2011 spring SURGERY III

BY ismail
Past papers question and
answere

Pyogenic infection of clinical manifestation and treatment of the TB?

SYMPTOMS :
Onset of symptoms of tuberculosis spondilitis is typical more insidious than
pyogenic infection
Constitutional symptoms
Chronic illness
Malaise
Night sweats
Back pain
Often a late symptoms that only occurs after significant boney destruction
and deformity
Signs
kyphotic deformity
neurologic deficit(present in 10-47% of patients with potts disease
for joints subluxution and dislocation
treatment
nonoperative
isoniazid,rifampin and pyrazanamide therapy
indicantions of surgical intervention of duodenal alcer?
1 accompanied by sever complications:acute perforation,massive
hemorrhage and scarring pylorus obstruction
2 failure after three course of formal internal medical therapy
3 operation method:subtotal gastrectomy or vagotomy.
Indications of surgical intervention of gasric ulcer?
1 non-healing after 8-12 weeks internal medical therapy
2 recurrence
3 accompanied by complications:perforation, hemorrhage and scarring
pylorus obstruction
3 duodenal ulcer
4 huge ulcer (>2.5cm) or malignancy suspected

Whate is the surgical indication for removal of simple goiter

and Whate are the complications of thyroidectomy?*****
Part1:
1. Symptom of pressure (dyspnea, dysphagia)
2. Substernal extension
3. Large goiter
4. Nodular goiter secondary hyperthyroidism

5. Suspicon of malignant.
Part2
1. Dyspnea and stridor
2. Reccurent laryngeal nerve injury
3. Superior laryngeal nerve injury
4. Parathyroid glang injury
5. Cramping of extremities
6. Thyrotoxic crisis( thyroid storm)
Extracorporeal circulation**?
Most open heart surgery through sternotomy. At the beginning of the
operation, heparin is infused (3mg/Kg). The arterial cannula is placed
in the ascending aorta. Venous cannula is inserted into either cava or
the right atrium. Extracorporeal circulation starts.
Please describe the normal value of intracranial pressuse?
Multiple rib fracture: Flail chest**?
Ventilation is severely impaired in these patients. paradoxical
respiratory .
Flail chest move in and out following respiration movement
paradoxically. The flail chest moves in while inspiration and move out
while expiration. This will bring to mediastinal flutter which lead to
anoxia and carbon dioxide accumulation, et al.
indications for strangulated intestinal obstruction***?
1 Shock
2 Failure in conservative treatment
3 Severe pain, continuous pain
4 Peritonitis
5 Bloody ascites (paracentesis)
6 Asymmetric distention (closed-loop ileus)
7 Xray
single dilated loop .
The signs of the pancreatic head cancer**?
Jaundice
Palpable liver
Palpable gallbladder
Tenderness
Acites
Abdominal mass.
What is the early complications of bone fractures****?
1. shock
2.Fat embolism syndrome
3.Injuries of internal organs
4.injury of blood vessels and nerve.
5.Osteofacial compartment syndrome.
Please briefly state the therapeutic mthod for lumber intervertebral
disc protrusion?*****
1. Disk bulge - Annular fibers intact.
2. Disk protrusion - Localized bulging with damage of some
annular fibers
3. Disk extrusion - Extended bulge with loss of annular fibers, but

disk remains intact

4. Disk sequestration - Fragment of disk broken off from the
nucleus pulposus.
5.
The types of urinary stone by the composition**?
Calcium-Containing Stones
Calcium oxalate calculus
Phosphate calculus
NonCalcium-Containing Stones
Uric acid and urate calculi
Struvite
Cystine calculi
Xanthine calculi
Paraneoplastic syndrome**?
Elevated erythrocyte sedimentation rate
Hypertension
Anemia
Cachexia and weight loss
Pyrexia
Abnormal liver function
Hypercalcemia
Polycythemia3.5Neuromyopathy
Amyloidosis
What is the common CABG bypass conduits**?
Internal Thoracic Artery
Radial artery
Gastroepiploic arter
Inferior epigastric artey
Greater saphenous vein
Complications of postgastrectomy**?
hemorrhage
duodenal stump rupture
rupture of the anastomosis
postoperative vomiting (gastric paralysis )
postoperative obstruction (stoma, afferent and efferent loop)
Standars of functional reduction****?
Rotation and separate dislocation: should be completed rectified.
Overlap: adultarea. 1cm, children2cm
Angulation: lateral angulation should be completed rectified.
Lateral dislocation: the shaft of the long bone should be contacted at
least 1/3 area, metaphysis contacted at least 3/4
What is the seze different and constancy of colon cancer**?
The size different and the consistency of luminal contents make
tumors produce obstruction in the left side more often than in the
right side tumors in the right side become so large that patients
develop superfacial necrosis from ischemia and then chronic
bleeding and anemia occurs
Criteria of clinical union?******
A No direct or indirect tenderness.
B No motion of the pseudoarthrosis.
C On x-ray film there is continuous

callus across the fracture line,

and the fracture line is not clear.

1/ Cervical spondylosis is commonly seen in outpatient

department. Please state its classification and main
symptom of each type***.
Cervical spondylotic radiculopathy;
Symptom:
Pain or numbness of neck and shoulder, radiating to the
the upper limb
Cervical spondylotic myelopathy;
Symptom:
weakness of limbs instability when moving or holding
sth.
Paralysis from upper motor neuron disease
Sympathetic type;
Symptom:
* Excitement of sympathetic nerve
headachevertigo, nausea, vomiting
Blurring of visionchange of pupil
Increasing of pulses, arrhythmia ,elevated blood
pressure
Sweating ,tinnitus descending of hearing disorder
of vocal sound
* Inhibition of sympathetic nerve
Vertigo, eyes blurred, tearing, blocked nose,
bradycardia, descending of blood pressure, gassiness
of bowel
Vertebral artery type;
Symptom:
Vertigo, headache, dysfunction of vision, cataplexy.
Presentation?*
Symptoms, which occur at the site of the bunion, may
include:
Pain or soreness
Inflammation and redness
A burning sensation
Possible numbness.

Soft Tissue***?
Muscle
Ligament
Bursa
Tendon sheath
Tendon
Mixed (Shoulder)

2/ What are the surgical indications of the lumbar disc

protrusion?***
The nonsurgical treatment is invalid or recurrence,
Symptoms affect job and living;
Nerve damage symptoms obvious;
The central type prolapse of lumbar intervertebral disc has
urine dysfunction;
With obvious lumbar spinal stenosis disease.
3/ Please state the therapeutic principle for chronic injuries
of motor system.
*Distributing of the centralized-attentions;
improve the strength of muscles, restrict the actions of
induced injury, correct the malposture, keep the unbearing
movement,
*Physiotherapy and massage;
*Local injection of hydrocortisone acetate suspension;
Definite diagnose strictly aseptic technique accurate
location
*Non-steroid anti-inflammatory drugs (NSAID);
*Operation;
stenosing tenosynovitis compression of peripheral nerve
syndrome
What are symptoms and signs of acute appendicitis and differential
diagnosis**?
Symptoms
1: 1)Pain in the epigastrium 2:Anorexia ,nausea ,or vomiting 3) Other
symptoms include low-grade fever and constipation
4) Infants with
appendicitis are lethargic ,irritable and anorexic
Signs 1: 1) Localized tenderness in the right lower quadrant is the most
important
2) Other signs include fever ,muscular rigidity ,rebound tenderness ,referred
tenderness
Differential diagnosis
1)gastroenteritis
2).mesenteric lymphadenitis
3) gynecological diseas: 1)Acute salpingitis
2)mittelschmerz.
3)Ruptured ectopic pregnancy.
4)Twisted ovarian cyst.
4 urinary tract disease:
1)Ureteral colic.
2)Acute pyelonephritis.
Local manifestations**
1.General signs
pain, tendernese, swelling , dysfuction, ecchymosis
2. special signs******* Deformity Abnormal movement Fricative
sound or sensation , must not be routinely examined.
Fracture Healing (three stages)*****

1 hematoma organization (Inflammation);2weeks

2callus formation (Repair);12-24weeks
3callus remoulding ( Remodeling);1-2years
Factors on Displacement*
1, the size and direction of the violence
2, weight of distal limb segment
3, traction of muscle
4, improper transportation
Systemicfactors*****
Agechild the elder
General conditions: malnutrition obesity,
diabetes, alcohol abuse, nicotine abuse
local conditions*********
type of fracture:
Blood supply
Infection
Degree of soft tissues injuries
Soft tissues lying between the two bone ends
Closed reduction Percutaneous screw fixation****
1Gustilo Type I Open Fracture
2. Gustilo Type II Open Fracture
3. Gustilo Type III Open Fracture
Three principles of fracture treatment*********
1. Reduction
2. Immobilization
3Fuctional exercise
b. There are three components within the skull****
(1)80% brain tissue and water
(2)10% cerebrospinal fluid (CSF)
(3) 10% blood: Cerebral blood flow (CBF)
. ICP**:
Intracranial pressure or ICP is the pressure or force exerted on the skull by
the brain and fluid inside the skull cavity.
d. Normal range of ICP***:
adult:70-200mm H2O(0.7-2.0kPa)
child:50-100mm H2O(0.5-1.okPa)

2. The concept of intracranial hypertension(IH*****:

adult: ICP>200 mm H2O
child: ICP>100 mm H2O
3. Common causes of ICH******
a. Brain tissue:brain edema
b. CBF: cerebral venous obstruction
c. CSF: obstruction of CBF pathway
d. Intracranial space-occupied lesions
e. Decrease of intracranial volume: cranio-

synostosis,

large

depressed skull fracture.

4 Factors influencing the clinical progress of IH
a. Age: Infant: Separation of skull sutures, compensatory volume
increase
Senile: Atropy of brain tissue compensatory volume increase
b. Expansion of lesions: Pressure-volume exponential curve( langfitt
curve)
If critical volume is reached, dditional volume increase produces
prominent increase of ICP.
The outcome of ICP elevation******
a. ICP
CBF
b. Brain herniation
c. Brain edema
e. G-I tract disturbances
f. Cushings response
g. Pulmonary edema
6.Clinical features of IH******:
a. Headache
b. Vomiting
Triad
c. Papilloedema
e. Cushings response: Cushing's triad involves an increased systolic blood
pressure, a widened pulse pressure, bradycardia, and an abnormal respiratory
pattern
d. abducent nerve paresis, Epilepsia
f. coma, Incontinence
g.Child:circumstance of head increase
7. Diagnosis:
a. clinical features
b. X-ray
c. CT/MRI etc..
2.Classification
a. Transtentorial herniation:
b. Tonsillar herniation:
3.Clinical manifestations: (please write the mechanism of
Transtentorial herniation)******.
a. Trans-tentorial H:
(1)Triad
(2)Loss of consciousness
(3)Ipsilateral mydriasis
(4)Contralateral hemiparesis
(5)Vital signs change
b. Tonsillar H:
(1)nuchal rigidity, neck pain, cough reflex
(2)respiratory failure early stage
(3)loss of consciousness late stage
e. Compensatory Mechanism******
The skull is rigid and does not allow much
expansion of the brain, so increases in ICP
is a critical medical condition that can lead to
brain damage.
An increase in one should cause a
decrease in one or both of the remaining two.
Cranio-cerebral trauma can involve scalp, skull, and brain or in any
combination.

Craniocerebral Trauma
Cranio-cerebral trauma can involve scalp, skull, and brain or in any
combination.
.Scalp:
a. hematoma:(1)subcutaneous H:lower in center
(2)subgaleal H:diffuse
(3)subperiosteal H:bony suture
b. laceration: bleeding shock suture
debridement within 24hrs with
antibiotics.
complications:
1)Fracture
2)Open injury
c. avulsion:
detached from the skull , skin graft
.Skull fracture
a. Vault skull fracture:
(1)linear, non displaced: no specific T.
(2)depressed
indications for operation:
1)large depressed fracture ICH
2)deficit of Neurological system :paraplegia,
epilepsy.
3)depth>1.0cm
4)open injury
5)near sagital sinus:comtraindication
2) Clinical manifestatiions : ICH herniation death*
1)Epidural
2) Subdural
Mechanism: acceleration
deceleration
Location: coup injury
contrecoup injury
bleeding: middle meningeal A.
coriical A, bridging V.
Lucid interval: obvious
atypical
CT: convex mirror

semilunar

Combination: less
more
Prognosis: good
bad
3)Interacerebral H: mainly secondary to brain
laceration, may occur in any part of the brain.
4)Delayed traumatic intracranial hematoma
Brain Injury:
Primary, Secondary
Close,
Open.
a. Mechanism: acceleration injury: coup injury
deceleration injury: contrecoup injury
b. Primary brain injury:
(1)Concussion: 1) loss of consciousness
2) recovery within 30mins
3) no positive neurological findings
2)Cerebral contussion and laceration .
Organic damage to the brain tissue (grey and white matter) accompanying
laceration of blood vessels which results in intracerebral hemorrhage.
Clinical manifestations**
1). disturbance of consciousness:>30min
2). local symptoms and signs
3). ICH herniation

(3)Diffuse axon injury(DAI)

pathological diagnosis:
rupture of the axon
axonal retraction ball
severe brain injury with high mortality.
Primary brain stem injury is nothing but a special type of brain injury
.
3.Essential Diagnosis:
(1) Evidence of SAH : abrupt onset of headache, stiff neck, impairment of
consciousness, seizures, etc.
(2) Evidence of an expanding intracranial mass: progressive cranial nerve.
(3) Demonstration of an aneurysmal sac by angiography, CT scan, or MRI.
1.Classification
Spontaneous SAH
Traumatic SAH
2.Concept:
Spontaneous subarachnoid haemorrhage is caused by arterial bleeding into
the subarachnoid space.
3.Causes of SAH.
Aneurysm rupture accounts for more than 60% of all spontaneous
subarachnoid hemorrhage
Arteriovenous malformations(AVM)-10%
Hypertensive hemorrhage
Not defined-20%.

acute abdomen: is the term used for an episode of severe abdominal pain
that lasts for several hours or longer and requires medical attention.prompt
pyonephritis**:
The kidney is converted into a multilocular sac containing pus or purulent
urine, pyonephrosis can result from infection of hydronephrosis, follow acute
pyelonephritis or, most commonly, arise as a complication of renal calculus
disease. Pyonephrosis is usually unilateral.
Stress incontinence** sudden leakage of urine with cough, sneeze,
exercise or other activities that increase intra-abdominal pressure.
Galeazzi fracture*** Fracture of the distal third radius and subluxation or
dislocation of the distal radioulnar articulation
Colles fracture**: A fracture of the distal radius with dorsal displacement
and associated ulnar styloid fracture
Most common type of wrist fracture in adults.
Monteggia fracture: Fracture of the proximal ulna and dislocation of the
radial head
Radial nerve is easily injuried
Callots triangle**
Its bounded by the common bile duct on the left, the cyst duct inferiorly,and
the cyst artery superiorly.it arterial blood
reaches via the cystic artery,
It originates from right hepatic artery
Chacots traid**also know as Reynolds pentad
Jaundice
Fever
Abdominal pain
Mental obtundation
Hypotension
Common channel
Variations in the relation between the intra
pancreatic portion of the common bile duct
and the main pancreatic duct at the ampula
of Vater. A short common channel contain
flow from both secretary system.
Indirect hernia**: Through inguinal canal
Internal ring and external ring
Lateral to inferior epigastric artery
Most common
Closed-loop intestinal obstruction** outlet and inlet obstructed
to strangulate
Emergent operation needed
Examples:
internal hernia
volvulus
colonic obstruction
Direct force** Fracture occurs at the same site where the force is
applied to. The fracture line may be comminuted or transverse, and
it is accompanied by severe soft tissue injury. In leg or forearm
fractures the fracture line of two bones are at the same level.
Indirect force The fracture site is far away from where the force is applied
to. For example, when one has a fall with his palm hits the ground, fracture
may occur at the humeral neck, not at the palm its soft tissue injury may be

mild(slight). In leg or forearm fractures the fracture lines of two bones are at
different level.