General Surgery OSPE Revision for SMS Z PDF

General Surgery General Surgery Revision  General Surgery Wound healing Factors affecting wound healing Systemic factors Age Gender Comorbidities Obesity Medications Lifestyle and...

General Surgery General Surgery Revision  General Surgery Wound healing Factors affecting wound healing Systemic factors Age Gender Comorbidities Obesity Medications Lifestyle and nutrition Factors affecting wound healing Age It is experienced that wound healing is better in youngsters and children but is slow or normal in old age. Inflammatory phase (delayed) Proliferative phase (decreased or delayed) Remodeling (lesser degree) Factors affecting wound healing Gender Women experience faster wound healing than men. Most of the studies showed that estrogen have a beneficial effect on the wound healing process, while, testosterone delays wound healing. Factors affecting wound healing Comorbidities (DM) Diabetic patients may experience delayed or even complicated wound healing due to: Autonomic neuropathy that may cause cutaneous ischemia Reduced inflammatory response and increase the risk of infection Factors affecting wound healing Obesity Obese patients may experience delayed or even complicated wound healing due to: Poor vascularity of adipose tissues Vascular insufficiency Increase risk of infection Decrease collagen synthesis Factors affecting wound healing Medication Some medications may impair wound healing such as (anticonvulsant, and angiogenesis inhibitors), while others enhance the process of wound healing such as (Vitamins and thyroid hormones). Factors affecting wound healing Nutritional & Lifestyle factors Protein deficiency (albumin) delay wound healing as it prolongs the first phase. Iron deficiency: Decrease oxygenation to the wound and hence delay wound healing. Vit. C deficiency: The wound become edematous, and the dead tissue is not quickly absorbed. The tensile strength is low and wound might break down. (it is essential for absorption of iron and synthesis of collagen) Vit K. deficiency: important for blood clotting Smoking: decrease blood supply due to ischemia Local factors Oxygenation Infection Blood supply Foreign body  Factors affecting wound healing Oxygenation Oxygen is essential for wound healing It prevent infection, induce angiogenesis, enhance collagen synthesis, and re-epithelization Due to vascular disruption and high oxygen consumption by metabolically active cells, the microenvironment of the early wound is depleted of oxygen and is quite hypoxic. If oxygenation is not resorted, healing is impaired Sometimes the use of hyperbaric oxygen therapy improve healing in a room called a hyperbaric oxygen chamber. Exposing a wound to 100% oxygen may speed healing.  Factors affecting wound healing Infection Contamination Colonization Infection Presence of non- Presence of Presence of replicating micro- replicating micro- replicating micro- organism organism in the organism in the without causing wound without wound with injury of any type of wound damage. tissues (requires AB). infection  General Surgery General Surgery Thyroid  THYROID GLAND Anatomy Consists of two lateral lobes that are connected by a narrow tissue band known as the isthmus Each lobe is approximately 4 cm in length, 2cm in width, and 2-3cm in depth. The isthmus usually overlies the region from 2nd to 4th tracheal cartilage Posteriorly there are four parathyroid glands During tracheotomy, the isthmus is encountered and must be retracted Anatomy Relations Larynx & trachae medially Sternocleidomastoid laterally Carotid sheath posterolaterally Sternothyroid & sternohyoid muscles anteriorly Prevertebral fascia and parathyroid posteriorly Applied Anatomy External branch of superior laryngeal nerve It innervates the cricothyroid muscle, which play an important role in sound formation with the vocal cords. Recurrent Laryngeal nerve Supply all the other muscles of the larynx other than cricothyroid muscle.(passes in adherence to the posteromedial surface of the thyroid) Its injury can cause horesness of voice or aphonia Parathyroid gland In 17% within the capsule of the thyroid gland In 26% within the cervical part of the isthmus Fascia & ligaments True capsule Condensation of CT around the gland Visceral (pretracheal) Fascia Middel layer of deep cervical fascia Attah it to the laryngeo skeleton Suspensory ligament of Berry Attach the posteromedial aspect of the gland to the cricoid cartilage  Salivary Gland Definition The salivary glands are exocrine accessory digestive glands that produce and release 1.5 Liters of Saliva per day Salivary Glands Composition of Saliva Substance Percentage Function Water 99.5% Moisting oral cavity mucous membrane Linugal lipase Generates nonstratified fatty acid from dietry fat Salivary amylase Breaking down carbohydrates Lysozyme 0.5% Antibacterial Ions as chloride, bicarbonate, sodium, potassium, and IgA Mucin Lubrication and softening Salivary Glands Functions of Saliva Salivary Glands Intrinsic Minor Salivary 600-1000 glands Salivary Glands Parotid gland Submandibular Extrinsic Major Salivary gland glands Sublingual gland Salivary Glands Parotid Gland It is located anterior to the External acoustic meatus ear and is invested by fascia that suspends the gland from Masseter the zygomatic arch. The parotid compartement Buccinator contains parotid gland, nerves, blood vessels, and Parotid duct (penetrate lymphatic vessels. buccinator opposite crown of the 2nd upper molar Sternocleidomastoid tooth) Parotid gland Parotid Gland Completely outside the oral cavity in a superficial location (retromandibular space) Extends anteriorly over the masseter muscle, and inferiorly over the posterior belly of digastric muscle The Parotid duct (Stensen’s duct) is approximately 5 cm length (it runs anteriorly across the external surface of the masseter muscle and then turns medially to penetrate the buccinator muscle of the cheek) Parotid Gland Parotid duct (stensen’s duct) is located 1 cm below the zygomatic arch and runs horizontally It passes anterior and lies superficial to the masseter muscle then turns medially penetrating the buccinator muscle to open intra-orally. 3mm in diameter 5-6 cm in length  The parotid gland encloses the external carotid artery Parotid Gland and the origin of the extracranial part of the facial nerve. It is the largest of the Major salivary glands (14-30 Medial gm). Pterygoid The gland is divided by the facial nerve into superficial and deep lobes A fascial capsule called the parotid sheath surrounds the parotid gland The parotid duct arise from the superficial lobe Parotid Gland Blood Supply Arterial supply: The superficial temporal artery a branch from external carotid artery Venous drainage: Retromandibular vein (formed from the joining of maxillary and superficial temporal veins) ----- drains to the external jugular vein Parotid Gland Lymphatic Drainage The lymphatic drainage of the parotid gland is present within the gland substance divided into two layers (superficial and deep). Between the gland and the capsule. It drains to extra-parotid nodes. Salivary Glands  Submandibular Gland The second largest major salivary glands (10-15 gm) Located in the posterior portion of the submandibular triangle (mandible, anterior belly, and posterior belly of digastric) The gland is surrounded by a capsule, which is formed as a part of the deep cervical fascia. The gland duct (Wharton’s duct) is approximately 5 cm in length and end in the oral cavity in the sublingual caruncula (on each side of the lingual frenulum. Submandibular Gland The gland is hook-shaped Divided into superficial and deep lobes by the Mylohyoid muscle The superficial part is the large part and lies outside the oral cavity; while the deep part lies within the oral cavity. Submandibular Gland Duct Wharton’s duct: passes forward along the superior surface of the mylohyoid adjacent to the lingual nerve. 2-4 mm in diameter and 5 cm in length It opens in the floor of the mouth through the punctum. The punctum is a constricted portion of the duct to limit the retrograde flow of bacteria and oral fluids Submandibular Gland Blood Supply Arterial supply: Branches of the facial and lingula arteries that are branches of the external carotid artery. Venous Drainage: Common facial vein and sublingual vein that drains to the internal jugular vein. Submandibular Gland Lymphatic Drainage Not within the gland Drains to the submandibular LNs 3-6 lymph nodes located beneath the body of the mandible. Salivary Glands Sublingual Gland Sublingual salivary gland is the smallest of the major salivary glands (2-5 gm). Located inferolateral to the tongue, below the mucosa of the mouth, and above the mylohyoid muscle The duct is palpated behind the mandibular canines. Sublingual Gland Duct This gland differs in that it doesn’t have striated ducts and secret directly through the ducts of Rivinus (8-20 small ducts) in an elevated ridge called plica fimbriate (sublingual folds). The largest sublingual gland excretory duct called the sublingual duct of Bartholin and joins the Wharton’s duct near the sublingual caruncle. Sublingual Gland Blood Supply Arterial supply: Branches of the facial and lingual arteries that are branches of the external carotid artery. (same as submandibular) Venous Drainage: sublingual vein that drains to the internal jugular vein. Sublingual Gland Lymphatic Drainage Not within the gland Drains to the submandibular LNs 3-6 lymph nodes located beneath the body of the mandible.  Complete blood count Components: Lymphocytes WBCs Monocytes RBCs Basophils Hemoglobin Immature granulocytes Hematocrit Reticulocyte count MCV MCH MCHC RDW Platelets Neutrophils Complete blood count Red Blood Cells (RBCs): Normally range from 4.7 – 6.1 million cells per microliter for males 4.2 – 5.4 million cells per microliter for females Low RBCs count in the following conditions: ✓ Anemia ✓ Acute/ chronic bleeding ✓ RBCs destruction (hemolytic anemia) ✓ Nutritional deficiency (iron, vit. B12, or folate deficiency) ✓ Bone marrow disorders ✓ Chronic inflammatory disease ✓ Renal Failure Complete blood count Red Blood Cells (RBCs): High RBCs count in the following conditions: ✓ Polycythemia ✓ Dehydration ✓ Renal tumors that produce erythropoietin ✓ Smoking ✓ Polycythemia vera ✓ Genetic alteration Complete blood count Hemoglobin: This is the oxygen carrying pigement (rich in iron), normally the red blood cells in human has no nucleus and is considered like a sac of hemoglobin: ✓ Normally it ranges from 13.8 -17.2 g/dL in males ✓ In females, it ranges from 12.1 – 15.1 g/dL. Complete blood count Hemoglobin: Low: ✓ Iron, vitamin B12, or folate deficiency; bone marrow damage; leukemia or lymphoma; acute or chronic blood loss; red blood cell hemolysis High: ✓ Dehydration, renal problems, pulmonary disease, congenital heart disease, polycythemia vera Complete blood count Hematocrit: It is the percentage of red blood cells volume to the total blood volume: ✓ Normally in males 40-50% ✓ Normally in females 35-45% Complete blood count Hematocrit: Low: ✓ Iron, vitamin B12, or folate deficiency; bone marrow damage; leukemia or lymphoma; acute or chronic blood loss; red blood cell hemolysis High: ✓ Dehydration, renal problems, pulmonary disease, congenital heart disease, polycythemia vera Complete blood count Mean Corpuscular Volume (MCV): It is the average size of the RBCs: ✓ Normally, 80 -95 fL (femtoliters) Low: ✓ Indicates that RBCs are smaller than normal (microcytic); caused usually by iron deficiency anemia, thalassemia, congenital sideroblastic anemia, lead poisoning, chronic disease anemia. High: ✓ Indicates that RBCs are larger than normal (macrocytic); such as in folate deficiency and vit B12 deficiency. Complete blood count Mean Corpuscular Hemoglobin (MCH): MCH measures the amount or the mass of hemoglobin present in one RBC. It is obtained by dividing the hemoglobin to the total RBCs count. It is measured using the picogram unit (23-31 pg). Low in Iron deficiency anemia, microcytic anemia. High Vit. B12 or folate deficiency, sickle cell disease. Complete blood count Mean Corpuscular Hemoglobin Concentration (MCHC): MCHC the concentration of hemoglobin in a given volume of red blood cells. Its normal value (32-36 g/dL). Low in Iron deficiency anemia. High sickle cell disease. Complete blood count Red Blood Cells Distribution Width (RDW): RDW is a measurement of the variation in the size of the RBCs. Its measured as a percentage (11-15%) Low (Generally is not a concern). High in the following conditions: Iron deficiency, vitamin B12 or folate deficiency, recent blood loss (immature RBCs tend to be larger). Complete blood count Reticulocyte count: Measures the percentage of circulating immature red blood cells. Normally, 0.5-2.0%. Low (Generally is not a concern), in a condition of anemia low count indicates a condition affecting RBCs production such as bone marrow damage. High in the following conditions: Anemia (generally indicating bleeding or hemolysis). Complete blood count White Blood Cells (WBCs): The normal number of WBCs in the blood ranges from 4,500 – 11,000 white blood cells per microliter (mcL). Leukopenia Low count due to viral infections (Influenza, HIV). It may also results from chemotherapy, radiation, aplastic anemia. Leukocystosis Low count due to mainly bacterial infections. It may also results from Leukemia, allergy, asthma, inflammation.  Complete blood count White Blood Cells (WBCs): Differential count: Neutrophils 50-70% (Measures the number or percentage of neutrophils, which are normally the most abundant circulating white blood cells and respond quickly to infection ) (shift to the left means there is inflammatory process indicated by the increased number of immature neutrophils). Eosinophil 0-3% (Measures the number or percentage of eosinophils, which combat parasitic infections and are involved in asthma or allergy responses ) Basophil 0-1% (Measures the number or pecentage of basophils, which are involved in allergy responses).  Complete blood count White Blood Cells (WBCs): Differential count: Lymphocytes 20-40% (Measures the number or percentage of lymphocytes, which are white blood cells that include B-cells, T-cells, and natural killer cells) Monocytes 2-6% (Measures the number or percentage of monocytes, which are white blood cells that move out of the circulating blood and into the tissues, where they mature into macrophages)  Complete blood count Platelets: Normal platelets count range from 150,000 – 450,000 per microliter. Thrombocytopenia (low count of platelets) as in splenomegaly, familial thrombocytopenia, chemotherapy, radiotherapy. Thrombocytosis (high platelets count) as in chronic infections, malignancy, inflammation, polycythemia vera. Blood sugar  Bleeding profile Prothrombin time Partial thromboplastin time Liver Function tests