SURGERY

· SURGERY
· Hypotension not responsive to fluid administration is suggestive of ongoing blood loss and such patients with abdominal trauma need an immediate exploratory laparotomy.

· Vital signs, hemodynamic stability, and need for blood transfusion are important determinant for surgical v/s non-surgical management of patient with splenic trauma.

· Choledocholithiasis symptomatic of biliary colic and without any systemic toxicity is treated with analgesic and spasmolytics and elective surgery is done at a later date.

· Tetanus prophylaxis depends upon whether the patient had his 3 doses or not. If yes, it depends upon when did he have it. For any wound, clean or minor, patients should be administered tetanus toxoid if the last dose was administered 5 years ago. However, if the patient has clean wound & he has previously received 3 or more doses, but received the last dose 10 years ago, then again he should receive the tetanus toxoid.

· Transient submandibular gland swelling may occur during feeding due to partial obastruction of its duct and further evaluation is required if swelling is persistent or recurrent.

· In a young individual who present with a fleshy immobile mass on his hard palate, the most likely Dx is torus palatinus. No medical or surgical therapy is required.

· Technetium pertechnetate scintigraphy is the best diagnostic test for Meckel’s diverticulum.

· Colonoscopy is difficult and rarely performed in settings of active bleeding. If the bleeding stops, however, it should be done.

· Angiodysplasia may be seen as cherry-red spots that may be coagulated.

· Labeled erythrocyte scintigraphy, although not a very precise study, could be helpful to define the site of bleeding.

· The diaphragmatic rupture is more common on the left side, since the right side is protected by the liver. The leakage of intraabdominal contents into the chest causes compression of the lungs and mediastinal deviation. Elevation of the hemidiaphragn on the chest X-ray may be the only abnormal finding. Sometimes, there may be evidence of small bowel in the thoracic cavity.

· Approximately 5-10% of unconscious patients who present to the ED as result of a motor vehicle accident or fall, have a major injury to the cervical spine. One third of injuries occur at the level of C2, and one half of the rest occur at the level of C6 or C7. Most fatal cervical spine injuries occur in upper cervical levels, either at craniocervical junction, C1 or C2.

· It is important to rule out a fracture or dislocation of cervical spine as the first priority because of grave consequences of missing a cervical spine injury.

· Cast immobilization is recommended in the tx of all non-displaced scaphoid fractures (fractures <>10
· ï‚• Neuromuscular scoliosis: secondary to neuromuscular disturbance or muscle disease.
· ï‚• Congenital scoliosis: secondary to structural bony deformities.

· Highest detection rate of prostatic carcinoma in early stages---PSA+digital rectal examination

· Kidney stones:
· ï‚• Oxalate stones: in a patient who undergoes bowel resection and then develops kidney stones, one should always suspect oxalate.
· ï‚• Cystine stones: rare and occurs as part of a rare inherited disorder of defective renal transport resulting in over-excretion of cystine. Sone formation begins in childhood and are a rare cause of staghorn calculi.
· ï‚• Uric acid stones: occur when urine is saturated with uric acid in the presence of an acidic urine and dehydration. Seen in gout, myeloproliferative disorders and diarrhea. Tx: fluid, alkalinization of urine, allopurinol.
· ï‚• Struvite stones: form in the collecting system and become infected with urea splitting organisms. Condicitons required for formation of struvite stones are presence of high urine pH, magnesium, ammonium and carbonate levels.
· ï‚• Calciu phosphate stones: associated with hypercalciuria (sarcoidosis, immobilization, Cushing’s syndrome, renal tubular acidosis.) std Tx: fluid, thiazide.(note Furosemide in CI).

· Acute appendicitis: Rovsing’s sign +. Requires immediate surgery.

· Acute appendicitis may be complicated by pelvic abscess that presents with lower abdominal pain, malaise, low-grade fever and tender pelvic mass on rectal examination. (most of the pelvic abscesses are due to perforation of appendix. Tx. Drainage of the abscess).

· Laxatives should not be given in the setting of intestional obstruction.

· Intestinal obstruction with metabolic acidosis and shock indicates serious disease and it requires laparotomy. (suggesting bowel ischemia or necrosis).

· In case of simple mechanical obstruction, there would be metabolic alkalosis.

· Patients who present more than 5 days after the onset of symptoms of appendicitis, and have localized right lower quadrant findings, should be treated with IV hydration, antibiotic and bowel rest. Antibiotics should cover enteric gram-negative organisms and anaerobes (cefotetan)

· Cefotetan: has a good coverage of gram-negative organisms and anaerobes; therefore, this can be used as monotherapy in complicated appendicitis.

· Erythromycin and vancomycin are effective against gram-positive organisms, they do not cover gram-negative organisms or anaerobes.

· Persistent symptoms (e.g. mechanical symptoms) in patients with probable meniscal injury should be further evaluated by MRI or arthroscopy. Surgery (arthroscopic or open) is often necessary to correct the problem.

· Boerhaave’s syndrome is esophageal perforation due to severe vomiting and it produces pneumomediastinum.

· Saphenous vein cut down or percutaneous femoral vein catheterization are alternatives to have an intravenous access in trauma patients with collapsed veins.

· Interosseous membrane cannulation is an alternative route in children <4>40 yo, one or more additional risk factors, minor/non-major surgery. The risk of DVT is 2-10%.
· ï‚• High risk: patients > 40 yo, additional risk factors, major operation (e.g. orthopedic procedures of the lower extremity). The risk of DVT in these patients is between 10-20%.

· Bucket handle tear of medial meniscus is the MC meniscus injury at knee and leads to locking of the knee joint during terminal extension.

· Lachman’s test is the most sensitive physical test for Dx of anterior cruciate ligament injury. (A popping or snapping sensation is commonly felt at the time of ACL injury, ACL prevents anterior gliding of the tibia under the femoral condyles). Patients complain of instability of the knee. Commonly associated with injury to medial meniscus and medial collateral ligament of the knee (terrible triad). Lachman’s test: is done with knee flexed at 20 degrees, and pulling the proximal tibia with one hand while stabilizing the femur with the other hand.

· Anterior cruciate ligament: prevents anterior glinding of the tibia under the femoral condyles. Isolated injury is seen after hyperextension of the knee. A “popping or sanpping” sensation is commonly felt at the time of injury. Patients complain of instability of the knee (giving out, looseness etc.) It is commonly associated with injury to medial meniscus and medial collateral ligament of the knee. (terrible triad)

· Osgood Schlatter disease: is an apopysitis of tibial tubercle seen in young teenager due to overuse. (swelling and marked tenderness over the tibial tubercle. Pain increases on contraction of quadriceps muscle.)

· Slipped femoral capitis: is an emergency condition and should be promptly corrected with external screws. (Dx is made by a high degree of clinical suspicion in presence of limited range of hip movements. Loss of abduction and internal rotation are very characteristic and external rotation of thigh is seen when hip is flexed. Frog-leg lateral view X-ray of hip joint is the imaging technique of choice for Dx.)

· Lateral collateral ligament injury: tackled while playing football, knee pain, swollen, direct palpation over the lateral aspect of the knee elicit pain. Anterior drawer and posterior drawer test, and Lachman test are all negative.

· Anterior drawer test: is also used for Dx of ACL injury but is less sensitive. It is done in supine position with the knee flexed at 90 degrees and hips flexed at 45 degrees, while tibia is pulled forward over femur to note the degree of displacement.

· Posterior drawer test: is used for Dx of posterior cruciate ligament injury. It is similar to anterior drawer test except that posterior pressure is exerted on tibia to note posterior displacement.

· McMurray’s test: is used for Dx of meniscus injury. In case of meniscus injury a click is heard on forced flexion and rotation of the knee. (popping sound on passive flexion/extenstion of the joint)-specific for meniscal injury.

· Valgus stress test: is used for Dx of medial collateral ligament injury in which case valgus stress leads to marked angulation of knee joint as compared to the normal knee.

· The immediate management of splenic trauma caused by blunt abdominal injury depends on the patient’s hemodynamic status and response to IV fluids. If the patient is initially hemodynamically unstable but improves with fluid administration, the best next step is to obtain an abdominal CT scan. If the patient is initially hemodynamically unstable and is unresponsive to fluid administration, then emergent exploratory laparotomy is required.

· Intermittent claudication is best treated with aspirin and an exercise program.

· MRI is now the investigation of choice for ligamentous injuries of the knee with an accuracy rate of 95%. Surgery is rarely necessary for MCL tear.

· Non-communicating hydrocele disappears spontaneously by 12 months of age and it is therefore managed expectantly.

· CT scan of a diffuse axonal injury shows numerous minute punctuate hemorrhages with blurring of grey-white interface. It is the most significant cause of morbidity in patients with traumatic brain injuries.

· A sternal fracture is very likely to be complicated by myocardial contusion, serial ECG is needed.

· Paget’s disease of the nipple: Dx-mammogram and punch biopsy.

· Tx. of Mitral stenosis: cardiovascular surgeons prefer to repair the patient’s own mitral valve, rather than replacing it. Stenosis is due to fusion at the commissures---commissurotomy can correct.

· As a rule: internal hemorrhoids bleed but do not hurt, wherears external hemorrhoids hurt but do not bleed. (discomfort could be pain, or itchy)

· Brain examinations:
· ï‚• CT scan is our best tool when intracranial bleeding is suspected.
· ï‚• MRI is our choice when brain tumor is suspected..
· ï‚• Duplex scanning is our choice if transient ischemic attack is suspected.

· Fogarty balloon tipped catheters: an embolectomy used in treating embolic occlusion of the artery. Heparin etc anticoagulants are an adjunct to vascular procedures, but are not the primary Tx for a clot that has already traveled from the atrial appendage to the lower extremity. Anticoagulants cannot dissolve existing clots.

· The urinary retention is extremely common in the immediate postoperative period after lower abdominal inguinal or perineal surgery. Tx: in and out bladder catheterization. (don’t use indwelling Foley catheter unless in and out fails twice to resolve the urinary retention.)

· If a scaphoid fracture is suspected, even without a visible fracture on X-ray, it must be treated as if there was a fracture. (long arm cast)---fall on an outstretched hand. Pain with wrist movement, tenderness in the anatomical snuffbox. 10% go on to develop avascular necrosis due to tx error.

· Spinal cord ischemia with lower spastic paraplegia is a rare complication of abdominal aneurism surgery.

· Acute adrenal insufficiency is a potentially lethal postoperative complication. Preoperative steroid use is the main cause. A high index of suspicion is required. Commonly, they present with nausea, vomiting, abdominal pain, hypoglycemia, and hypotension.

· Burns:
· ï‚• 1st degree: superficial burns, confined to the epidermis with minimal skin damage. The skin is mildly erythematous and pain is the chief complaint. (such as sunburn, heals without scaring.)
· ï‚• 2nd degree: partial thickness burns-involves the entire epidermis and various layers of the dermis. Skin is painful, red, edematous and blistered.
· ï‚• 3rd degree: full thickness burns-no dermal appendages remain, all epidermis and dermis is completely destroyed. (flame burn)

· Patients have obvious signs of hemorrhagic shock (loss of about 25-30%, 1500 mL blood), can only occur with intraabdominal bleeding, intrathoracic bleeding, and fracture of femur, pelvic, extremities or bleeding in neck. USG and DPL are the procedure of choice to diagnose intra abdominal bleeding in an unstable trauma patient. (ultrasonogram, diagnostic peritoneal lavage).

· In case of amputation injury, amputated parts should be retrieved and brought to the ED. The amputated part should be wrapped in a saline-moistened gauze sponge placed in a plastic bag. The plastic bag should be sealed and placed on ice.

· Cirrhotic patients with ascites may develop spontaneous primary bacterial peritonitis, which gives a “mild picture of acute abdomen”, Dx: culture of the ascetic fluid.

· Sigmoid volvulus, a common condition in elderly patients. The endoscopic instrument (proctosigmoidoscopy) can untwist the bowel from the inside, relieve the obstruction, and allow placement of a long rectal tube.

· Nerves of the lower extremities:
· Femoral N.:innervated the muscles of the anterior compartment of the thigh, and is therefore responsible for knee extension and hip flexion. It provides sensation to the anterior thigh and medial leg via the saphenous branch.
· Tibial nerve: supplies the muscles of the posterior compartment of the thigh, posterior compartment of the leg, and plantar muscles of the foot. The tibial nerve provides sensation to the leg (except medial side) and plantar foot.
· The obturator nerve: innervated the medial compartment of the thigh (ie, gracilis adductor longus, adductor brevis, anterior portion of adductor magnus), and controls adduction of the thigh. It provides sensation over the medial thigh.
· The common peroneal nerve: gives rise to the superficial and deep peroneal nerves. These two nerves supply the muscle of the anterior and lateral leg. These nerves provide sensation to the anterolateral leg and dorsum of the foot.

· Current Tx. to full thickness burn: immediate excistion, grafting

· DDH:
· Ultrasound is the most sensitive investigation for DDH (developmental dysplasia of the hip) for infants less than 6 months of age.
· X-ray of hip is not useful in young infants, as the cartilage and epiphysis are not ossified.
· However, in older infants and children, plain radiography is the preferred modality of investigation.
· MRI of hip joint though sensitive is reserved for complicated cases
· CT though sensitive is not the first investigation of choice. It is particularly used for evaluating complicated dislocations and for postoperative evaluation of the hip.
· After rhinoplasty, if there is whistling noise during respiration, one should suspect nasal septal perforation.

· Unless strangulation or perforation is suspected, bowel obstruction is treated conservatively with fluids, nasogastric suction and enemas.

· Retrograde cystogram with post void film is the investigation of choice for patients with suspected bladder trauma.

· Retrograde urethrogram should be the first step in management of suspected posterior urethral injury. (inability to void, trauma history, high riding prostate)

· Anterior urethral injury due to injury to urethra anterior to the perineal memebrane. Anterior urethral injuries are most commonly due to blunt trauma to the perimeum (straddle injuries), and many have delayed manifestation.

· Posterior urethra consists of the prostatic urethra and memebranous urethra. Posterior urethral injuries are most commonly associated with pelvic fracture. (presents with blood at meatus, high riding prostate, scrotal hematoma and inability to void in spite of sensation to void).

· When suspecting a urethral injury, do a retrograde urethrogram, inject the dye directly into the urethra. Inserting a Foley catheter is absolutely contraindicated in suspected urethral injury, you may change a partial urethral disruption into a complete transaction.

· Retrograde ejaculation occurs in up to 90% patients undergoing transurethral resection of the prostate (TURP).

· TUIP (transurethral incision of the prostate) involves incision of the periurethral prostate without resection of any tissue. This procedure is minimally invasive and can be performed on an outpatient basis. It frequently results in symptomatic relief without the adverse effects of TRP.

· The disease with the highest incidence of perioperative death or cardiac event is a recent myocardial infarction. (other causes: coronary disease, worsened or poor baseline exercise tolerance, recent infarction)

· Postoperative period, patient has persistent difficulty swallowing solids and even more difficulty swallowing liquids. Any attempts to do so results in violent coughing ans aspiration.Lesion: ----------sensory fibers of the 9th (glossopharyngeal) nerve.

· When a patient presents with a pulsatile abdominal mass and hypotension, a presumptive Dx of ruptured abdominal aortic aneurysm must be entertained and the patient should be taken straight to the operating room.

· Aortic aneurysm rupture, best diagnostic exam: Spiral CT scan or MRI angiogram.

· Ureteropelvic junction obstruction and profuse diuresis: a congenital narrowing at the ureteropelvic junction allows normal passage of urine at a normal flow rate, but the lumen can’t accomadate a suddenly increased flow rate. (remember, beer is a wonderful diuretic.)

· Most common nontraumatic casue for SAH is: berry aneurysm in the anterior portion of the circle of Willis.

· Any gunshot wound of the abdomen requires exploratory laparotomy. Any gunshot wound below the 4th intercostals space (level of nipple) is considered to involve the abdomen.

· Subluxation of radial head is a common condition in preschool children and needs closed reduction by flexion and supination of forearm.

· Small amount of intraperitoneal bleed that is not visible on abdominal ultrasound can be detected by diagnostic peritoneal lavage.

· Consider bowel ischemia and infarction as an early complication of operation on the abdominal aorta.

· Hallmark triad of urethral injury is:
· ï‚• Blood at urethral meatus
· ï‚• Inability to void
· ï‚• Distended bladder

· For carcinoid tumors located at the tip of the appendix, appendectomy is sufficient Tx. Carcinoids do not have the tendency to spread and have a good prognosis. When carcinoid spreads to the liver, it may produce the carcinoid syndrome, which is characterized by flushing, diarrhea, cramping, and valvular heart lesions.

· Rule out vascular injuries in case of penetrating wound near the site of important vessels. (arteriogram)

· Monteggia fracture: an isolated fracture of proximal third of ulna, with anterior dislocation of radial head. May be associated with injury to radial nerve, so careful neurovascular examination at the time of evaluation is mandatory. Tx: open reduction and internal fixation in adults, closed reduction and casting are optimal for children.

· Galeazzi fracture: an isolated radial shaft fracture, associated with disruption of distal radio ulnar joint also need open reduction and internal fixation.

· Osteogenic sarcoma usually presents with painful swelling around the knee without any systemic signs and radiographic findings are osteolytic lesions with periosteal reaction.

· Hyperventilation helps to prevent and treat intracranial hypertension by causing cerebral vasoconstriction and thus decresing cerebral blood flow. (goal: to have pCO2 in the range of 30-35 mmHg.)

· Harvesting team’d evaluate any dying patient as a potential donor.

· Typical history for fracture of the posterior lateral talar tubercle: standing on a chair and falls backward, a cracking sound -develop pain and swelling behind the ankle. Pain is exacerbated by plantar flexion and dorsiflexion of the hallus (big toe).Tx: with immobilization in a cast for 4-6 weeks. Dx: lateral x-ray film of the ankle.

· After rectal surgery, patient experience impotence, cause?-erectile nerve damage.

· In cirrhotic patient with hepaticencephalopathy, porto-systemic shunt may worsen the encephalopathy.

· Patient with cirrhosis may have upper GI bleeding due to:
· ï‚• Erosive gastritis
· ï‚• Varices
· ï‚• PUD (peptic ulcer disease)
· ï‚• Mallory-Weiss tears.

· In cases of bleeding esophageal varices, need for 5 or more units of blood transfusion in a period of 24 hours is considered an indication for surgery and transjugular intrahepatic portosystemic shunt is the best choice in emergency situations.

· When clavicle injuries occur and a bruit is present, an anterial injury must be ruled out with an angiogram.

· Atelectasis on chest X-ray can be confused with pneumonia and pleural effusion. However, it is more common after surgery in smoker and requires bronchoscopy to remove the mucus plug.

· Fever on the first postoperative day is almost invariably from atelectasis, the Tx of which requires active participation and cooperation from the patient. If atelectasis does not resolve, it leads to the development of pneumonia, which can be identified in chest x-ray and confirmed with sputum cultures.

· Sclerotherapy and surgery are indicated after first variceal bleeding, but not prophylactically. (sclerotherapy may have complications such as perforation, stenosis, and bleeding.)

· Pelvic X-ray should be routinely done in all patients with trauma to screen for pelvic injury.

· Fibrocystic disease: (mammary dysplasia) typically seen in women aged 20-40. It is characterized by painful breasts and recurrent formation of cysts.

· Malrotation: 3 week old infant, protracted bilious vomiting. With double bubble sign with a little gas beyong is highly suggestive. Dx must be promptly confirmed by barium enema or contrast study from above. Tx: emergency surgery.

· A patient must be left with at least 800mL in FEV1 to live a semi-decent life.

· Even being left with at least 800 mL in FEV1, a patient with SCC in lung still needs to do a CT scan of the chest and upper abdomen to rule out lymph metastasis before a pneumonectomy can be done.

· The best initial therapy for rhabdomyolysis is infusion of copious amounts of alkalinized saline to assist the kidneys in clearing the myoglobin from the blood. Alkalinizing the urine allows the renal tubules to retain the myoglobin and excrete it in the urine. (saline+bicarbonate)

· Percutaneous lithotomy: used for large renal sontes located within the pelvicaliceal system. Smaller stones located in this position are best treated with ESWL.

· Extracorporeal shock wave lithotripsy (ESWL): particularly effective on stones impacted in the distal ureter that have failed to pass spontaneously with conservative management.

· Testicular torsion needs immediate de-torsion if the testis is to be saved. No time should be wasted doing further studies.

· In patients sustaining trauma, there is a chance of bony cervical spine injury-lateral cervical spine x-ray can rule it out.

· A COPD patient with a 1100 mL in FEV1, suffers from a SCC at the hilar. What to do? ---only radiation + chemotherapy. If surgery and have the bad lung removed, then only leave him 40% FEV1 (440 mL).

· Expectant therapy is a rule for all patients with uncomplicated basilar skull fracture. Clinical signs of basilar skull fracture includes rhinorrhea, raccoon eyes (black eyes), and ecchymosis behind the ears and otorrhea. Patient’s head should be elevated and fluid intake should be restricted to 1200 mL/day. Patient should also be cautioned against the maneuvers that increase the intracranial pressure like blowing the nose.

· Legg calve Perthes disease (avascular necrosis) is serious but self-limiting condition of young children characterized by avascular necrosis of femoral head. Can be painless. But hip pathology can present as referred knee pain. Also named: avascular necrosis of the capital femoral epiphysis.

· The Tx of choice for isolated diaphyseal humeral fracture is by closed methods.

· Scaphoid fracture: nonunion and avascular necrosis are common complications. The proximal third of the scaphoid is prone to avascular necrosis in fractures involving the wrist or proximal pole.

· Gentle traction to attempt alignment of the fragments of a fractured long bone is important to prevent further vascular and neurological damage and it should be attempted immediately.

· Nasopharyngeal cancer usually presents initially as a painless neck mass. (other symptoms: epistaxis, hearing loss, nasal blockage)

· Warfarin treated patients should be given fresh frozen plasma instead of vitamin K when emergency surgical procedure is to be performed.

· Intravenous pyelography is very useful for the Dx of renal stones.

· Open fractures should not be closed primarily because of the associated increased risk of infection and subsequent osteomyelitis.

· Rhabdomyolysis can occur with severe crush injuries and should be managed with IV fluids, osmotic diuretics and alkalinization of urine.

· Hyperkalemia due to crush injuries needs IV calcium gluconate (acts as a membrane-stabilizing agent to balance against the imminent hyperkalemia-induced global depolarization of the myocardium.

· Elderly patients with displaced femoral neck fractures should be treated with primary arthroplasty.

· Tx of choic for intertrochanteric fracture: internal fixation with sliding screw and plate and early mobilization.

· Patients treated with high-dose methylprednisolone within eight hours of spinal cord injury have significant and sustained neurological improvement, thus its use is warranted as the first priority after stabilizing the patient. *important Q.!!!*

· 213. Garden classification for femoral neck fracture:
· ï‚• Type 1: valgus impaction of femoral head commonly seen with stress fracture
· ï‚• Type 2: complete but non-displaced femoral neck fracture.
· ï‚• Type 3: complete fracture with displacement <50%>50%

· Delayed emergency from anesthesia is characterized by hypotension, which is evident by decreased in respiratory rate, HTN progressing to hypotension, tachycardia progressing to bradycardia, restlessness and pallor/cyanosis.

· After blunt trauma to the chest, if an x-ray shows a deviated mediastinum with a mass in the left lower chest, one should suspect a diaphragmatic perforation.(Dx. barium swallow)

· Patient with head injury can never have hemorrhagic shock due to intracranial bleeding.

· Beck’s triad of hypotension, elevated JVP, and muffled heart sounds confirms the Dx of pericardial tamponade.

· Volkmann’s ischemic contracture is the final sequel of compartment syndrome in which the dead muscle has been replaced with fibrous tissue. Tx: immediate fasciotomy.

· Displaced anterior fat pad is a radiographic sign of supracondylar fracture, which may be complicated by Volkmann’s ischemic contracture.

· Presence of brachial pulse on the fracture side can’t rule out the possibility of vascular compromise because of collateral flow.

· Two locations in the body have the highest risk for development of the dreaded compartment syndrome: the forearm and the lower leg.

· Hirschsprung’s disease in neonate presenting with obstruction: diverting ileostomy +appendectomy (for Dx. of the disease). Definite repair can be done when the child is older.

· A known complication of ling-standing use of birth control pills is the development of hepatic adenomas that may rupture and bleed. (acute onset of abmominal pain, followed by a faint)

· The MC site of ulnar nerve entrapment is the elbow where the ulnar nerve lies at the medial epicondylar groove. *extremely HY Q for USMLE* (decreased sensation over the 4th and 5th fingers of the hand and a weaker grip compared to the normal side.) Prolonged, inadvertent compression of the nerve by leaning on the elbows while working at a desk or table is the typical scenario.

· APKD (adult onset polycystic kidney disease) diagnosed, you should order an MRA (magnetic resonance angiogram) of the brain to rule out berry aneurysms. (10%-20% incidence of this in APKD).

· Virtually all solid testicular masses are malignant tumors. The best way to avoid dissemination is to open the inguinal canal, do a high ligation of the cord, and pull the testicle out.(radical inguinal orchiectomy)

· Mixed connective tissue disease represents the over lapping symptoms of SLE, scleroderma and myositis. It is associated with autoantibody to ribonuclear protein.

· The rule is that lymph nodes that progressively enlarge over several months are malignant.

· Lymph nodes which are in the supraclavicular area, typically harbor metastasis from a primary tumor below the clavicles (i.e., not in the head and neck).

· Inhalation injury is common in burns patients and may take several days to manifest. Diagnosis is best done with a bronchoscopy.

· Body surface involved in burn injury is calculated with the rule of 9:
· ï‚• Each arm: 9%
· ï‚• Each lower extremity: 18%
· ï‚• Anteiror torso: 18%
· ï‚• Posterior torso: 18%
· ï‚• Face 9%
· ï‚• Perineum: 1%

· Burns patients need 4 ml/kg/% of the body area involved of fluid in first 24 hours, half of which is given in the first 8 hours. Plus 2000 mL dextrose 5% in water.

· Infection is the MCC of death in burns patients.

· Burns:
· ï‚• Superficial and erythematous burns while painful do not require any special wound care (not even antibiotics)
· ï‚• Early excision therapy is indicated for extensive partial-thickness and full-thickness burns, as they do not heal spontaneously. Also, it allows for early skin grafting and lesser complications.
· ï‚• Prophylactic systemic antibiotic is not indicated in all the patients. However, topical antibiotics should be used for burn wound care.
· ï‚• The most commonly used topical anti bacterial agent: silver sulphadiazine. Mafenide sulphate is only used if deep penetration is required in case of wound with eschar. Mafenide sulfate is associated with severe pain and acidosis.
· ï‚• Eschar is dead rigid tissue formed in burns wounds. The eschar restricts outward expansion of the compartment as edema occurs in the injured extremity following the burns. As a result, interstitial pressure rised to the point that vascular flow is compromised. This can be relieved by performing an escharoctomy.
· ï‚• Tetanus prophylaxis should be considered in all the burns wound patients using std guidelines as burn wounds are prone to tetanus infection.
· Cholesteatoma is an epithelial cyst that contains desquamated keratin. Patients generally present with chronic ear discharge and granulation tissue that are unresponsive to antibiotic treatment. (This is not a tumor)

· Carcinoids are most commonly found on the appendix; however, patients who present with carcinoid syndrome usually have carcinoids located in the small bowel.

· Dog bite:
· ï‚• May result in rabies (fatal disease)
· ï‚• Post exposure prophylaxis: active and passive immunization.
· ï‚• Capture the dog, if fails to do so, the dog is assued to be rabid and post exposure prophylaxis is indicated.
· ï‚• If the dog is available and it does not show any features of rabies, observed it for the development of rabies (10 days). If it shows rabies, it is killed and its brain is examined to confirm the presence of rabies and post exposure prophylaxis is given when rabies in dog is confirmed by FA.(fluorescent antibody)