High ligation and vein stripping
2) Sclerotherapy

Q4: Mention 2 complications?

1) Ulcers
2) Bleeding
3) Thrombophlebitis
4) Discomfort, pain
 Q5: Mention 2 minimally
invasive procedures to do for
this condition?
1) Sclerotherapy
2) Radiofrequency Ablation
3) Endovenous Laser Ablation

Q6: Best imaging test?

- Doppler US or Venogram

Q7: How to determine the level

of defect in the varicose veins?
- Turncate test
 Q1: What is this?
- AV shunt
Q2: Done in patients that undergoes what?
- Hemodialysis
Q3: What is the complication seen in the picture?
- Aneurysm
Q: A 60 year old female with CKD on hemodialysis:
Q1: What is the following complication?
- Pseudoaneurysm
Q2: Mention other complications that may occur?
- Thrombosis, Steal syndrome, CHF, infection
Q: Patient complained of abdominal
pain and a pulsatile mass:

Q1: Name of this study?

- Angiogram

Q2: What is this pathology and

where is its location?
- AAA (Abdominal aortic aneurysm)
near the bifurcation

Q3: Mention 2 lines of Mx?

1) Open surgical repair
2) Endovascular surgery
Q1: Name of this study?
- 3D angiography

Q2: What is your Dx?

- AAA
Q: A patient with a hx of atrial fibrillation, presented with a sudden
severe abdominal pain:

Q1: Name of this study?

- CT Angiogram

Q2: Dx?
- AAA (Abdominal aortic aneurysm)
based on the Hx: Rupture AAA is more accurate
 Q1: What is the structure?
- Abdominal Aorta
Q2: What’s the best repair method for this?
- Stent
 Q3: What is the Mx (2 Mx modalities)?
- Medical or Surgical according to the size
1) Endovascular repair
2) Open repair
Abdominal x-ray with evidence of the calcified
edge of the abdominal aortic aneurysm.
Q: This is a CT Angio for the renal arteries:

Q1: What is the Dx?

- Bilateral Renal Artery Stenosis

Q2: What is your Mx?

- Renal Angioplasty & Stenting
 Q: After RTA, the patient
present with dilated veins?

Q1: Mention 2 causes?

1) Pericardial Effusion
2) Cardiac Tamponade

Q2: What is your Mx?

- Pericardiocentesis
 Q1: What is the Dx?
Cardiac Tamponade

Q2: What is the C/P that the

patient come with?
1) Beck’s triad :
hypotension
increased JVP
muffled heart sounds.
2) Pericardial effusion
3) Kussmaul’s sign.

Q3: What is the Mx?

immediate decompression via
needle pericardiocentesis.
Q: Post-RTA patient came to ER, he
was hypotensive with SOB:

Q1: What is the pathology?

- Cardiac tamponade

Q2: What is the next step in Mx?

- Pericardiocentesis

Q3: What is the consequence for

this pathology?
- Obstructive shock
- Pulmonary Edema
- Beck’s Triad
 Q: a Pt experienced sudden
severe pain radiating to the
back:

Q1: What is the X-Ray finding?

Widened Mediastinum

Q2: What is the Dx?

Aortic dissection

Q3: What is the gold standard

for Dx? And what is the
disadvantage for it?
Aortography, time consuming

Q4: What is the Mx:

1) Standford A: Surgical
2) Standford B: Medical (control BP)
Westermarck's sign: Decreased pulmonary vascular markings
on CXR in a patient with pulmonary embolus
 Mitral stenosis
X-ray findings :
• Enlarged left atrium.
• Straight line sign.

Diagnostic tests :
• Echocardiogram.
•Catheterization.

Mx:
• Open heart surgery.
• Balloon valvoplasty.
• Valve replacement.
 Q1: What does the arrow indicate?
Cervical rib

Q2: What is your concern?

It can cause a form of thoracic outlet
syndrome due to compression of the
lower trunk of the brachial plexus or
subclavian artery.

Q3: What might the pt complain of?

1) parasthesias & numbness in the
upper part mainly usually in 90% of
cases are in the ulnar distribution.
2) Weakness manifested by difficulty
grasping or holding a pen , this is a result
of arterial and or neural compression.
3) The hand is usually cold.
 Q1: What is this sign?
Raynaud’s phenomenon.

Q2: What is the most likely Dx?

Buerger Disease
 Q1: What is the Dx? Venous Ulcer

Q2: What is the pathophysiology?

- Blood stasis and increased Pressure
inside the veins due to venous
valves insufficiency

Q3: if this happened after 5 days of

surgery what is the main cause?
DVT

Q4: Risk of transformation to? SCC

Q5: Name 2 causes?

- venous insufficiency and stasis
(as DVT, varicose veins)

Q6: What is the sign?

- Lipodermatseclarosis
 Q7: What is the most
common site?
Most Common site is lower
1/3 of the leg just above the
medial malleolus.

Q8: Name 2 points that

goes with your Dx?
1) Location: lower medial
aspect of the leg
2) Hyperpigmentation
around the ulcer
 Venous Ulcer Characteristics :
where ?
*Lower 1/3 of leg *gaiter area *anterior to medial
malleolus.

cause?
Commonly a history of:
* (DVT) *Obesity *Calf muscle pump function deficits
*Valve incompetence in superficial perforating veins.

description?
*Ulcer has uneven edges *Ruddy granulation tissue *No
dead tissue.
*Reddish brown pigmentation (Hemosiderin) *Evidence of
healed ulcers *Edema that may leak and cause maceration,
varicose eczema, itchy skin and scale
*Dilated and tortuous superficial veins *Leg may be
warm *Hair on leg
*Normal leg and foot pulses.

pain?
*Moderate to no pain at all *Pain if present is eased by
raising the leg
Q: A 75 year old male, heavy
smoker, presented with this
lesion.

Q1: Identify the lesion:

ischemic arterial ulcer

Q2: Give two symptoms which

might be associated with the
condition:
1) claudication
2) rest pain
 Arterial Leg Ulcer Characteristics
where?
*At tips of toes or between toes *Over phalangeal heads
*Above lateral malleolus, over the metatarsal heads,
on the side or sole of feet.
* MC distal end of the limbs

cause?
Commonly a history of:
*Aging *Diabetes *Arteriosclerosis * Smoking *Hypertension.

description?
*Deep pale base *Well defined edges *Black or necrotic tissue
*Minimal / no hair *Thin, dry and shiny skin *Thickened toe nails *Leg
may be cool *Leg becomes pale when elevated *May have neuropathy
*Nil or diminished leg and foot pulses. * Punched out-apperance

Pain?
*Very Painful *Pain is reduced by lowering the leg to a dependent position.
* Not palpable pulses
 Q1: What is the most
probable cause for this
patient’s condition?
Lower Limb Ischemia

Q2: What is the best

imaging test to put a
treatment plan?
CT Angio, Angiogram,
Doppler US
 Q1: What is the pathology?
- Gangrenous necrosis of the big toe

Q2: Mention 4 signs of peripheral ischemic disease?

1) Pale
2) Hair loss
3) Cold
4) Pulselessness
Remember the 6 P’s of
peripheral vascular disease:
Pallor
Pain
Paresthesia
Paralysis
Pulselessness
Poikilothermia
Q: A patient walks 400 meters before feeling
pain and having to rest, his job requires him
to walk for 1 kilometer everyday, what do
you do for this patient?
a) Lifestyle modification
b) Medical therapy
c) Bypass
d) Angiogram (correct answer)
Q1: What is the imaging?
- MCUG

Q2: Mx?
- Antibiotic for UTI
- Endoscopic injection
- Surgery
Q1: What is the name of this study?
- MCUG

Q2: What is the name of this

pathology (without abbreviation)?
- Vesicouretral reflux (VUR)
 Q1: What is the pathology?
- Left dilated tortuous ureter and
hydronephrosis (right pic)
Q2: What is the cause behind this?
- Posterior urethral valve
- Congenital
Q3: What are the 2 complications
that might occur?
1) Recurrent UTIs
2) Kidney scarring
 Q1: Name the finding?
- Staghorn stone or
Struvite stone

Q2: What is the Etiology?

- Urease producing
bacteria (proteus,
klebsiella, pseudomonas)
Q: A 60 yo male patient
came complaining of
Dysphagia, halitosis,
swelling in the neck:

Q1: What is the Dx?

Pharyngeal pouch

Q2: How to Dx the pt?

Barium Swallow
Q: Patient came complaining of May lead to esophageal
carcinoma 2ry to Barrett’s
dysphagia for both liquids & esophagus from food stasis.

solids:

Q1: What is the sign?

- Bird peak sign
Q2: Name the study?
- Barium swallow
Q3: What is the definitive Dx?
- Achalasia
Q4: What is the definitive
diagnostic test?
- Manometry
Q5: Mention 2 modalities
of Mx?
1) Esophageal sphincter
(Hellers) Myotomy
2) Balloon dilation
 Q: a pt came complaining of dysphagia for both
solids and liquids.

Q1: What is the Dx?

Diffuse Esophageal Spasm (DES)

Q2: What is the sign?

corkscrew appearance

Q3: How to Diagnose?

1) Barium
2) Manometry (most accurate)

Q4: What is the Mx?

diltiazem or nifidipine and nitrates

Q5: How to differentiate it from Nut-cracker

esophagus?
By manometry (the nut cracker: peristaltic
contractions with high amplitude, while the DES
is non-peristalic with high contractions)
 Q1: Define Barret’s esophagus?
Change in the normally squamous lining of the lower esophagus to
columnar epithelium (metaplasia)
Q2: What common type of cancer you will see? Adenocarcinoma
Q3: What is the cause? Chronic GERD
Q4: How to Dx? Endoscopy
Q5: Mx? PPI and follow up
 Q1: What is the Dx?
Mallory Weiss Tear Syndrome

Q2: How to Diagnose it?

Hx & Upper Endoscopy

Q3: Mx?
It resolves spontaneously
 Q: Patient with Intermittent dysphagia for
solids only with no pain:

Q1: What is the Dx?

Schatzki ring (lower esophageal ring)

Q2: Name an abnormality associated with it?

Hiatal Hernia

Q3: How to diagnose it?

Barium swallow and endoscopy

Q4: Mx?
Dilation by bougie method or through the scope
hydrostatic balloon, and the patients are placed
on PPI after dilation
Q: Patient with Intermittent dysphagia
for solids only with no pain:

Q1: What is the Finding?

Esophageal Webs
(E.g. Plummer vinson syndrome)

Q2: How to diagnose it?

Barium swallow and endoscopy

Q3: Mx?
Dilation
 Plummer-Vinson
syndrome:
1. Esophageal web
2. IDA
3. Dysphagia.
4. Spoon-shaped nails
5.Atrophic oral & tongue
mucosa.

*especially occurs in elderly

women; 10% develop
squamous cell carcinoma.

*May respond to
treatment of IDA.
 Esophageal stricture

- Dysphagia : constant/ slowly

progressive/ solids then liquids.
- Causes : long history of incomplete
treated reflux/ prolonged NG tube
placement/ lye ingestion.
- Dx : barium swallow.
- Treatment: dilation.
 Zenker’s diverticulum:

- It is a false diverticulum(not involving

all layers of the esophageal wall).

- Outpouching of the upper esophagus.

- Halitosis / food regurgitation/

dysphagia.

- Elderly.

- Dx : barium swallow/ endoscopy and

NG tube are contraindicated (risk of
perforation).

- Treatment : surgical resection.

 Q1: What is the Dx?
Esophageal Varices

Q2: Mx?
1) Therapeutic endoscopy
2) Ligation, banding,
sclerotherapy
3) β-blockers (e.g. propranolol).
 Hiatal hernia
Sliding hernia (type 1) Para esophageal hernia (2) Type 1 (more common)
Mostly asymptomatic but can Dysphagia/ stasis gastriculcer/
cause reflux no reflux
Complications :reflux> Complications:
esophagitis> Barrett's esophagus hemorrhage/obstruction/
> cancer/ aspiration pneumonia strangulation.
Treatment: medical with Treatment : surgical.
antacids, PPI, H2 blockers/ if
failed : surgical (lap. Nissen
fundoplication )

Type 2
Epiphrenic diverticulum

Presentation: Dysphagia to
solid foods with upper
abdominal discomfort.

Often associated with

hiatal hernia.
 esophageal cancer
-is more after 50 years, mostbetween
60-70 years.
-more in males.
-risk factors: smoking, alcohol, and hot
fluid drinkers.
-Relevant Hx: GERD and Barrett’s, stricture,
Plummer Vinson syndrome, Celiac disease,
Esophageal achalasia and diverticulum.
-common symptomsare dysphagia, reflux,
weight loss, and mediastinal invasion
symptoms (chest pain, hoarseness, etc.)
-they might also suffer from anemia due to
nutritional deficiency.
-treatment : surgical resection if small and
localized.
- If large or Metz: combination ofCTX
and RTX prior to surgery.
easy mnemonic to remember esophageal CA riskfactors
ABCDEFGH:

A- Achalasia/Alcohol
B- Barrett’s esophagus
C- Cigarettes
D- Diverticula
E- Esophageal web, stricture
F- Fat/Family hx
G- GERD
H- Hot liquid
 Gastric cancer
Adenocarcinoma: m.c type (95% ).
R.F: diet ( smoked meat , high nitrates ,
low fruits and vegetables) , smoking ,
family history , blood group type A , H.
pylori , prev. partial gastrectomy ,
adenomatous gastric polyps , atrophic
gastritis .

Subtypes: Ulcerating adenocarcinoma

diffuse type: 70% ,from lamina propria,
proximal , worse than intestinal type ,
invasive and Metz , in younger pt.

intestinal type: 30%,from gastric mucosa,

distal , ass with H.pylori , well formed
glandular structures.

Intestinal type
Diagnosis: endoscopic with biopsy
is the method of choice/ double
contrast barium meal .

Treatment: surgical resection

with wide margin >5cm and
lymph nodes dissection .

If tumor is proximal or midbody A. CT image of Linitis plastic (arrows

do total gastrectomy withroux- denotes a thickened gastric wall).
en-y ,if tumor is distal do distal
subtotal gastrectomy . Linitis Plastica (leather bottle):
when the entire stomach is involved and
looks thickened .
 Sx: abdominal pain/ nausea/
abdominal mass/ occult GI bleeding.

Q1: What is the Dx?

Gastrointestinal Stromal Tumor
(GIST)
Q2: What is the MC site?
Greater curvature (Stomach)
Q3: What are the cells of origin?
Cells of Cajal
Q4: Name the Gene Mutation?
C-KIT
Q5: How to Mx?
Resection
Chemo (Imatinib)
Q6: How to Diagnose?
CT / EGD/ colonoscopy
Q: A 50-years old male patient
has recently become cachectic
and developed ascites.

1. Name the findings on

examination (lower picture) and
CT scan (upper picture).
- Sister Mary Joseph Nodule

2. Mention 2 possible sources

for this lesion.
- GI cancers, Gynecological
cancers, Melanoma
Q: You are doing endoscopy
and you found this lesion?

Q1: Describe what you see?

- Comment on the shape, size,
location, color, presence of
necrosis, discharge, etc..

Q2: What is the likely Dx?

- Stomach cancer or ulcer

Q3: Next step in Mx?

- Biopsy
 Q: You are doing endoscopy and
you found this lesion, pain is
relived by eating and exacerbated
in empty stomach?

Q1: What is the likely Dx?

- Peptic (duodenal) ulcer

Q2: name 2 complications?

1) Perforation
2) Bleeding
 Q1: What is A and B?
A > Gastritis “not sure”
B > Duodenal Ulcer

Q2: Name 2 causes?

1) NSAID
2) H. Pylori
Q: The patient presented with sudden
severe pain and abdominal distension:

Q1: What is the sign?

- Coffee bean sign

Q2: Name the signs you?

1) Dilated large bowel
2) Coffee bean sign

Q3: What is your Dx? Sigmoid volvulus

Q4: What is the MC site? in Sigmoid

 Q5: Mx?
- Resuscitation and untwist (detorsion)
the bowel and go for surgery (this is done
by means of sigmoidoscopy or
colonoscopy

Q6: Mention 2 causes for this condition?

- Chronic constipation
- Sigmoid tumor
Q1: What is the study?
- Barium Enema

Q2: What is the Dx?

- Volvulus

Q3: What is the Mx?

- Detorsion
 Q1: What is the study?
- Barium follow through

Q2: What is the pathology?

- Midgut volvulus
 Q1: What is the Dx?
- Volvulus (Midgut)

Q2: If the bowel was viable and not gangrenous, what to do?
- Viable SB > Close and observe
- Other option: Ladd’s Procedure
 Q1: What is the study?
- Barium follow through

Q2: What is the pathology?

- Midgut volvulus due to malrotation

Q3: What is the Clinical ER

Presentation?
- acute abdominal pain , destination ,
constipation , vomiting
 Malrotation
normally the
duodenojejunal junction is
to the left of the spine. In
malrotation it is to the right
of the spine .
 Q1: What is the Dx?
Small intestinal obstruction

Q2: What is the radiological findings?

Dilated bowel loops (Jejunal), and air in the rectum

Q3: This is a picture of obstruction, Is it

partial/complete? Why?
- Partial obstruction
- Because there is air in rectum

Q4: What is the appearance?

Step-ladder appearance
 Q: A 30 year old female presented with
sudden abdominal pain and fever and
diffuse tenderness of the abdomen:

Q1: What is the Dx?

Perforated viscus
Q2: What is the radiological finding?
Air under diagram
Q3: What is the Mx?
Laparotomy and exploration
Q4: What is the mcc?
Post-op

Causes:
1. Perforation of duodenal ulcer.
2.Following Laparoscopic procedure
3.Following Tubal Insufflation Test
4.Infection with gas formingorganisms
5.Most common cause is post operative.
6.Chilaiditi's sign-due tointerposition of colon between the Diaphragm and the Liver
such a gas shadow can be obtained even in a normal individual.
 Q: A 55 years old patient with PUD
came with forceful vomiting:

Q1: What is the pathology?

- Gastric outlet obstruction (pyloric
obstruction) – Pyloric Stenosis
Q2: What is the electrolyte
disturbances the patient has?
- Hypokalemic hypochloremic
metabolic alkalosis
Q3: What is the gold standard for Dx?
- US “not sure”
Q4: Mention 2 causes?
1) Gastric Carcinoma
2) Peptic ulcer disease (PUD)
Q5: Name it’s effect on ventilation?
- Hypoventilation
Q: A 48-years old patient presented with acute
abdomen. PMH shows atrial fibrillation.
Laparotomy was done:
Q1: What is the Dx?
- Acute Mesenteric Ischemia

Q2: What is the most

affected artery in this
condition?
- Superior mesenteric artery

Q3: Appropriate Mx?

- Resection & Anastomosis
 Q1: What is the Dx?
- Diverticulosis

Q2: Mention 2 complications?

1) Infection
2) Perforation
3) Obstruction

Q3: What is the most

common site?
- Sigmoid
 Diverticulosis or
Diverticular disease
of the sigmoid colon

Dx. Colonoscopy
Mx. Mainly
supportive: diet rich of
fiber
 Colovesical fistula

- the most common cause is

diverticulitis and it's the most
common fistula formed in DD.

- other causes : colon CA ,

crohn's , radiotherapy ,trauma.

- This picture is double contrast

diverticula
barium enema.
 Q: Female patient came complaining
from fistulas and other symptoms and a
colonoscopy was done:
Q1: What is the Dx?
- Crohn’s Disease
Q2: What are the usual Sx?
- Abdominal pain
- Fever with weight loss
- Diarrhea
Q3: How do we treat those patients?
- Azathioprine (6 mecaptopurine) +
steroids
 Crohn's disease (IBD):
- Autoimmune disease
- SKIP LESIONS
- the m.csite is the terminal ileum,
- often no involvement of the rectum (in UC the rectum
is always involved )
- Extraintestinal manifestations: arthritis ,
pyoderma gangrenosum ,erythema nodosum
- it involves the full thickness of the bowel wall ,
with the serosa ,mesentery and regional LNs (
while in UC it was only the mucosa that's
involved)
- Macroscopically : the bowel wall in thick and red ( in
UC its very thin ), the mucosa has a cobblestone
appearance
- Microscopically we will find non- caseating
granulomas , with narrow deep fissure ulcers.
- Complications : strictures and fistulae ( in UC :
hemorrhage , perforation , CA , and toxic megacolon)
- Radiology : Barium enema --> STRING SIGN
- Surgery plays a minor role in the treatment
 Q1: What is the Dx?
- Ulcerative colitis

Q2: Mention 2 drugs used in

Mx?
1) Steroid
2) Azathioprine
 Q: Known case of UC, with Hx of
bloody diarrhea and abdominal pain:

Q1: What is the abnormality?

- Transverse Toxic megacolon

Q2: One complication?

- Perforation
- Peritonitis
 Ulcerative colitis ( IBD )
UC is an autoimmune disease
the rectum is always involved
* smoking: protective.
- extracolonic manifestations :
arthritis ( sacroiliitis and ankylosing spondylitis), eyes
( iritis , keratitis) , renal ( calculi & pyelonephritis , Skin
(erythema nodosum & pyoderma gangrenosum),
blood (anemia & higher risk of DVT), hepatic disease
Lead pipe colon
& cholangitis (PSC)
• investigations:
- if perforated --> Air under diaphragm on AXR
- in chronic UC --> LEAD PIPE colon + and TOXIC
MEGACOLON on AXR .
• Treatment :
- medical : mainly steroids ,/
- Surgery (proctocolectomy with Brooke ileostomy
) is indicated when : medical treatment is failed ,
toxic megacolon , perforation and subsequent
peritonitis , too frequent relapses , duration of
more than 10 years ( >15 years --> 5% risk of CA )
 Q1: What is the Dx? -Adenomatous polyps are precancerous.
Colon Cancer

Q2: What is the screening method?

Colonoscopy

Q3: What is the tumor marker?

CEA

Q4: What is the appearance?

Apple-core
 Gardner's Syndrome

( AD)

a familial adenomatous polyposis

syndrome with cutaneous manifestations.

1) Colonic polyps ( hundreds with 100%

risk of malignancy if untreated).

2) Ostromas ( the picture of an osteoma of

the mandible).

3) Lipomas and epidermoid cysts ( on the

forearm )
multiple small ulcers located
in the distal duodenum in a
patient with gastrinoma
(Zollinger- Ellison syndrome)
Q: What is the Dx?
Gross Appendicitis
 Acute appendicitis
• Sx : pain (periumbilical area) >> nausea and
vomiting >> anorexia >> pain migrates to RLQ
(constant and intense, usually < 24hrs.).
• Tenderness maximally at McBurney’s point.
• Obturator sign/ psoas sign/ rovsingsign/
valentino sign.

• Appendectomy is the m.c.c ofemergent

abdominal surgery.
• Dx of ruptured appendix : fever >39 / high
WBC/ rebound tenderness/ periappendiceal
fluid collection on ultrasound.
• If normal appendix is found upon exploration,
take it out ( even in chron’s ).
• Appendiceal abscess : percutaneous
drainage/antibiotics / elective surgery 6 wks
later.
 Q: Appendicitis Scenario:

Q1: What is the pathology?

- Acute Appendicitis

Q2: What is the name of it’s scoring system?

- Alvarado scoring system

Q3: What is the sequence of the pain?

- Visceral somatic sequence of pain

Q4: Write 2 features found on US?

1) Blind-ending tubular dilated structure >6mm
2) Appendiocolith with acoustic shadow
3) Distinct appendiceal wall layers
4) Periappendiceal fluid collection
5) Periappendiceal reactive nodal enlargement
Alvarado scoring system (Appendicitis)
 Q: What is the Dx?
- Peutz-Jeghers syndrome

- autosomal dominant.
- hereditary intestinal polyposis
syndrome.
- hamartomatous polyps in theGI
tract.
- circumoral pigmented nevi.
 Q1: What is you diagnosis ?
FAP (focal adenomatous polyposis – in the colon & rectum)

Q2: What is the cause of death before the age of 50?

Cancer (untreated patients develop cancer by the age of 40-50)

Q3: MOI? Autosomal Dominant

Q4: Associated tumors? Duodenal Tumors

Q5: Mx? Total Proctocolectomy and ileostomy

Q: patient with Hx of lower GI bleeding
& this is the colonoscopy:

Q1: What is the Dx?

- Angiodysplasia

Q2: the Cause?

- Degeneration of submucosal venous
wall and formation of AVM

Q3: the Mx?

1) Laser
2) Electrocoagulation
3) Surgery

Q4: What is the most common site?

- the cecum or ascending colon
 Pseudomembranous colitis

Colonoscopy showing
pseudomembranes • Abdominal CT.
• similarity between the
cause: C. difficle thickened edematous wall of
pseudomembranous colitis to
risk factors: use of Antibiotics. that of an accordion.

diagnosis: toxin assayin stool. • What is the sign?

Accordion sign.
treatment: Metronidazole
 Q1: What is this triangle?
- Calot’s Triangle

Q2: Name 3 borders?

1) Inferior border of the liver
2) Cystic duct
3) Common hepatic duct
 Q: This 60-years old patient developed abdominal pain,
bloody diarrhea and fever. He came back from a tour trip to a
south west Asian country 3 weeks ago. CT was done.
1. What is the most likely diagnosis? Liver Abscess (Ameobic)
2. What is the treatment of choice? Metronidazle
Q: Name the following complications
of liver cirrhosis:

A > Ascites
B > Caput medusa (dilated veins)
C > Hematoma (easily bruised)
Q1: What is the sign? Caput Medusa
Q2: What is the Dx? Liver Cirrhosis
 Liver Abscess
- Pyogenic (bacterial “gram negative’’) /
parasitic (amebic) / fungal.

- Most common site is rightlobe.

- Treatment : pyogenic ( IV antibiotics +

percutaneous drainage) / amebic
(metronidazole+ drainage).

- Indications of surgical drainage in

pyogenic : multiple lobulated abscesses/
multiple percutaneous attempts failed.

- Indications of surgical drainage in amebic:

refractory to metronidazole/ bacterial co-
infection/ peritoneal rupture.
 Q: Patient presented
lethargic and febrile a week
after a surgery for
cholangitis:

Q1: What is your Dx?

- Liver abscess

Q2: Mx?
- Percutaneous drainage, &
- Antibiotic administration
Q: A 45 year old male presented with
RUQ discomfort and pain, this is his
abdominal CT.

Q1: What is the radiological finding?

Peri-cyst and daughter cysts Abdominal CT scan
(hydatid cyst disease).

Q2: Mention 2 complications:

Rupture and anaphylaxis/
obstructive jaundice.

Q3: Give 2 drug that can be used?

Albendazole, Mebendazole

is a parasitic infestation by a tapeworm of

the genus Echinococcus.
ultrasound
Q: Abdominal US image for a woman lives in rural area:

Q1: What is the name of this sign?

- Water lily sign

Q2: Most probable etiology for this sign?

- Caused by tapeworm Echinococcus granulosus
- Another cause is E. multiocularis
 Caroli disease
is a congenital disorder comprising of
multifocal cystic dilatation of
segmental intrahepatic bile ducts.

presentation is in childhood or young

adulthood. The simple type presents
with RUQ pain and recurrent attacks
of cholangitis with fever and jaundice.

Prognosis is generally poor. If disease

is localized, segmentectomy or
lobectomy may be offered. In diffuse
disease management is generally with
conservative measures; liver
transplantation may be an option.
 Hepatic
Hemangioma
Most common benign solid
tumor. - Until recently, no medical therapy capable of
 Variants: reducing the size of hepatic hemangiomas had
- Capillary : m.c / <2cm /no need for beendescribed.
surgery. - Surgical treatment may be appropriate in cases of
rapidly growing tumors. Surgery may also be
- Cavernous : giant. warranted in cases where a hepatic hemangioma
Vague upper abdominal tenderness cannot be differentiated from hepatic malignancy
with no mass. on imaging studies.
 Not premalignant.
Percutaneous biopsy is
contraindicated (risk of hemorrhage).
 U/S is the first test.
MRI is the most sensitive & specific.
Hepatic Adenoma
Risk factors:
Female/ birth control pills/ anabolic
steroids/ glycogen storagedisease.

it is estrogen sensitive
(pregnancy may cause it to
increase in size, OCP).

Complications: rupture with

bleeding/ necrosis/ risk ofcancer.

Treatment: if small, stop pills> itmay

regress> if not, surgical resection.
If large or complicated : surgical
resection
 Focal nodal
hyperplasia
Use of estrogen OCP may have a role.
 Not premalignant.
Most are solitary, 20% multiple.
Most common indication for surgery
is inability to exclude malignancy.
 LFT : normal.
Angiography : hypervascular mass
with enlarged peripheral vessels and a
single central feeding artery.
ttt : nucleation/ diagnostic
uncertainty will require an open
excisional biopsy. Classic CT finding: liver
mass with centralscar.
 Hepatocellular carcinoma
(hepatoma)
- Most common 1ry malignant liver tumor.
- Risk factors: hepatitis B / cirrhosis/ Alfa
toxin/ alpha 1 antitrypsin deficiency.

- Painful hepatomegaly.

- Tumor marker: alpha fetoprotein.

- Dx: needle biopsy with CT or U/S

guidance. CT : black arrows (hepatoma)

- The m.c site of Metz :lungs.

 Q1: What is the finding?
- Fluid in Morrison’s pouch Morison's pouch: The
hepatorenal recess is the
Q2: The Dx? space that separates the liver
from the right kidney.
- Hemoperitoneum (blood)
- Ascitis (fluid)
Q: a patient with RUQ pain:

Q1: What is the Dx?

- Porcelain gallbladder

Q2: What is the major risk?

- Adenocarcinoma of
gallbladder

Q3: What is the Mx?

- Elective Cholecystectomy
 Q: A 40 year old female patient after a
bariatric surgery, presented with this US?

Q1: What is the Dx?

- Gallstone

Q2: What are the indications of

performing a surgery in asymptomatic
patient for this condition?
- Porcelain gallbladder
- Congenital hemolytic anemia
- Gallstone >2.5 cm

Q3: If the organ got inflamed where

would be the pain and where it would
radiate?
- Pain would be in the RUQ, and radiate into
the right subscapular area
Gallbladder stones
(Cholelithiasis)

Acoustic shadow

- 80% of patients are asymptomatic.

- Complications: acute and chronic cholecystitis/ CBD stones/ gallstone
pancreatitis/ cholangitis.
- U/S detects GB stones in more than 98% of cases.
- Abdominal X-ray detects only 15%.
- If symptomatic/ complicated / asymptomatic but (sickle cell diseas, DM,
pediatric, porcelain GB, immunosuppression) : cholecystectomy.
 Acute cholecystitis

- HIDA scan (the mostaccurate test).

- U/S (the diagnostic test of choice).
- Constant pain (not biliary colic).

acoustic shadow
 Gallstone ileus
• occurs when a large
gallbladder stone erodes into 2
the duodenum via a fistula,
eventually obstructing the ileal 3
lumen usually some
centimeters proximal to the 1
ileocaecal junction.

On the X-ray :
1radiopaque gallstone in the
bowel.
2 gas in the gallbladder.
4- small bowel distention.
 emphysematous
cholecystitis

- Gas forming bacteria

(E.coli).
- Often results in perforation.
- Usually in males/ elderly/
DM.
 Q: After RTA, the
patient present with
left shoulder pain:

Q1: What is your Dx?

- Splenic Rupture

Q2: What is your Mx?

- Splenectomy
Splenic laceration
Q: RTA patient, HR = 130, he was hypotensive, a CT was done
and shows the following?

Q1: How much blood did he loss?

- Stage 3 hypovolemic shock – 30-40% - 1500-2000 ml

Q2: What does the CT show?

- Splenic Rupture
 Acute Pancreatitis
-Cut off sign and Ileus.

-White arrow points to Transverse

colon cut off at Splenic flexure.

-No air in descending colon.

-TC: Transverse colon.

- I: Represents small bowel loopswith
air suggestive of Ileus.

Causes : gallstones/ ethanol/ trauma/ steroids/ mumps/autoimmune/

scorpion bite/ hyperlipidemia/ drugs (diuretics, INH)/ ERCP.

Treatment : supportive (90% resolve spontaneously)

Q: A 45-years old male patient,
alcoholic, presented with a 24-
hour history of upper
abdominal pain and repeated
vomiting. On examination of
the abdomen, he was found to
have these signs.
Q1: Name those signs? A
A > Cullen’s
B > Grey Turner’s
Q2: Mention 2 causes?
- Any retroperitoneal
hemorrhage
1) Acute hemorrhagic
pancreatitis
B
2) Abdominal trauma bleeding
from aortic rupture
 Chronic Pancreatitis
most common cause is chronic alcoholism.
Abdomen x-ray showing pancreatic calcifications.
 Pancreatic necrosis
- Dx: abdominal CT with contrast.
- Dead pancreatic tissue doesn’t take up the contrast.
 Pancreatic pseudocyst

• The m.c.c is chronic alcoholic

pancreatitis.

• findings : high amylase/ fluid filled

mass on ultrasound/

• it is a collection of fluid rich in

pancreatic enzymes, blood, and
necrotic tissue.

• to exclude malignancy >>you have

to check the level of CA 19-9 ( tumor • If not resolved
marker). spontaneously within 6
• Complications: bleeding into the weeks : drainage.
cyst/ infection/ pancreatic ascites.
Q1: What is the type of
imaging?
- MRCP

Q2: Mention 2
abnormalities?
1) Stone in the CBD
(arrow – filling defect)
2) Dilated CBD
 Q1: What is the study? MRCP
Q2: The structure pointed? Pancreatic duct (Stricture)
Q3: What is the next step? ERCP
 Q: 60 year old female with RUQ
pain and fever.

Q1: Identify this type of image:

MRCP

Q2: Give two radiological findings:

CBD stone shadow/ CBD dilation.

Q3: What is your diagnosis?

Ascending cholangitis.
 Choledocolithiasis
- Common bile duct stones.
- ERCP (the diagnostic test of choice, also therapeutic).
- If ERCP fails, CBD is opened surgically and stones removed.

The huge tube is the endoscope. It is

going down from the esophagus, through
the stomach, to the duodenum (1st then
2nd parts), and stops near the ampullaof
vater.
A tube in the endoscope is pushed into
the ampulla and fills the CBD with a dye.
X-ray is taken.
As you can see, there is a black shadow
stone in the CBD.
 Q1: What is the name of this investigation? ERCP
Q2: Mention two abnormalities seen in this picture:
Filling defect & distended common bile duct
Q1: What is the type of imaging?
- ERCP

Q2: Indications?
- Obstructive jaundice

Q3: Complications of ERCP?

- Pancreatitis

Q4: Mention 2 findings?

1) Dilated CBD
2) Multiple stones
 Q1: What is the Dx?
- Primary sclerosis cholangitis
(Beading)

Q2: Which disease is associated

with it?
- Ulcerative colitis

Q3: Which type of malignancy

the patient may develop?
- Cholangiocarcinoma

Q4: Diagnostic test?

- ERCP
 Q: a patient with thyroid Q2: If the patient has no genetic
medullary cancer, & a CT was abnormality and the lesion is not
done: functioning what will you do next?
- Because it is very large > surgery
Q1: What is your next step? (not adrenalectomy, the dr said : If it
sure what the dr. meant so here is was more than 4 cm then you have
the possibilities): to remove it immediately
- Assess the functionality of the
adrenal tumor by hx, physical ex
and ordering lab tests: KFT (Na, K,
Creatinine, Urea) / Aldosterone
levels/ cortisol/ metanephrine /
noremetanephrine / vanillyl
mandelic acid (VMA)
- pheochromocytoma
- 24h urine analysis for
catecholamine metabolites
(VMA/Meta)
 Q: a patient presented with episodic
sweating and hypertension:

Q1: What is the Dx?

- Pheochromocytoma

Q2: What is the 1st thing to do?

- Check if functional or not by checking
cortisol, renin, angiotensin and VMA,… etc

Q3: What raise the possibility of

malignancy?
- >4 cm
- necrosis
- hemorrhage

Q2: What is the size that would be

considered an indication for surgery?
- >4 cm
 Q: Lab investigations
show high aldosterone
level and high ratio of
PAC to PRA:

Q1: What is your Dx?

- Conn’s tumor

Q2: Mention a common

presentation for this
patient?
- Hypertension
 Functional adrenal tumors can cause several problems
depending on the hormone released. These problems include:
1. Cushing’s Syndrome:
This condition occurs when the tumor leads to excessive secretion of
cortisol. While most cases of Cushing’s Syndrome are caused by tumors in
the pituitary gland in the brain, some happen because of adrenal tumors.
Symptoms of this disorder include diabetes, high blood pressure, obesity
and sexual dysfunction.

2. Conn’s Disease:
This condition occurs when the tumor leads to excessive secretion of
aldosterone. Symptoms include personality changes, excessive urination,
high blood pressure, constipation and weakness.

3. Pheochromocytoma:
This condition occurs when the tumor leads to excessive secretion of
adrenaline and noradrenaline. Symptoms include sweating, high blood
pressure, headache, anxiety, weakness and weight loss.
 Q: A 40-years-old female,
previously healthy, presented
with acute abdominal pain,
fever and itching

1. What is the diagnosis?

Ascending Cholangitis

2. What is the next imaging test

to order for this patient?
MRCP, ERCP

3. Why is she having itching?

Bile salts accumulation
 Pneumobilia
( Air in the biliary tree )
Causes : Abdomen CT

-Recent biliary instrumentation (e.g.

ERCP or PTC)

-Incompetent sphincter of Oddi (e.g.

sphincterotomy, following passage of
gallstone.)

-Biliary-enteric surgical anastomosis.

-Spontaneous biliary-enteric fistula

(cholecystoduodenal accounts for
~70% ).

-Infection (rare) (e.g. ascending

cholangitis, anaerobes).
Q: About the anatomy of anal canal:
A: External anal sphincter
B: Internal anal sphincter
C: Dentate line
 Q: Patient has anal pain and
itching:

Q1: What type of anal condition

in this area (Area A)?
- Ischiorectal abscess

Q2: What is the Mx?

- Cruciate incision with drainage
with drainage of pus
(without antibiotic)

- Extra: we use antibiotic in: systemic

inflammatory response or sepsis extensive
cellulitis, diabetes, immunosuppression
Q: This is a 35-years-old patient c/o severe anal area pain
1. What is the diagnosis? Perianal Abscess
2. What is the treatment? Drainage & Antibiotics Cover
3. What is the possible sequel for this condition? Fistula
 Q: A 25 year old male presented with anal pain
and fresh blood PR, the peri-anal area is shown:

Q1: What is the Dx? Bleeding Hemorrhoids

Q2: What do you recommend?

1) Bath sitz 2) Laxatives 3) High-fiber diet

Q3: Beside bleeding, name 2 more complications?

1) thrombosis 2) Infection 3) Ulcers

Classification: Internal (above dentate line)

external (below dentate line).

Risk factors: constipation/ straining/

pregnancy/ ascites/ portal HTN.

Hemorrhoidectomy:
* contraindicated in chron’s.
* complications: pelvic infection/ anal
stricture/ incontinence.
 Q1: Name the Dx?
- Pilonidal Sinus (PNS)

Q2: Name 4 sites for it?

1) Inter-digital space
2) Natal cleft
3) Between breast
4) Axilla

Treatment If your PNS does get infected,

surgery will most likely be recommended
and may include the following:
1) Incision and Drainage
2) Wide Excision (reduce your chances of a
reinfection. However; Your wound may take
a long time to heal)
3) Excision and Primary Closure (reinfection
chances are higher)
 Q: A 22-years old male patient
presented with upper natal cleft
area increasing in pain for the last
3 days.

1. What is your diagnosis?

Gluteal Cleft Abscess of a Pilonidal
Sinus

2. What is the treatment?

Incision & Drainage
 Fistula –in- ano

- From rectum to anal skin.

- Causes:
anal crypt infection
perianal abscess.

- Sx :
perianal drainage
itching
diaper rash.
 Q: This pt has painful defecation:
1. Name the findings on examination
of the anal area.
A > Anal Fissure
B > Sentinel Pile
2. Mention 2 treatment options.
-Lifestyle modification with high fiber A
diet and increase fluid intake
-Medical Management (Laxatives, B
stool softeners, local anesthetic
creams, botulinum toxin injection,
sitzbath…etc)
-Surgical Management (Sphincter
dilatation, Lateral internal
sphincterotomy, Fissurectomy)
This is a chronic fissure with hypertrophic papilla & pile formation, the guidelines state that for
chronic fissures medical management with botulinum toxin, stool softeners and anesthetic
creams is indicated first. If the fissure is refractory to medical management then surgical
intervention with lateral internal sphincterotomy is highly indicated, but sphincter dilatation
could also be used.
 Anal fissure
- Hypertonic internalsphincter.
- Chron’s disease may cause it.
- Very painful.
- Posterior fissures more common
than anterior ones.
- Signs : sentinel tag/
Hypertrophic
hypertrophied papilla/ blood on papilla
toilet paper.
- Surgery indication: chronic
fissure / refractory to
conservative treatment.
- Surgery: lateral internal
sphincterectomy.
- Triad of chronic fissure: sentinel
pile/ hypertrophied Sentinel pile
papilla/hypertonic sphincter.
 Perianal warts
- Cause : condylomata acuminate (HPV).

- The major risk is SCC.

- Treatment : if small, topical podophyllin/ if

large, surgical resection or laser ablation.
- Weight reduction surgery for the morbidly obese.
- Morbid obesity : BMI > 40 or BMI> 35 with a medical problem
related to morbid obesity (sleep apnea/ CAD/ DM/ HTN/
pulmonary disease/ breast cancer/ colon cancer/ arthritis/ sex
hormone abnormalities/ venous stasis ulcers.
 Q1: Name this surgery?
- Gastric bypass
(Single Anastomosis Gastric Bypass)

Q2: Mention 2 types?

1) Gastrojejunostomy
2) Duadenoileostomy

Q3: What BMI is an indication

for a surgery in a DM patient?
- >35
 Lap Sleeve
Gastrectomies (LSG)
 Q: A Patient that needed to
reduce weight ASAP, and this
surgery was done:

Q1: Which procedure is this?

- Gastric Sleeve

Q2: 2 Complications for it?

1) Blood clots.
2) Gallstones
3) Hernia.
4) Internal bleeding
5) Leakage.
6) Perforation
7) Stricture
 Q1: Name this surgery?
- Roux-en-y gastric bypass (RYGB)

Q2: Mention 2 mechanisms?

1) Malabsorption
(Decrease gastric absorption)
2) Less space for food
(early satiety)
Roux-en-Y gastric bypasses
(RYGB)
Gastric Band (LABG)
Mini Gastric Bypass
 Q1: What is the organ affected?
- Parotid gland

Q2: What is the most likely Dx?

- Parotid Pleomorphic Adenoma

Q3: What is the most common subtype?

- Myoxoid (not sure)

Q4: What is 1 sign that will confirm your Dx?

- Rubbery-hard, does not fluctuate and of
limited mobility on physical examination

• Benign salivary gland tumor.

• The most common salivary gland tumor.
• Usual location : parotid gland.
• single firm, mobile, well- circumscribed mass.
• Painless.
• Slow growing.
 Q5: How do we treat this pt?
- Superficial parotidectomy, some
said total parotidectomy

Q6: Histology?
Epithelial
Myoepithelial
Stroma
Pseudopods
No true capsule
 Q: a patient had a
superficial parotidectomy:

Q1: What is the most likely

indication?
- Parotid gland tumor
(most likely pleomorphic
adenoma)

Q2: What is the nerve in

risk of being damaged?
- Facial nerve
Some said: great auricular nerve
Q: 50 yo pt presented with
bilateral neck swelling:

Q1: What is the Dx?

- Warthin’s tumor

Q2: What is the malignancy

risk? - is the 2nd mc benignsalivary gland tumor.
- 0.3% -
-
More in males.
Associated withsmoking.
- Only in parotid.
- Usually at parotid tail.
- Cystic mass.
 Q1: if a surgery was done
what is the nerve at risk to
be injured?
- Marginal Mandibular Nerve

Q2: What is the risk of

malignancy?
-50%
 Sialolithiasis = salivary stones
Submandibular salivary gland stone
• The stone is located in the Wharton's duct (most common site) :
in the floor of the mouth near the frenulum of the tongue.
DDx of neck lumps
 Q1: What is the Dx?
- Lacerated neck wound

Q2: What zone?

- Zone 2

Q3: Name the borders for it?

- From the angle of the
mandible to the cricoid
cartilage

Q4: When to intubate the

patient?
1) Expanding hematoma
2) Obstructive complication
3) Cervical vertebrae injury
VERY COMMON QUESTION!
 Q1: What is the Dx?
- Thyroglossal duct cyst
Q2: What is the structure on U/S Neck mass that increase
(involved bone)? with protrusion of the
- Hyoid bone tongue
Q3: What is the Mx?
- Sistrunk’s procedure
(if the hyoid bone not removed
the recurrence rate is > 50-60%)
 Q4: What is the malignancy risk?
- 2%

Q5: Name the malignancy that does

not occur here?
- Medullary Ca

Q6: Complications?
- Infection, malignant risk

Q7: Sign to confirm your Dx?

- Movement with tongue protrusion

Q8: What is the risk of recurrence?

- Sistrunk procedure reduces the
recurrence risk from 60% to < 10%
 Q: This is the US of a 20 yo male with a neck lump.
1. What is the next step in approaching his
condition? FNAC
2. What is the most likely Dx? Thyroglossal Duct Cyst
 Q: This patient underwent surgery for the pathology
depicted by the yellow arrow. Histology reported a
malignancy of non-thyroid origin.
What is the most likely malignancy? SCC
What structure does the red arrow point to? Hyoid bone
Q1: Name the triangle of the
neck in which the lesion is
situated:
anterior triangle.

Q2: Give 2 DDx for the lump:

sialodenitis/ lipoma.
 Ludwig angina
pus accumulation in
the submental triangle.
causes pressure on the
larynx and epiglottis and
suffocation.
treated surgically by
opening the submental
area and draining the
pus.
Carotid body tumor : in carotid triangle
- moves side by side.
- Dx: carotid angiogram.
- Surgical excision and preoperative embolization.
- Lateral mass.
 Branchial fistula
•formed by the 2nd branchial cleft
and pouch.
•lined by ciliated columnar
Branchial cyst epithelium.
- Smooth surface and globular. • Discharge : mucus or muco-pus.
- At the level of junction • in anterior triangle.
between upper and middle •at junction between middle and
1/3 of SCM. lower third of SCM.
• congenital.
• surgery (excision).
Sublingual dermoid
cyst
Ranula : cystic mucosa extravasation
- Medline congenital mass. from sublingual salivary gland.
- Contents : hair follicles/
sebaceous cyst/ sweat Plunging : if extended through
glands. myelohyoid muscle.

Treatment : excision.
 Q: Hx that suggest a
thyroid nodule:

Q1: What is the Dx?

- Multi-nodular goiter

Q2: How to approach the

patient with this Dx?
- TFT
- US
 Q1: What is the Dx?
- Graves disease

Q2: Mention 2 signs that you can see?

- Exophthalmos
- Significant hair loss
- Lid retraction

Q3: What is the 1st Sx patient will

develop if she develops opthalmoplagia?
- Diplopia or Proptosis (not sure)

Q4: What is a drug you can give this

patient before getting into surgery?
- PTU (Propyl thiouracil), propanlol
Q: 50 year old female patient
present with hypothermia:

Q1: What is the endocrine

disorder?
- Hypothyroidism

Q2: Mention 3 signs on face?

1) Puffy face
2) Periorbital edema
3) Coarse hair
Q: Patient with hyper diffuse functioning thyroid:
Q1: What is the Dx?
- Graves Disease
Q2: What is the serological marker?
- TSI (thyroid stimulating immunoglobulin)
Q3: Mention 3 lines of Mx?
1) Anti-thyroid drugs (carbimazole) + β-blockers
2) Radio-iodine
3) Surgery
** All 3 are considered 1st line Mx
 Q1: What is the pathology?
- Papillary Thyroid Carcinoma

Q2: What is the rate of the

malignancy?
- 97-99%

Q3: Mention 2 features seen in

the picture?
1) Nuclear Crowding
2) Orphan Annie Nuclei
 Papillary thyroid carcinoma:
a. Nuclear groove (blue arrow).
b. Psammoma body.
 Papillary thyroid carcinoma:
(Intranuclear cytoplasmic inclusions)
Q1: What type of thyroid cancer do
you expect to see in this patient?
- Medullary

Q2: What’s the marker?

- Calcitonin
Q1: What type of thyroid cancer do you expect to see in this
patient?
- Medullary cancer

Q2: Before surgery what type you must exclude?

- MEN 2 (Pheochromocytoma)
 Q: Hx of thyroid nodule, US
showing: micro-calcifications,
investigation of blood vessels and
reactive LN:

Q1: Bethesda Grade?

- Bethesda 6

Q2: What is your Mx?

- Total Thyroidectomy
 A

Q: Images A & B
demonstrate thyroid
nodules that are considered
sonographically suspicious
for malignancy. Name the
feature labelling each
nodule suspicious. B

A > Heterogeneous
B > Calcification
 Q: What shall you do in the following cases ?
A. Thyroid → repeat cytology
B. Parathyroid → removal (parathyroid adenoma)
 Q1: Name the study?
- Sestamibi scan of parathyroid

Q2: What is the most common cause of the condition?

- Adenoma
 Q1: Name the study?
- Sestamibi scan

Q2: What is the pathology you see?

- Hyperfunctioning parathyroid glands
Q1: Risk of disease to be from single nodule?
- 85-90% Adenoma

Q2: What is your Dx?

- Single parathyroid gland adenoma

Q3: What is your Mx?

- Removal
 Q1: What is the Dx?
- Parathyroid adenoma (1ry hyperparathyroidism)

Q2: The 1st Sx to develop if the patient had high PTH & Calcium?
- Bone pain (Since it’s Hyper)
if Hypo: Peri-oral numbness, carpal spasm
Q: A 60-years old female complains of
pain in her bones. She presents with a
palpable central neck lump below the
cricoid cartilage that moves upward
upon swallowing.

1. What does the lump mostly

represent?
Parathyroid Carcinoma

2. What is the bone condition called?

Osteitis Fibrosia Cystica
 Q1: Name the Dx?
- Parathyroid hot nodule

Q2: Name the Rx?

- Surgery (Lobectomy)

Q3: Risk of malignancy?

- Low risk (<3-5%)
 Q: Hx of palpable neck mass,
recurrent renal stone, high
level of calcium and
parathyroid hormone:

Q1: Name the Dx?

- Parathyroid carcinoma

Q2: What is the minimal Mx to be done?

- Parathyroidectomy or en-bloc resection of the
parathyroid mass and any adjacent tissues that have been
invaded by tumor . (from uptodate)

*** Note: En-bloc resection could include the ipsilateral thyroid lobe, paratracheal alveolar and
lymphatic tissue, the thymus or some of the neck muscles, and in some instances, the recurrent
laryngeal nerve
 Q: The morning post-total
thyroidectomy the patient
developed the sign seen in this
figure:

Q1: Name of he sign?

- Trousseau Sign

Q2: What is the cause? Trousseau’s sign : Carpal spasm

after occlusion of blood to the
- Hypocalcemia after removal of forearm with a BP cuff in pt with
hypocalcaemia.
parathyroid glands

Q3: What is the most likely cause

of hypoparathyroidism?
- Ischemic Injury
 Q1: What are the signs?
- Chvostek and Trousseau signs

Q2: What is the cation that influx and cause this sign?
- Na+ Sodium
https://radiologyassistant.nl/breast/bi-rads-for-mammography-and-
ultrasound-2013
 Q1: What is the finding? Male breast nipple changes

Q2: Most common gene mutation associated with male breast

cancer? BRCA 2
 Q: A nipple biopsy for a
female patient shows large
cells with a clear cytoplasm,
high grade nuclei and
prominent nucleoli:

Q1: What is your Dx?

- Paget disease of the
breast/nipple (PDB)

Q2: Mention 2 immuno-

histochemical tests to
differentiate it from
melanoma?
1) CEA (pos. in PDB)
2) Protein S100 (neg. in PDB)
 Q1: What is the Dx?
- Breast mastitis, Abscess

Q2: MCC?
- S. Aureus

Q3: Mx?
- Abx
- Incision & Drainage
 Q: 50 yo female has breast pain,
breast only shows skin redness?

Q1: What is the Dx?

- Inflammatory breast cancer

Q2: Diagnostic procedure?

- Tissue biopsy

Q3: Mx?
- Mastectomy + Radiotherapy

Q4: What is the modality of Dx?

- Triple assessment
- Mammogram + US

Q5: According to TNM stage system

the T stage is?
- T4d
Nipple retraction Peau d’ orange
(inversion). (orange peel).

Paget disease of the nipple

Skin dimpling (eczema around the nipple)
 Duct ectasia
-AKA Plasma cell mastitis.
duct ectasia :bilateral
inversion and displaying
-Condition Mimics cancer (nipple transverse slit pattern
retraction, inversion, pain, Nipple
discharge).

-disorder of peri- or post-

menopausal age.

-Self-limiting condition.
Fine needle aspiration
(FNA)
** Advantages :
- done in office
- minimal discomfort.

** Disadvantage :
- may not always rule out cancer
when it’s negative.
 Incisional Excisional Lumpectomy
biopsy biopsy Excisional biopsy may be
sufficient for the lumpectomy, if
 Local anesthesia, often the margins were negative.
with mild sedation. The mc biopsy procedure.
With radiation therapy, it is as
 Only part of the tumor is  Outpatient procedure.
removed for Dx.
effective as modified radical
The entire lump is taken out using a mastectomy.
 Outpatient procedure. smallincision.
 Done when the tumor is large.
 Radiotherapy Chemotherapy
Side effects (self limited)
skin reddening & irritation/ darkening of
Side effects
the skin/ blistering/ minimal ↓ in blood hair loss/ ↓ blood counts/ nausea &
counts/ mild fatigue/ lymphedema in the vomiting/ ↓ platelet count when high
arm ( arm sleeves are used to control dose is used/ mouth sores/ diarrhea/ loss
the swelling).
of appetite/ wt gain/ menopause.
 Q1: What is the
pathology?
- Carcinoma en cuirasse

Q2: What is its TMN?

- Stage 4
Q: Name the following views for mammogram:
- Craniocaudal (CC)
- Mediolateral Oblique (MLO)
 Q1: Name the study?
- Mammogram

Q2: Mention 2 abnormalities?

- Mass with irregular border and
calcification

Q3: What is the Dx?

- Breast Ca

Q4: How to confirm your Dx?

- Biopsy
 Q1: What is this view?
- Mediolateral oblique

Q2: What is this structure

(arrow)?
- Pectolaris major muscle

Q3: What are the malignant

changes seen on
mammograms? Mention 3?
1) Calcifications
2) Speculations
3) Mass with greater density
than normal tissue
 Q: A 23-year-old single female
presented to the clinic with rapidly
growing (9cm) left breast mass
over the last 6 months. The mass
was irregular, hard and fixed at the
time of examination:

Q1: Your Dx?

- Phyllodes tumor
Q2: What is this structure (arrow)?
- Pectolaris major muscle
Q3: if it is malignant, what is the
common route of METS?
- Hematogenous
Q4: The mc site of METS?
- Lungs
Q: Female with ACR of 4 and BIRAD 0:

Q1: What is the % of breast density?

- >75%

Q2: What to do next?

- Birads score: requires further
investigations
 Q: Breast with Birad 2:
Q1: What is the next step in Mx?
- Routine screening
Q2: What is the view in B?
- Mediolateral oblique view
Q: A 37-year-old female presented with right breast pain for
the last 3 months. A breast ultrasound showed these
findings consistent with BIRAD 4c.
Q1: The likelihood of malignancy is: 50-90%
Q2: The clinical T stage “if a diagnosis of invasive carcinoma
is proved” is: T4
 Q: A 40-years old married female presented with a right breast mass
for 1-year duration. The patient had a history of a right breast mass
excision 3 years ago. Physical exam showed a 4cm hard right breast
mass which is fixed to the chest wall & the skin. Mammogram and
ultrasound were consistent with BIRADS 5.
1. Based on the TNM, the clinical T stage for this patient is? T4c
2. The likelihood of malignancy based on imaging findings is? >95%

**T4a : to chest wall only**

**T4b : to skin only**
**T4c : to both**
**T4d: Inflammatory breast
cancer**
 Q1: What is the pathology?
- Infiltrative ductal carcinoma

Q2: What is its TMN?

- Stage T3

Q3: What is the sign?

- Peau’d orange and nipple
retraction, skin dimpling
Q5: What is the cause of this?
Q4: Give 2 DDx? - Invasion of lymphatics,
1) Invasive ductal carcinoma causing lymph nodes
2) Inflammatory breast cancer obstruction
Q: A pt came complaining of a tender cord like subcutaneous
structure, pain, swelling and redness of the left breast:

Q1: Dx? Mondor’s Disease (Superficial Thrombophlebitis)

Q2: What is the Mx?
- NSAIDS
- Usually benign and self-limiting condition
 Q1: What is the name of
this study?
- Mammogram

Q2: Mention 2 signs you see.

1) Speculated mass
2) Microcalcifications

Q3: What is the Dx?

- Infiltrative Ductal Carcinoma
 Q1: What is the pathology?
- Phyllodes tumor (Brodie’s)

Q2: What is the Mx?

- Wide local excision

Q3: What is the like hood (%) of this tumor to be benign?

- 90% benign
Q: Female with mobile, mouse
like lump in one breast:

Q1: What is the Dx?

- Fibroadenoma

Q2: What is the stage according

to FNA?
- C2
 Q: a 35 yo female patient:
Q1: What is the Dx?
- Breast Cyst
Q2: Name the sign (black arrow)?
- Acoustic enhancement
Q3: What are the indications for a
biopsy in this female?
1) Bloody aspiration
2) Failure to completely resolve
3) Recurrence after 2nd aspiration
4) Atypical cells
 Q1: Describe the discharge?
- Uniductal Bloody Discharge

Q2: What is the pathology?

- Intraductal papilloma

Q3: Give a DDx?

- Intraductal papilloma
- Duct Ectasia
- Ductal invasive carcinoma

Q3: 2 imaging studies?

1) Ductogram, Ductoscope
2) Mammogram, US

Q4: What is the risk of malignancy of

this lesion?
- 15%
 Q1: What is the mechanism
that the breast cancer causes
hypercalcemia?
- Parathyroid hormone - related
protein
(not due to osteoclastic METS)

** Note: The main pathogenesis of

hypercalcemia in malignancy is increased
osteoclastic bone resorption, which can
occur with or without bone metastases.
The enhanced bone resorption is mainly
secondary to PTH-related protein
 breast cancer:
dense mass with a
Breast Cyst spiculated margin.
clustered microcalcification: five or more calcifications ,each
measuring less 1mm in onecubic cm, the possibility of
malignancy increases as a size of individual calcification
decreases and the total number of calcification per limit area
increases.
 The 2 major signs of
malignancy in
mammography:

1. Mass with spiculated

margins or stellate
appearance
( the single arrow ).

2. Microcalcifications
(the double arrows ).
Breast Infiltrating ductal cancer
ultrasound.

This shows an irregular ductal

tumor with nodules
infiltrating the area around it.
Sentinel Lymph Node

The sentinel nodes are the first place

that cancer is likely to spread.
 Q1: What are the skin
changes indicative of breast
cancer in this image?
Nipple retraction
Peau dé orange

Q2: What is this procedure?

Core needle biopsy
(true-cut biopsy)
 Lymphangiosarcoma
-As a complication of long-
standing lymphedema , usually in the
edematous arm of post radical mastectomy patient.

-to prevent it : use elastic compression stockings.

Q: This 1 year old baby had this
lesion since birth:

Q1: What is the most likely Dx?

Hemangioma

Q2: What is the best Mx?

Observation and reassurance
Vascular malformation

Sturge weber syndrome

port wine stain vascular malformation
involving the ophthalmic division.
- Usually not evident at birth.
mnemonic :
S : seizures / U: unilateral weakness
R: retardation ( mental ) / G:Glaucoma
E : other eye problems
 Capillary hemangioma in the
eyelid obstructing the eye , might
lead to Amblyopia "lazy eye" .
The same patient at different
ages (hemangioma)
 hemangioma Vascular malformation
Start as small lesions at the seen at birth but may appear
age of 3-4 months late
Grow to reach their maximum Grow parallel to the child’s
size at the age of 1 year then growth
involution

Female to male (3:1) Female to male (1:1)

Rarely to cause any High flow can lead to
complications destructive changes
Spontaneous resolution unless Treatment : surgery/laser/
complicated you should treat embolization
 Bilateral cleft lip and palate
Cleft lip:
No functional deformity, only cosmetic deformity
and surgery is done at age of 3 months.
Breast feeding is not contraindicated.

Cleft palate:
baby can’t feed, cant speak and may lose his hearing
by time (acquired).
surgery is done at age of 1 year as a compromise
between not losing his speaking abilities and the
normal growth of face.
Pentalogy
of Cantrell
1. Omphalocele.
2. Anterior
diaphragmatic
hernia.
3. Sternal cleft.
4. Ectopia cordis.
5. Intracrdiac defect.
Q1: What is the Dx? Prune belly syndrome
• thin flaccid abdominal
wall.
Q2: Mention 2 associated anomalies? • AKA eagle Barrett
1( Undescended testicles syndrome.
•absent abdominal wall
2) Urinary tract abnormality such as musculature.
unusually large ureters, distended bladder, • dilation of bladder,
Vesicoureteral reflux, frequent UTI’s ureter
and renal collecting
3) VSD system.
4) Malrotation of the gut • 95% in Males.
5) Club foot
 Bickwith-
Wiedman
syndrome

1. Macrosomaia.
2. Macroglossia.
3. Organomegaly.
4. Abdominalwall defects.
5. Embryonal tumors.
 Torticollis
• Tilted neck.
• Causes:
1) congenital ( dueto
abnormal position of the fetus
in uterus which leads to
fibrosis of sternocleidomastoid
muscle >> shortness of this
muscle)
• Occurs at any age but most common
in the 1st few months oflife.
2) acquired : due to trauma
• Palpable hard mass in 1/3 of patients.
leads to muscle spasm onone
• The baby usually sleeps on the same
side/ fibrosis of SCM due to
side >> craniofacial deformity.
any cause.
• Treatment : conservative using
3) infection: lymphadenitis physiotherapy for 2-3 months.
• If no improvement, surgery is
indicated (SCM myotomy).
 Cystic hygroma
• Fluid-filled sacs caused by blockages in the
lymphatic system.
• most hygromas appear by age 2.
• soft, non-tender, compressible lump.
• high recurrence rate.
• usually located in the posterior triangle
of the neck.
• transillumination.
• DDx: teratoma/hemangioma/
• encephalocele.
Congenital malformations

Think of Albort Syndrome

Preauricular sinus
 Esophageal atresia and
tracheoesophageal fistula
 Manifestations of esophageal atresia:

1) Upper part: drooling of saliva/ bubbling of the saliva/ respiratory distress/

choking/ failure to pass nasogastric tube.

2) Lower part: accumulation of secretions which will lead to regurgitation and

vomiting/ ischemia>> physiological death>> biological death (necrosis) >>
rupture.

* The more distal the obstruction, the more the distention of the lumen and so the
more the possibilityof rupture.

Neonates with esophageal atresia

usually develop copious, fine white
frothy bubbles of mucus in the
mouth and nose. Secretions recur
despite suctioning.
 Esophageal atresia and
tracheoesophageal fistula

 Atresia of the upper esophagus

evidenced by failure to pass a feeding
tube.

 Gas in theabdomen.

 These findings are likely due to a

esophageal atresia with a distal
tracheoesophageal fistula (Type C TEF).
 Q: New born x-ray, cyanosis and distressed:

Q1: What is your Dx?

- Tracheoesophageal fistula (because of the cyanosis)

Q2: Characteristic sign?

- Failure to pass the nasogastric tube
Q: A new-born baby had inability to
swallow milk and frothy mouth
secretions, this is his x-ray.

Q1: Mention two radiological signs?

inability to pass nasogastric tube/ air in
the stomach.

Q2: What is the diagnosis?

Esophageal atresia with tracheo-
esophageal fistula.
 ARDS
(bilateral diffuse
pulmonary infiltrates )

Other DDx:
1-severe pulmonary edema.
2-pulmonary hemorrhage.
3-pulmonary fibrosis.

( history differentiates
between these conditions)

Ground Glass Appearance

 This chest X-ray shows air trapping indicating foreign body aspiration.

It is the most common radiological sign shown on the X-ray after F.B aspiration.

Whenever you suspect F.B aspiration you have to do bronchoscopy.

 Tetralogy of Fallot Transposition of great
"boot" shaped heart on vessels
chest X-ray. Egg shaped heart
 Congenital
diaphragmatic hernia
• X-ray of the abdomen and
chest.
• features :
- scaphoid abdomen.
- bowel is located in the left
side of the chest.
- mediastinal shift
towards the right.
• mortality is mostly due
to pulmonary
hypoplasia. • Types :
1) Bockdalek hernia
• Diagnosis: In prenatal (mostly on left side): posterolateral, mc.
period (ultrasonography) 2) Morgangi hernia
(mostly on the right side) : retrosternal.
Hiatus hernia.
Neonate with a prenatally diagnosed left congenital
diaphragmatic hernia pre surgery.
 Q1: What is the Dx? Gastroschisis

Q2: Name the procedure? Silo

Q3: The prognosis depends on?

- Bowel status

Q4: The indication of this procedure?

- if the bowel is inflamed and primary
closure is not possible
- to prevent dehydration, hypothermia,
contamination
• location : lateral to the umbilicus ( to the right ).
• defect size : 2-4 cm.
• no sac.
• cord is normally inserted into umbilicus.
• contents : only bowel (edematous and matted ).
• GIT function : prolonged ileus.
• associated anomalies : infrequent.
Q1: What is the Dx?
- Omphalocele

Q2: How is the GI

function?
- Normal
• location : umbilical ring.
• The protrusion is covered by peritoneum.
• defect size : >10 cm.
• cord : inserted into the sac.
• GIT function is normal.
• contents : bowel +/- liver.
•malrotation : present.
• associated anomalies : common (30-70 % ).
 Q1: What is the
diagnosis in A,B?
A > Omphalocele
B > Gastroschesis

Q2: Which of these are

more associated with
congenital anomalies?
- Omphalocele
 Q3: What is the 1st
aid Mx for both?

- Carefully wrap in saline-

soaked pads.
- Support without tension.
- NG tube.
- Abdominal ultrasound.
 Q: Malrotation:

Q1: What’s A and B?

A > Non-Rotation
B > Incomplete Rotation

Q2: Which one is the most

commonly associated with
volvulus?
-B
 Q: What is the Dx according to:

A: Preterm baby > Necrotizing enterocolitis (NEC)

B: Full-term baby > Hirschsprung disease

 Intussusception
 It is a cause of intestinal
obstruction.
 M : F ( 3:2)
 In a previously healthyinfant.
 (5 months - 3 yrs) idiopathic / (
>3yrs) 2ry.
m.c.c of I.O in the age of (5
months-3 yrs)
Sudden onset, abdominal colic,
vomiting.
begins proximal toileo-cecal
junction.
Ba enema ( diagnostic and
therapeutic).
The part that prolapses into the
other is called the intussusceptum,
and the part that receives it is called
the intussuscipient.
Q1: What is the investigation?
- Abdominal US

Q2: Name of the sign?

- Target sign

Q3: What is the pathology?

- Intussusception

Q4: How do we treat those

patients in uncomplicated cases
(stable)?/1st line of Mx?
- Resuscitation, Hydrostatic
(pressure) reduction using gas
air or barium enema
 Target sign
(doughnut sign).

Pseudokidney
sign
 Pyloric stenosis
stomach
pylorus
 M : F (4:1)
 Age (3-6 wks)
Progressive, persistent,
projectile, non-biliousvomiting. Barium study : string sign
 Succation splash.
Olive sign (enlarged pylorus is
palpable).
 Hypochloremic alkalosis.
 Dx by abdominalU/S
Higher risk when mother is
affected.
Surgical ttt: Ramstad's
pyloromyotomy.
 No recurrence after surgery.
 Q1: What is this?
- Meckel’s Diverticulum

Q2: Name 2 complications?

1) Intestinal hemorrhage
2) Intestinal obstruction
3) Diverticulitis

Q3: Mention one common

ectopic tissue you can find?
- Gastric and pancreatic
tissues
 Q4: Is it a true or pseudo-diverticulum?
- True Congenital Diverticulum

-A memory aid is the rule of 2s:

2% (of the population).
2 feet (proximal to the ileocecal
valve).
2 inches (in length).
2 types of common ectopic
tissue (gastric and pancreatic)
2 years is the most common age
at clinical presentation
2:1 male: female ratio
Types of intestinal atresia
Q1: What is the Dx? Q: Intra-op image of a baby
Jejunal atresia. with symptoms of obstruction.
Q2: Age of presentation?
Neonate (till one month) Q1: Give two findings:
Dilated proximal loop,
Q3: How would umanage? collapsed distal loop.
Admit to NIC
fluid resuscitation
Q2: What is the diagnosis?
Antibiotic
NG suction and parental nutrition. Type 1 intestinal atresia.
 - Apple peel intestinal atresia
(also type IIIb or Christmas tree atresia).

- Due to vascular accident.

- All the intestine is atretic, and forms a

loop around the superior mesenteric
artery.
 Intestinal obstruction

• Abdominal X-ray.
• Double bubble sign.
•represents dilation of the
proximal duodenum & stomach.
Multiple air fluid levels seen in
•DDx : duodenal stenosis (mostly mechanical intestinal
in the 2nd part of duodenum) /
obstruction.
duodenal atresia.
 Meconium ileus

• Intestinal obstruction from

solid meconium concretions.
• >95% have cystic
fibrosis.
• Sx: bilious vomiting/
abdominal distention/ failure
to pass meconium.
Hirschsprung’s
disease
• Congenital megacolon.
•It is an absence of ganglion
cells distal in the bowel.
•Contracted non-peristaltic
affected segment and a
dilated hypertrophied
proximal segment.
• M:F (4:1)
•Failure to pass meconium in
the 1st 24-48 hrs of life.
•When compared to
habitual constipation ( no Plain abdominal X-ray : Barium enema study: funnel
dilated loops of bowel/ shaped appearance of
soiling/ no anal fissures).
air-fluid level. colon ( megacolon –
•DDx : hypothyroidism/ transitional zone- the
sepsis. affected narrowed
segment).
 Q: A neonate failed to pass
meconium, so a barium enema
was done and shows this:

Q1: What is the Dx?

- Hirschsprung disease

Q2: What does the arrow indicate?

- Transition zone

Q3: What is the diagnostic test?

- Biopsy
- Full thickness or rectal suction

Q4: Name the radiology study?

- Barium enema
 Umbilical Hernia

• more common in blacks.

• familial tendency.
•repair is carried out if closure
does not occur by the end of 2nd
year of life.
•repair performed after the age
of 2 and before the age of 10.
• associated anomalies :
- hypothyroidism.
- hurler syndrome.
- beckwith-wiedman
syndrome.
 Patent
urachus
•It is a remnant presents
as fistula connecting the
umbilicus & urinary
bladder.

•Patients with prune

belly syndrome have a
patent urachus.

•Other forms : blind

sinus/ cyst/ abscess.
 Vesicointestinal fissure
The terminal ileum
is herniating
through the cecum
forming the so
called elephant
trunk deformity.
 Omphalitis
• Inflammation of the
umbilicus.

• Occurs only in
newborns.

• Can be fatal because of

portal vein thrombosis.

• Infection can spread to

the abdominal wall.

• Antibiotics and
intensive care.
 Bladder Extrophy
• Defective enfolding of caudal folds.
• Associated with prolapsed vagina or rectum /
epispadias / bifid clitoris or penis.
Vesicoureteral reflux
• Presentation : either antenatal
hydronephrosis or clinical UTI.

• Diagnosis : urine culture/

ultrasound/ voiding
cystourethrogram.

• Nuclear cystogram for screening.

• DMSA scan to detect kidney

scarring.

• Urodynamic study for lower urinary

tract abnormalities (neurogenic Spot film taken during VCUG
bladder). shows unilateral grade 4
vesicoureteral reflux
 UVR grades

Treatment :
- Spontaneous resolution is common in young children (only antibiotics).
- Indications for surgery: grade 4 and 5/ poor compliance with medications/
breakthrough febrile UTI despite adequate antibiotic prophylaxis/ poor renal
growth/ kidney scars/ mild or moderate reflux in females that persist during
puberty despite several yrs of observation.
 Q1: What is the pathology?
- Right scrotal swelling (Hemi-scrotal swelling)

Q2: Give two benign DDx?

- Inguinal hernia, hydrocele

Q3: What is the name of peritoneal part remain patent?

- Patent processus vaginalis
 Inguinal hernia
• Due to patent processus
vaginalis.
• More common at the right side.
• Bilateral hernias occur in 5-15%
of children with hernia.
• Uncomplicated hernia will bulge
when the baby cry and reduces
when the baby is relaxed ,
sleeping. Etc.
• Uncomplicated hernia must be • Complicated hernia presents in
operated (herniotomy). the ER with pain/ management :
• Herniotomy must beperformed resuscitation, reduce hernia, then
ASAP. repair within 24-48 hrs. ( as we
• 10-15% of children with on the fear strangulation and testicular
other side. hernia on one side will atrophy).
develop a hernia
 Q1: What is the Dx?
- Epispidias and Hypospadias

Q2: Mention 2 associated anomalies?

1) Bladder extrophy
2) Bifid penis
3) Rectum prolapse

Q3: Name 2 commonly associated

features with this pathology other
than the abnormally located urethral
meatus:
1) Chordee
(downward bending of the penis)
2) Hooded appearance of the penis
 Q1: What is the Dx?
- Hypospadias

Q2: What is the

classification?
1) Anterior (50%)
2) Bifid Middle (30%)
3) Posterior (20%)

Q3: When is the surgery

performed? • Glanular (opening on the glans)
6 – 18 months of age is the most common.
 Epispadius: urethral opening is on the dorsal surface
with abnormal penis. It is usually a part of a syndrome
includes extrophy of the urinary bladder.

- Extremely rare.
 Q: This is a 5 yo boy.
Q1: Give two clinical findings:
scrotal swelling
transillumination

Q2: What is the Dx?

hydrocele
• Fluid filled sac ( fluid in a patent processus
vaginalis or in the tunica vaginalis around the
testicle).
• Communicating with the peritoneal
cavity VS non communicating.
• In most infants it will resolve in the 1st year.
• If there is increase in size >> operation
• Any hydrocele appearing after a
1st year must be operated as it will
not resolve.
 Undescended testicle

• Significant risks: infertility/

trauma/ torsion/ hernia/ cancer.

• Treatment : orchidopexy bythe

age of one year (6-12 months).

• After 2 years the testicle is

abnormal and wouldn’t be
functioning.
Q1: What is the Dx?
- Testicular torsion DDx for Acute scrotum:
1. Testicular torsion.
Q2: What is your Mx? 2. Torsion of testicular appendages.
3. Epididymorchitis.
- Orchidectomy 4. Scrotal edema.
5. Complicated hernia.
 Imperforate anus
• Males > females.

• High lesion vs. low lesion.

• Meconium or air per urethra or vagina.

• One of the common findings that the anal

opening anteriorly located.

• Treatment : resuscitation/ the low types

managed by a one stageprocedure in the
neonatal period (anoplasty).

• Other types treated by colostomy in the

neonatal period followed by a definitive
procedure called pull-through (posterior
sagittal anorectoplasty).
 Q1: Name the Dx?
- Melanoma

Q2: What is the most accurate

prognostic factor?
- The Depth

Q3: Increased melanin

production with normal
number of cells is known to
cause?
- Freckles

Q4: Mention 2 staging

systems?
1) Clark’s level
2) Breslaw’s thickness
 seborrhoeic keratosis
-in the elderly " aka senile warts “.

-special diagnostic feature : because

they are patches of thick squamous
epithelium they can be picked off if
you try to pick the edges with a blunt
forceps.

-when it peals off , it leaves a patch of

pale-pink skin with slight bleeding.

-no other skin lesion behaves like this.

- doesn’t need surgery. Completely

benign.
• If a nevus undergoes changes in the pigmentation or in
the shape or ulceration it indicates a melanoma.

• We differentiate the nevus from the vascular anomaly

by its color.
 • In general, hair tuft or
lipoma or hairy nevus
located at the lower end
of the back, it is associated
with spina bifida.

Hairy nevus

• It's premalignant and must be

surgically removed.
• Congenital.
• Black or brown pigmented
area with excess hair growth.
 Q: a patient with pain and fever:

Q1: What is the Dx?

- Cellulitis

Q2: What is the micro-organism causing this?

- Group A streptococci (GAS – mc!), Staph. Aureus
 Erysipelas
1. usually caused by streptococcus bacteria
(beta hemolytic group A ).

2. Erysipelas is more superficial than

cellulitis.

3.It's typically more RAISED and

DEMARCATED.

4. The infection may occur on any part of the

skin including the face, arms, fingers, legs
and toes, BUT IT TENDS TO FAVOR THE
EXTREMITIES.

5. Fat tissue is most susceptible toinfection,

and facial areas typically around the eyes,
ears, and cheeks.
 Q: a patient post-splenectomy due to RTA:
Q1: What is the micro-organism causing this?
- Meningococcus

Q2: How can you prevent it?

MCV Vaccine
Vaccine should be 14 days BEFORE surgery , and in case of emergency surgery like this case it
should be as soon as possible after surgery not 14 days after, others said in elective surgeries, it
should be given 14 days before the operation But in emergent surgeries, it should be given at
least 14 days post operatively.

Post-
Splenectomy:
We Give MCV,
PCV, HiB
Post Splenectomy Vaccination
 Non melanoma skin cancer
• The most common type of cancer.
• Its mortality is low.
• 75% BCC and 25% SCC.
• BCC is slow growing, locally destructive and
rarely metastasize.
• 80% are on head and neck.
• Melanin is a protective against tumor so blacks
are less to have skin tumors.
Q: Lesion on the face <1cm:
Q1: What is the Dx?
- Basal cell carcinoma (BCC)

Q2: What is the MCC?

- Long exposure to sunlight

Q3: Mention 2 ways of Mx?

A) Non surgical:
(topical immunotherapy, intralesional interferon INJ, photodynamic)
B) Surgical (Excisional or destructive):
- Destructive: cautery, curettage, cryotherapy, CO laser ablation
- Excisional: Moh’s micrographic surgery (MMS), Wide local excision

Q4: What is the safety margin?

- 4-10mm

Q5: Write an alternative Mx?

- Moh’s micrographic surgery (MMS)
 Q6: Name 2 complications?
- METS, Ulceration

Q7: Potential METS rate:

- <0.55 (from google)

Q8: Do you expect to find enlarged LN?

- No (local disease)

Q9: What does the arrow indicate?

Rodent ulcer (complication of BCC)

- Arising in the germinating basal cell layer of epithelial cells.

- Nodular ( ulceration, telangiectasia, pearls).

- Morphea( manysites at the same time/ more aggressive

than the nodular type).

- Slow growing.

- Local ( rare risk of metastasis).

 Q: What is the type of cancer seen in this
histology (biopsy taken from the nose tip):
- Basal Cell Carcinoma
 Q: A 75 year old male farmer,
heavy smoker presented with
this lesion.

Q1: What is the most probableDx?

Squamous cell carcinoma.
Q2: What is the LN of this area?
Submental and submandibular??
Q3: What will you do to confirm Dx?
Biopsy for histopathology.

- Arising from epidermal cells.

- Risk factors: sun exposure/ pale skin/ arsenic/ xeroderma
pigmentosum/ immunosuppression.
- Actinic keratosis : theprecursor skin lesion.
- Raised, slightly pigmentedskin lesion/ ulceration/ exudate/ itching.
- Dx: excisional biopsy for small lesion/ incisional biopsy for large lesions.
- Most common sites : head,neck and hand.
- Involves the lower lip and BCC involves the upper lip or above this
level.
 Q1: Name the lesion?
- Onion cluster cells

Q2: Mention the Dx?

- SCC (Squamous cell carcinoma)
 Q: Two patients came to ER
complaining of neck swelling:

Q1: What is the pathology?

- Carbuncle
Carbuncle is an abscess larger than
Q2: MCC? furuncle, usually with one or more
openings draining pus onto the skin
- Staphylococcus Aureus

Q3: Mx?
- Incision, drainage and antibiotics
 Q1: Identify this picture:
Furuncle

Q2: Mention one risk factor?

DM

Q3: it is more common in?

In the back of the neck

Q4: Name 1 treatment?

Incision and drainage plus
antibiotics
 Keratoacanthoma
actinic self limiting growth and
keratosis subsequent regression of
hair follicle cells
 Q1: Dx of picture (1)? Keratoacanthoma
Q2: Dx of picture (2)? Actinic Keratosis
Q3: Dx of picture (3)? Sebborhoeic Keratosis
Q4: Dx of picture (4)? Necrobiosis Lipodica

Q5: Which doesn’t have pre-malignant potency?

3

Q6: Picture 2 can convert to? SCC

 Q1: What is this?
- Lipoma

Q2: What is the risk of wound

infection after removal (% of
wound infection)?
- 1-3% (clean wound)
Q: Give 2 DDx of a scalp lump?
1) Sebaceous cyst
2) Epidermoid cyst
 Sebaceous cyst
-Benign subcutaneous cyst filled with
sebum.

- found in hairy areas

(scalp, scrotum ,neck ,..).

- Most small cysts do not require

treatment. Large or painful cysts may be
removed surgically or by liposuction.

Important note: if there is a scalp lesion like this

it's impossible to be lipoma as a differential
diagnosis since lipoma emerges from fat under
the skin and scalp area is devoid from fat.
 Lipomatosis
AD condition in which multiple lipomas are
present on the body.
 Q1: Describe what you see?
1) Café au lait macules
2) Neurofibromas

Q2: What is your Dx?

- Neurofibromatosis

Q3: Mention type of inheritance?

- Autosomal Dominant
 Q: what is this and where do we find it??

A: Suppurative Hydradinitis in axilla Found in sites of apocrine

glands: axilla ,buttocks and perineum etc.

- caused by staph. Aureus.

- Treatment : antibiotics/ excision of skin with glands for
chronic infection.
 Gas Gangrene
- Caused by Clostridium perfringens.
- Surgical emergency.
 Contusion
- Bruising injury caused by blunt trauma.
- Small hematoma is resorbed by itself (except
on the face; need to be opened andevacuated)
- Large hematomas : if <24 hrs managed by
aspiration, if > 24 hrs by incision and drainage.

Abrasion
Managed by dressing to prevent 2ry bacterial infection.
 What is the type of this Lacerated wound usually
wound ? How is it treated? caused by blunt objects.
First, we clean the edges
It's an incised wound. (wound excision) to transform
Within the first 6 hours (or it to incised wound, then if
the first 24 hours in the face) within first 6 hours without
it's treated by primary contamination we close it by
closure if the edges can be closure if the edges can be
approximated without approximated without
tension. tension.
 Puncture wound
- Caused by pointed objects.
- Management: tetanus vaccine/ excision/ removal
of foreign bodies.

Avulsion flap
- Undermined laceration in the dermis and
subcutaneous tissue.
- Management: debridement of edges/ excision
of small avulsion flaps to preventtrap-door
effect/ suturing.
 pyogenic granuloma
- During wound healing if the capillaries grow too vigorously they may form a
mass covered with epithelium.
- Look for a history of trauma
- Very rapid growth
Keloid Scar Hypertrophic Scar
 Hypertrophic scar Keloid scar
Improves with time (2 years) No improvement with time
No genetic predisposition Genetic predisposition
Less collagen More collagen
Less cytokines More cytokines
fibers parallel to the dermis Fibers random in orientation
Remains within the borders of Extends beyond the original
the original scar scar margins
Regress spontaneously orby
medication

Treatment :
- Surgery (Z- plasty, W- plasty) / artificial skin/ steroids/ pressure
therapy/ topical silicon/ low dose radiation/ laser (CO2 and argon)/
calcium channel blockers/ interferon.
 Q1: Name the Dx?
- Keloid

Q2: Name 2 RF?

1) Dark skin
2) FHx

Q3: Name two characteristics?

1) Extend beyond borders of
original wound
2) More common in darker skin
3) Require years to develop
4) Thick collagen
Granulation tissue
(sign of healing ulcer)
 Q1: Name the Dx?
- DM/Peripheral arterial disease
Neurotrophic Ulcers:
punched-out appearance
Q2: Causes? painless.
Muscle atrophy may benoted.
- Prolonged pressure
- Uncontrolled long standing DM
Q1: What is the most common
etiology of this ulcer.
- Neuropathic Diabetic Ulcer

Q2: What is the most

important step to accelerate
healing?
- Diabetic control, Decrease
pressure at the area, Try to
prevent infection and increase
perfusion to the area
 Marjolin ulcer
(malignant ulcer)

- SCC arises in a long standing

benign ulcer or scar (long
standing venous ulcer or scar of
old burn ).

- Need 20-30 years to develop.

 Pressure sores grades

1) Erythema for >1 hour after relief of

pressure ( Hyperemia).

2) Blisters with break in dermis, erythema

requires 36 hr to disappear when relieved.
( Ischemia, pressure 2-6h).

3) SC tissue and muscle involvement, skin

is blue and thick ( Necrosis, pressure > 6 h).

4) Bone and tendon involvement, frank

ulcer develops.

Surgical treatment of pressure sores

1 excisional debridement. Flaps :

2 partial or complete ostectomy. - Local tissue flaps.
3 closure of the wound with healthy, durable tissue. Closure can be either : - Myocutaneous flaps.
- direct closure (in very small pressure sores). - Fasciocutaneous flaps.
- skin grafts.
- flaps.

Contributing factors : 1- pressure. 2- immobility. 3- shear (tangential pressure). 4- moisture. 5- malnutrition.

 Sacral pressure sore

Ischial pressuresore Trochanteric

pressure sore

Q: An 80 year old, bedridden male had this

lesion in the buttock and lower back area.

Q1: What is this lesion?

Pressure ulcer (bed sore)

Q2: What is the most common cause?

Pressure?
 Frost bite Chilblains
- Tissue freezing injury. - a type of non-freezing tissue injury.
- Mc type of coldinjury. - caused by chronic high humidity and low Temp
- At temperature (-2c). with normal core Temp.
- Treatment: rapid warming (40-42 C)/ debridement - seen commonly in mountain climbers.
of clear blisters whereas hemorrhagic are left
intact and aspirated if infected / elevation/ topical
thromboxane inhibitor/ NSAID.
- Massage is contraindicated.
 Trench foot
- The extremities are exposed to
damp environment over long
periods at temperatures ( 1- 10 C).

- Numbness/ tingling/ pain/

itching.

- The skin initially red and

edematous then gradually
turns to gray-blue
discoloration.

- Non- tissue freezinginjury.

 Pernio is an inflammatory skin
condition presenting after exposure
to cold as pruritic and/or painful
erythematous-to- violaceous acral
lesions. Pernio may be idiopathic or
secondary to an underlying disease.
- Non tissue freezing injury.

Cold urticaria

- Familial and acquired.

- History of cold stimulation.
 Fight bite
* over the dorsal metacarpophalangeal (MCP).

* organism : Eikenella corrodens (specific to

human mouth).

*Complications: cellulitis; extensor

tenosynovitis; septic arthritis .

*Management:
1) exploration (foreign body +extent)
2) local anesthesia
3) debridement
4)admission : drainage + ( IV) antibiotics
(amoxicillin +clavulanic acid )
Fournier Gangrene
necrotizing fasciitis in the perineum.

most commonly caused by c.perfringes.

Treat with tissue debridement and antibiotics.

 Kaposi sarcoma
- malignant proliferation
- associated with HHV-8.

- Classically seen in three groups:

1) Transplant recipient, early spread,
Rx decrease immunosuppression.

2) older eastern European males,

remain localized, Rx surgical
removal.
(cutaneous sarcoma appears
3) AIDS( Aids defining disease) - as red hemispherical nodules
tumor spreads early, Rx increase or plaques)
antiretroviral therapy. - is it painful ? no it is painless
- usually associated with what
? HIV infection & AIDS
 felon (whitlow): Paronychia:
distal pulp space infection infection of the nail fold ,
, if not treated results in happens due to bad manicure
osteomyelitis. or bad maneuvering of
cause : pricking. hangnails.
Most common hand infection.
 • The most causative organism of hand
infection (tenosynovitis, felon,
paronychia) is staph. Aureus.

• The 2nd is streptococcus.

• Initial treatment : oxacillin/

ampicillin.

• Then we do culture and give

antibiotics of choice.
Tenosynovitis
• If abscess formed, incision and
drainage.
- Infection of the
synovial sheath • Elevation to decrease the edema.
surrounding tendon.
• Resting the organ todecrease the
pain.
 Antibioma
Hard, edematous swelling
containing sterile pus
following the treatment of an
abscess with long term
antibiotics rather than incision
and drainage.

Treatment: exploration &

drainage if it is
indistinguishable from a
carcinoma, otherwise
spontaneous resolution takes
place over several weeks.
Bowen's disease
 Nevoid Basal Cell
Syndrome

( AD )

Presentation :

1)multiple BCC mostly on the face

2)Cysts in the jaw.
3)Intracranial calcifications.
4)Rib abnormality ( mostly bifid
ribs).
 Xeroderma
pigmentosa

• It might predispose to SCC.

• an inherited premalignant
condition associated with
increase risk of all types of skin
tumors.

• defect in the DNA repair genes

• AR
 Skin graft
Q: What are the signs of
graft take?

1.The graft is adherent to the

recipient site.

2. Pink color.

3.The graft blanches with

pressure ( denotes vascularity ).
 Skin grafts
1- split thickness skin grafts :
• Epidermis and thin part of dermis.
• The donor site heals by
epithelialization within 2 weeks.
• Used for large areas.

2- full thickness skin grafts:

• Taken from areas of loose skin as the
donor area is closed by approximation
of the edges (direct closure).
• Used for small areas.
• This is dermatome. Split thickness skin graft after it
• It's used for taking a split has been meshed, showing the
thickness skin graft. small perforations that allow the
graft to be expanded and cover a
greater area and also allows any
blood/serum to drain away.
 Flaps
- A flap is a piece of tissue carries its own blood supplies that is moved from its
original site, to cover a defect.
- Skin flaps/ muscle flaps/ myocutaneous flaps/ fasciocutaneousflaps/
osseofasciocutaneous flaps.
- Flaps are used when grafts are insufficient to cover the defect, or they wouldn’t be
taken.
- To cover an avascular area.
- When we need a more bulky tissue to deal with the defect and skin is not enough.
- The donor area is managed by approximation if it was loose or by skin graft.
1st degree burn 2nd degree burn
- Pain and erythema. - Necrosis of the epidermis and
- Limited to the dermis. varying depth of the dermis
- No contracture. (superficial/ intermediate/ deep).
- (1-6) days , heals by - Pain, erythema, blisters, blanching,
regeneration. burned area is wet with exudate.
- Applies only to thermal
- Applies only to thermal burns.
burns.
3rd degree burn

- Full thickness.
- Eschar (dead tissue, • Post burn contracture.
insensitive, lethargy, • a complication of 3rd degree burns.
inelastic, hard). • they should have put skin graft for the
- Applies only to thermal patient to prevent this complication.
burns.
Role of 9’s in Burns
Q: What is the Dx?
nd
- 2 degree burn
 Q1: What is the degree of burn in this
image?
- 3rd Degree

Q2: What is the name of the scar?

- Escharatomy

Q3: if the burn was circumferential and

the patient weight was 100 kg,
calculate:
1. TBSA%:
- 100% (all the areas affected!)
2. Fluid that needed in the 1st 8 hours if
the TBSA is 40%:
- 8L
(4 x 40 x 100 = 16K ml/1000 = 16 L, in the 1st 8 hr
we give ½ (so 8))
 Escharotomy VS fasciotomy
- fasciotomy is done in Mx of compartment Escharotomy
syndrome after electrical burn.
- Escharatomy is done to decompress tissues in
3rd degree burns.
- Beneath escharotomy you will see
granulation tissue, beneath fasciotomy you
will see muscles.
- If ischemia is suspected, escharotomy is
indicated.

Fasciotomy
 Electrical burn
• The severity depends on the voltage.
• Nerves, muscles and blood vessels have low
resistance, so they are affected most.
• Skin, bone and tendons have high resistance,
hence, they are less burned.

• Management:
Pt should be monitored for cardiac
arrhythmias.
Good hydration & alkalization of urine to
prevent renal impairment.
 Fluid management couldn’t be based
on calculated formula.
Observation of limb vascularity & fasciotomy.
What is the Dx? Electrical burn
What to do? Fasciotomy.
What is the cause of urine color ? Myoglobin.
(electrical burn causes myoglobinuria)
 Thermal Burn
Scald burn
- Temperature > 45 degrees.

- Duration of exposure is more

important than degree of temp.

- Classification: Contact burn

1) direct flame burn
2) scald burn (with hot liquids).
3) contact burn with hot metals.
4) friction burn.
Friction burn
 Q1: What category of burn does this
patient have?
-It's a facial flame burn ( facial edema ).

Q2: What is the main risk of this burn?

-the patient will have upper airway
obstruction and risk of CO poisoning.

Q3: What should you do?

-The patient should be intubated before
reaching to complete obstruction and
give 100% oxygen if CO poisoning is
suspected.
 Q: This lady had a flame burn 2 years ago.

Q1: What does the image show? Post-burn fibrosis and contracture.

Q2: What was the degree of her burn? 3rd degree.

Q3: Name the most suitabletype of skin graft to use in reconstruction?

Full thickness

Q: Serious complication that you fear from? Transformation into SCC

Q: This baby presented to theER with scald burn.

Q1: What is the degree of burn? 2nd degree.

Q2: Mention three lines of acute Mx of the burn:

Fluid resuscitation/ pain control/ dressing.
 Chemical burns
- Caused by acids or alkali.

- Acids produce less damage

and less penetration.

- Acids produce coagulative

necrosis.

- Alkali produce liquifactive

necrosis.

- Management : dilution by
water for 2-4 hrs in alkaline
burn, and 30 minutes for
burns caused by acids.
 Q: A trauma pt presented to the ER
and was assisted with FAST:

Q1: What does FAST stand for?

- Focused Assessment with
Sonography for Trauma

Q2: What are the 4 sites that we look

at in FAST?
1) RUQ (Morison’s pouch – Perihepatic)
2) LUQ (Perisplenic area)
3) Subcostal (Pericardiac)
4) Pelvic space
Q: A patient presented to the ER
after RTA:

Q1: What's your 1st priority?

- ABC
(some said only airway)

Q2: What's your 2nd priority?

- Stop bleeding
(some said only breathing)
Bleeding Classes
Q: This patient arrived to your ER after being stabbed
as shown 15 minutes ago. He was anxious and his
vital signs were BP: 95/55 mm Hg, pulse 105 BPM,
and RR 25 Per minute.
1. What is his class of hemorrhage? Stage 2
2. How much blood has he lost? 750-1500 ml
Q: A patient fell and broke her leg, then the doctor who saw
her put a cast on the leg, afterwards she complained from
pain, swelling, redness and numbness in the same limb:

Q1: What is the Dx?

- Compartment Syndrome

Q2: Next step in Mx?

- Decompression
- Remove the cast
- Fasciotomy
 Q1: Name this sign?
- Seat belt sign

Q2: Name 4 associated injuries?

1) Flail chest
2) Small bowel injury
3) Cervical spine injury
4) Fracture of the sternum, rips, clavicle & the vertebral bodies
 Q1: In penetrating trauma most affected organ?
- Liver
Q2: What type of injury more severe (blunt or penetrating)?
- Blunt
Q3: In a penetrating wound, what should you do?
- Exploration Surgery
Abdominal injury-
Evisceration
Q: picture of multiple abdominal bruises, he asked about the zones
of retroperitoneal bleeding and types of hemorrhage and where is
the least likely place to check and when to go for surgery:

- Traumatic retroperitoneal hematomas divided into 3 zones:

Zone 1: Centrally located, associated with pancreaticoduodenal
injuries or major abdominal vascular injury
Zone 2: Flank or perinephric regions, associated with injuries to the
genitourinary system or colon
Zone 3: Pelvic location, frequently associated with pelvic fractures or
ileal-femoral vascular injury

- Indication for exploration in retroperitoneal hematomas :

mandatory exploration should be performed in retroperitoneal
hematomas resulted from penetrating injury, but the selection of
treatment mode in blunt injury depend on the anatomical position of
hematoma, visceral injury and the hemodynamic status of patients.
Q: Hx of surgery for diverticulitis
before 10, the amount collected
over 24 hr is 1500 cc:

Q1: What is the pathology?

- Enterocutaneous fistula
(high output)

Q2: What is the complication?

1) Electrolyte disturbance
2) Skin excoriation
3) Sepsis

Q3: What is the prognosis?

- In most patients it closes
spontaneously
Q1: Type of stoma?
- End Colostomy

Q2: Mention 2
indications?
- IBD
- Rectal Tumors
 Q: What is the
A
complications in A, B, C?
A) Prolapsed Stoma
B) Infected Stoma
C) Stoma Necrosis

B
C
 Q: A 65 year old man underwent
abdomino-perineal resection 2 years
ago after diagnosis of rectal ca.

Q1: What is the type of his stoma?

End colostomy.

Q2: What is the complication shown?

Prolapse.
 - Usually at the RLQ.
- Bag contents : watery stool.
- Offensive smell.
- Surrounding skin isusually
inflamed (irritated from
acid).
- Median or paramedian scar
is usually seen.

Loop ileostomy End ileostomy

2 openings
 End Ileostomy
- Edges are spouted.
Q1: What is this? - Site: right iliac fossa.
Ileostomy.

Q2: How can you confirm?

By its site and skin irritation
around the stoma.

Q3: What is the disease

that probably was treated
by this?
Chron’s disease.
 End colostomy
- Sites : LLQ (sigmoid colon)/ RUQ
(transverse colon) / RLQ ( cecostomy)
- Formed stool in bag.
- No skin changes.
- Sigmoid colostomy expels stool 1/day.

Double barrel colostomy : together on left

picture and separated on right picture.
incisional hernia Femoral hernia
(notice the surgical scar) -most common herniain females.
m.c.c is wound infection - Medial to femoral vessels.
 Q1: Name of the test?
- Ring occlusion test

Q2: If you ask the patient to

cough while you maintain
pressure and you notice a
bulge, what is your Dx?
- Direct inguinal hernia

** Note: Ring occlusion test differs from 3

fingers test, You Ask the patient to cough>
Impulse felt on the index finger> Indirect
hernia So; Zieman’s Test (3 Finger Test) is
used to differentiate type of hernia.
- Index: deep inguinal hernia (indirect)
- Middle: superficial inguinal (direct)
- Ring: Saphenous opening (femoral hernia)
 Inguinal hernia
DDx of inguinal hernia :

Hydrocele/ saphena varix/

testicular torsion/ psoas
abscess .. Etc.

- Indirect : most
common type in both
males and females.
- Indirect : lateral to the
inferior epigastric
artery.
- Direct : medial within
hesselbach’s triangle. Herniotomy : only in peds patients.
Herniorrhaphy : tension due toapproximation/
high recurrence.
Hernioplasty : using a mesh/tension free/ open
or laparoscopic.
 Para umbilical hernias
crescent-shaped bulge develops in the
navel.
 Q: Patient presented with painful lump in his belly button:

Q1: What is the Dx?

- Strangulated Hernia

Q2: If the bowel still the same despite of all measures, what's
your next step?
- Resection and Anastomosis
 Pectus excavatum
( funnel chest )

Poland syndrome

Ganglion cyst
- is a non-neoplastic soft tissue lump.
- It's painful.
- recurrence may occur after surgery.
 Lower extremity amputations
Indications : irreversible tissue ischemia & necrotic tissue/ severe infection / severe
pain with no bypassable vessels, or if pt is not interested in a bypass procedure.

Syme’s amputation
Bellow knee amputation Above knee amputation Through the
articulation of the
ankle with removalof
the malleoli.

Ray amputation
Removal of toe
& head of
Transmetatarsal amputation Metatarsal.
 Flail chest
Segment occurs when three
or more contiguous ribs are
fractured in two or more
places.

It typically occurs after high

impact trauma.

Flail segment of chest wall that

moves paradoxically (opposite
to the rest of chest wall)
 DOG BITE

*Management :

1)exploration
2)analgesia
3)IV antibiotics
(clindamycin + penicillin)
4)elevation
5)tetanus toxoid
6)rabies vaccine
Erythroplakia Leukoplakia

- Reddish patch that appears on - White patch that appears

the oral mucosa. on the oral or genital
- It has 17 X more risk of mucosa.
malignancy than leukoplakia. - Risk factors : smoking/ ‫تاقال‬
- Premalignant (transform to
SCC).
 Q1: What is the Dx?
- Cushing Syndrome

Q2: Causes?
- Iatrogenic (cortisol
administration)
- Pituitary Adenoma

** Note: Cushing triad:

1) Irregular, decreased respirations
2) Bradycardia
3) Systolic hypertension
 Q1: White arrow?
- Pituitary Adenoma

Q2: Syndrome name?

- MEN

Q3: The most important thing

surgically to do for this patient?
- Pancreatic tumor “not sure”
 Q: Male with heart disease:
Q1: what is the abnormality in the picture?
- Gynecomastia
Q2: What drugs is the patient taking that might cause this?
- Spironolactone
- Digoxin
 Charcot foot

•Rocker-bottom
appearance.

•Develops as a result of
neuropathy such as in
diabetic pts.

• ttt : immobilization/
custom shoes & bracing.
 signs of basilar skull fracture

Clear rhinorrhea raccoon eyes otorrhea

battle's sign ( ecchymosis

hemotympanum
behind the ear )
 Hyphema: blood in the
anterior chamber of the eye
 Q: This is pelvic x-ray of a
patient post RTA:

Q1: What is the pathology?

- Pelvic fracture

Q2: What is the most serious

complication?
- Bleeding (Femoral artery)
 Question: about post- Question A: which of the following
operative fever: picture are consider as a source of
1. Lung Atelectasis fever after 1-3 days?
2. ECG change MI -Atelectasis (1)
3. UTI Question B: which of the following
4. wound surgical site infection picture are consider as a source of
5. drugs fever after 5-7 days?
-Wound infection (4)
 Pre-
cancerous
lesions
1. Leukoplakia of the tongue
(15 %malignant 1
transformation to SCC /
DDx: Oral candidiasis, how
to differentiate? Candidiasis
scrapes off).
2
2. Colon in FAP.
3. Colon in HNPCC.
4. Thyroid gland in MENS II.
5. Breast in BRCA mutations.

- Surgery has a role in 1ry cancer

prevention.
 Classic physical findings that
represent METS & incurable disease :
1) Virchows node enlargement (left supraclavicular
nodes).

2) sister merry josephs nodules : infiltration of the

umbilicus.

3) blumers shelf :fullness in the pelvic ,cul-de-

sac(solid peritoneal deposit anterior to the rectum
forming a shelf palpated on PR).

4) krukenburgs tumor :enlarged ovaries on pelvic

examination (Metz to ovaries).

5) hepatosplenomegaly with ascites and jaundice.

6) cachexia.
Virchow’s node
7) irishs node :left axillary adenopathy. enlargement
Q1: What are the names of those tools?
- Central line and cannula

Q2: What is better to insert in a trauma

Triple Lumen
patient & for fluid administration, why?
- Cannula, because it is easier to use,
require less experience and time, it also Double Lumen
deliver the largest volume of fluid

Q3: The smallest cannula in diameter is?

- Purple
(Cannula’s in the picture – Blue)

Q4: Cannula for large amount of fluid?

- Orange
(cannula’s in the picture - Green)
Cannula’s
 Q1: Name this tube?
- Chest tube

Q2: Give 4 indications?

1) Hemothorax
2) Pneumothorax
3) Chylothorax
4) Empyma
5) Hydrothorax
6) Pleural Effusion
7) Post-op
Chest tube drain
 Q1: What is this device?
- Nasogastric tube

Q2: Give 3 indications?

1) Feeding
2) Decompression
3) Administration of medication
4) Bowel irrigation

Q3: The tip of it should reach?

- Stomach body
 Q1: What is this?
- Gastric tube/G-tube/PEG
tube/ Gastrestomy

Q2: What is the main

indication for it?
- Feeding
 Q1: What is A,B?
A > Stroma base (Flange)
B > Stoma bag

Q2: Mention 3 indications?

- After proctocolectomy
- Imperforated anus
- Secondary healing
- Some said (colestomy,
ileostomy, double barrel)
 Q1: What is this?
- Tracheostomy

Q2: Mention 2 complications?

1) Infection
2) Blockage (Obstruction)
3) Bleeding
4) Pneumothorax

Q3: Mention 2 indications?

1) Upper airway obstruction
2) Obtaining an airway in severe facial or
neck trauma
3) Upper airway edema and copious
secretions
4) Failure to wean from mechanical
ventilation
5) Acute respiratory failure with need for
prolonged mechanical ventilation
(mc indication, 2/3 of all cases)
 Q1: Name the tube?
- Nephrostomy tube

Q2: Write 2 indications?

1) Urinary obstruction
secondary to calculi
2) Hemorrhagic cystitis
Q1: Which one is not used in primary survey?
- C (Foley’s Catheter)

Q2: Which one is your 1st priority?

- D (Neck collar), some said (B)
 Q1: What is the name of device?
- Foley’s Catheter

Q2: What is the unit used in measurement??

- French
Q1: What is this? Colonoscopy

Q2: Name 2 pathologic

finding?
1) Angiodysplasia
2) Diverticulosis
3) Colon tumor
4) Polyps, masses

Q3: Name 2 therapeutic

procedures done with it?
1) Laser Ablation
2) Polyps Resection
 Q1: What is this device?
- Pulse Oxymeter

Q2: What does it calculate?

- O2 Saturation
- Pulse Rate (HR)
Q1: What is the name of the drain?
- Penrose

Q2: Type of the drain?

- Open drain
Q: Name of the drain?
- Corrugated Drain
 Redivac drain
T-tube Drains can be:
used for post operative drainage of Open or closed
common bile duct. Active or passive:
 Q1: What is this device?
Intermittent pneumatic compression technique
(Inflatable leg sleeves).

Q2: Uses?
To prevent DVT.
 Q1: what is this?
incentive spirometer

Q2: Why do we use it?

used after surgery to prevent atelectasis .
(used while inspiration not expiration).
 Q1: Name of device seen in the CT?
- Inferior vena cava filter

Q2: Give 1 indication for it?

1) Proven VTE with contraindication for anticoagulation.
2) Proven VTE with complications of anticoagulation.
3) Recurrent VTE despite adequate anticoagulation.
 Q1: Name of device?
- Central venous catheter (CVC)

Q2: Where do you insert it?

- Subclavian vein
- Internal jugular vein

Q3: Mention 2 indications?

1) Total parenteral nutrition (TPN)
2) Hemodialysis
3) Chemotherapy

Q4: Mention 2 complications?

Pneumothorax, Hemothorax, Recurrent
laryngeal nerve injury, Arterial or Venous
injury, Arterial access instead of venous,
Hematoma, Infection, Thrombosis and
occlusion of the line…etc
 Venous access catheter

Small, flexible hollow tube.

Surgically placed into a large vein.
 Can be left for several months.
Used for repeated infusions of
chemotherapy drugs.
 Biological heart valves Mechanical
prosthetic valves
Used in the following cases:
Used if the age is < 60 + longlife
- Age > 60
expectancy.
- Previous thrombosed mechanical valve.
- Limited life expectancy.
- If Coagulation is contraindicated.
- Young women wishing to get pregnant.
Q: what can you see in
this chest X-Ray ?

sternal wires in the

midline (indicate that
patient U/W
sternotomy).

pacemaker.
Intra-aortic balloon pump (IABP) is a mechanical
device that increases myocardial oxygen
perfusion and increasing CO. These actions
combine to decrease myocardial oxygen demand
and increase myocardial oxygen supply.

Notes :
- the polyethylene balloon has a radiopaque tip.
x
- the balloon inflates during diastole and
deflates during systole .
- indications :Cardiogenic shock post-MI , (CABG)
,post cardiothoracic surgery, unstable angina .
- most important complication is lower limb
ischemia, we have to check the pulse and
perfusion .
- most important contraindication: aortic
valve insufficiency (AR) ,aneurysm .