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Emotional demons Imagine you’re on a boat out at sea. You’re alone, except for a pack of scary demons hiding below the deck. As long as you keep floating around on the open sea, they stay below deck and you feel okay—for the most part.  Except for that nagging feeling that there are frightening creatures just out of sight. When you decide you’ve had enough of floating around and turn the tiller to head toward shore, the demons come rushing up from below, gnashing their teeth and waving their razor-sharp claws at you. “You have to stay out on the open sea!” they roar at you. “We’re going to slice you up with our razor-sharp claws if you don’t turn away from the shore!” Frightened and intimidated, you turn your boat around and head back out to open sea. Slowly, the demons shuffle back under the deck. For a while, floating aimlessly again on the open sea is okay. At least you have some peace and don’t need to worry much about the demons lurking close by. But...

Overview Craniotomy is a cut that opens the cranium. During this surgical procedure, a section of the skull, called a bone flap, is removed to access the brain underneath. The bone flap is usually replaced after the procedure with tiny plates and screws. A craniotomy may be small or large depending on the problem. It may be performed during surgery for various neurological diseases, injuries, or conditions such as brain tumors, hematomas (blood clots), aneurysms or AVMs, and skull fractures. Other reasons for a craniotomy may include foreign objects (bullets), swelling of the brain, or infection. Depending on the reason for the craniotomy, this surgery requires a hospital stay that ranges from a few days to a few weeks.   What is a craniotomy? Craniotomy is any bony opening that is cut into the skull. A section of ...

Modified Radical Mastectomy Arm on the affected side is extended on a side table. The patient is draped and the affected breast and axilla are exposed. Drawing incision line (an optimal wound closure without any redundant skin must be taken into account) Skin incision and formation of upper flap Proceed cranially towards the pectoralis fascia just below the clavicula and laterally until the lateral margin of the pectoralis major muscle Formation of lower flap from medial to lateral Continue laterally until the latissimus dorsi muscle has been reached Dissection of the breast from medial to lateral including pectoralis major 's fascia Follow the lateral margin of the pectoralis major muscle and opening clavipectoral fascia Identification of upper axillary margin (=axillary vein) Dissection of axillary top (along axillary vein) Identify and preserve thoracodorsal nerve/vessels Identify and preserve long thoracic nerve Finalize axillary dissection and rem...

Mucosal advancement Flap, Step by step Position patient in lithotomy position Place the intra-anal retractor Identify fistula site Canulate and brush the fistula tract (or flush with hydrogen peroxide,or both) Excise the intra-anal fistula site (elliptical shape) Create a wide flap by extending the proximal anorectal wall upwards Close the internal fistula opening with absorbable suture Further dissect the flap above the fistula including a thin layer of internal sphincter Prepare the advancement flap and optimize the size before suturing Complete the repair with single sutures Mucosal advancement flap for treatment of anorectal fistula General information For classification and diagnosis of perianal fistulas MRI is the most appropriate diagnostic tool The majority of patients with perianal fistula show epithelialization of the fistula tract, that might prevent closure of the tract. Curettage of perianal fistulae must therefore be considere...

Tension free mesh repair, step by step Skin incision about 1.5 cm above and parallel to Inguinal ligament. Ligation of the superficial epigastrivc vein (do not coagulate) Opening Scarpa's fascia Opening external aponeurosis following fibre direction. Avoid damage to the ilioinguinal nerve. Isolate spermatic cord Identify genitofemoral nerve (genital branche), this runs dorsal and parallel to the spermatic cord, underneath the cremaster muscle fibers Isolate hernia sac and/or preperitoneal lipoma Repositioning hernia (do not ligate!) Lipoma can be ligated In case of a large lateral hernia (scrotal) the hernia sac can be transected and proximally ligated. The distal part can remain in situ however needs to be left open widely. Suture mesh with Prolene. First suture through the lateral rectus border just cranially to the pubic tubercle. Proceed along inguinal ligament with large steps and small bites. Tie a knot when the internal ring has been reached...

Appendectomy by laparotomy, step by step Skin incision at McBurney's point Opening Scarpa's fascia Opening aponeurosis Atraumatic spreading of muscle fibers Identify and opening of peritoneum Identify cecum and appendix Deliver cecum and appendix Identify and ligate appendiceal artery Crush appendix at base Ligate and remove appendix at base If desired place a purse string suture around base of appendix Closing peritoneum Closing aponeurosis Skin closure Thats all...CHILL ;-) Acute Appendicitis, General remarks Classification Acute appendicitis has 6 types: 1. catarrhalis appendicitis; slightly red 2. phlegmonous: moderate inflammation and ischaemia 3. gangrenous: (partial) necrosis 4. perforated 5. appendicular mass 6. appendicular abscess ...

Blood obtained through skin puncture (capillary blood) differs from blood that is obtained through venipuncture. When analyzing the major characteristics of capillary blood, such as pH, PCO 2 , PO 2 and oxygen saturation, freely flowing capillary blood is actually more similar to arterial than to venous blood. On the other hand, due to the method of collection, capillary blood is contaminated with interstitial and intracellular fluids, which will influence the analytic values obtained from these samples. It is for this reason that capillary blood is not recommended for coagulation testing. Differences also exist between venous and capillary blood analyte concentrations (see table below). This is by no means an exhaustive list, and since the data were taken from two different studies, does not include identical analytes for both specimen types, i.e. plasma and serum. Differences in Composition of Capillary and Venous Blood Specimen

Lumbar Stenosis Stenosis, the narrowing of the bony canal that protects the spinal cord and its branching nerves, in the lower back is often characterized by radiating pain in the buttocks and legs. Signs & Symptoms Frequently people afflicted with lumbar stenosis have varying degrees of low back discomfort. The pain typically occurs most often during activities and is relieved by resting, sitting or bending forward. In some cases, the pain is centralized in the lower legs and feet. In severe cases, it also can impact continence and sexual function. Diagnosis Doctors use two kinds of tests to diagnose spinal stenosis. Some of the tests are aimed at making sure there isn’t another cause producing the symptoms. Others can indicate that the vertebral narrowing has occurred. After asking you questions about your symptoms, your doctor probably will check your reflexes, gait and other indicators of spinal problems. Tests include: X-ray – High-energy radi...

Cervical Stenosis Stenosis in the neck, also called the cervical spine, affects the upper part of the body including the arms and hands. Stenosis is the narrowing of the bony canal that protects the spinal cord and its branching nerves to the point where it injures the spinal cord or nerves. This may be caused by a number of conditions including bone spurs or rupture of the spinal discs, the spongy pads of tissue that keep the vertebrae from grinding against each other when you bend your back. Signs & Symptoms Cervical stenosis may even cause pain, numbness, or weakness in the legs. The pain may move from one part of the body to another but is often most noticeable in the neck. Diagnosis Doctors use two kinds of tests to diagnose spinal stenosis. Some of the tests are aimed at making sure there isn’t another cause producing the symptoms. Others can indicate that the vertebral narrowing has occurred. After asking you questions about your symptoms, your d...

Thoracic Disc Herniation The thoracic spine consists of the 12 vertebrae between your neck and lower back. The ends of your ribs, although not attached to the spine, rest in indentations in the thoracic vertebrae that help support the ribs. This arrangement also makes the thoracic vertebrae more stable than other vertebrae. Disc herniation in the thoracic spine is relatively rare compared to the lumbar vertebrae in the lower back and the cervical vertebrae in the neck. Thoracic disc herniations account for less than 1 percent of all protruded discs. Signs & Symptoms Pain in the upper back Numbness, pain or tingling from the upper back and around the chest Leg weakness Chest pain Diagnosis Your doctor will examine your movements, strength and reflexes. He or she also may recommend the following tests: Magnetic Resonance Imaging (MRI) — An MRI provides detailed pictures of the spine that are produced with a powerful magnet linked to a comp...

Lumbar Disc Herniation The lumbar spine consists of the five vertebrae in the lower part of the spine, each separated by a disc, also called a lumbar disc. The discs in this part of the spine can be injured by certain movements, bad posture, being overweight and disc dehydration that occurs with age. Although the lumbar vertebrae are the biggest and strongest of the spinal bones, risk of lumbar injury increases with each vertebrae down the spinal column because this part of the back has to support more weight and stress than the upper spinal bones. The lumbar disc is the most frequent site of injury in several sports including gymnastics, weightlifting, swimming and golf, although athletes in general have a reduced risk of disc herniation and back problems. Signs & Symptoms Symptoms of disc herniation in the lower back are slightly different from symptoms in the cervical or thoracic parts of the spine. The spinal cord ends near the top lumbar vertebrae but t...

Cervical Disc Herniation The cervical spine consists of the top seven bones, called vertebrae, in your spine located between the skull and chest. The first symptom of cervical disc herniation is usually neck pain. Others symptoms may include: Pain in one arm or in both arms Limited head and neck motion, especially turning to the side of the herniated disc Hyperactive reflexes Spasticity Loss of bladder or bowel control, erectile dysfunction Signs & Symptoms The cervical spine consists of the top seven bones, called vertebrae, in your spine located between the skull and chest. The first symptom of cervical disc herniation is usually neck pain. Others symptoms may include: Pain in one arm or in both arms Limited head and neck motion, especially turning to the side of the herniated disc Hyperactive reflexes Spasticity Loss of bladder or bowel control, erectile dysfunction Diagnosis Your doctor will check your range o...

Scoliosis Everyone’s spine has natural curves. These curves round our shoulders and make the lower back curve slightly inward. But some people have spines that also curve from side to side, a common condition called scoliosis. On an X-ray, a spine with scoliosis looks more like an “S” or a “C” than a straight line. Some of the bones in a scoliotic spine also may have rotated slightly, making the person’s waist or shoulders appear uneven. Scoliosis affects about 2 percent of the population, including children and adults, and tends to run in families. If someone in a family has scoliosis, the likelihood of another family member having it is much higher – about 20 percent. As the population ages, adult degenerative scoliosis is becoming more common, with the condition typically developing at between age 50 to 70. The condition can have devastating effects on a person’s life in later years. Treatment in this older population presents particular changels due to othe...

Kyphosis Kyphosis describes the exaggerated curve of the spine that results in a rounded or hunched back. Kyphosis may develop for several reasons. Postural kyphosis in children and adolescents may be related to habit and posture rather than underlying spinal deformity. In contrast, structural kyphosis refers to a round-back posture that is not reversible by paying attention to your posture and making an effort to sit and stand up straight. In adolescents, structural kyphosis may be caused by initial spine development with a rounded shape that is made worse by further growth. In the elderly, compression fractures characteristically result in loss of height and kyphotic deformity. Signs & Symptoms Back pain Difficulty standing with an upright posture Early fatigue to the back and legs Diagnosis The diagnosis of kyphosis is based on physical examination of the spine and X-rays. Your doctor may ask you to bend forward so that he or she can evalua...

Spondylolisthesis Spondylolisthesis is a condition in which one vertebra slips forward on the one below it. In children, spondylolisthesis may occur as the result of a birth defect that affects the back of the spine or be caused by stress fractures within the back part of the spine. Spondylolisthesis is the most common cause of low back pain in adolescent athletes. In older people, the most common cause is degeneration of the discs between the vertebrae. With aging, the discs lose moisture, dry out and flatten, bringing the bones on either side closer together to the point where one slips forward on the other. Signs & Symptoms Typical symptoms of spondylolisthesis include pain across the lower back and legs, which occurs when the slipped vertebra irritates the nerves around it. However, a person can have the condition and not have pain. Diagnosis A number of test may be used to aid in the diagnosis of spondylolisthesis and to locate the affected bone, inc...

Anklosing Spondylitis Ankylosing spondylitis is an inflammatory condition that involves the spine and skeleton of the head and trunk. The disorder causes inflammation and pain in joints in the spine, pelvis and other parts of the skeleton. In addition, parts of the spine, the sacroiliac joints where the hips join the lower back, or the hips may fuse, or grow, together. Signs & Symptoms Pain Stiffness, especially in the morning, Functional limitation, When the disorder affects the spine, it also may result in progressive deformity including curvature of the back, called kyphosis, and the inability to stand up straight. Diagnosis The first clue in diagnosing ankylosing spondylitis is the presence of symptoms, especially back pain. In addition, X-rays are taken to look for signs of the disorder, such as fused joints. A blood test for the HLA-B27 gene, which is found in about 90 percent of the people with ankylosing spondylitis, also may be performed. Howeve...

Guidelines for the Treatment of Cervical Fractures with or without Spinal Cord Injury 1. Admission Guidelines: All patients with the following clinical conditions MUST be admitted to the ICU for close respiratory and neurological monitoring. The pre-printed Spinal Cord Injury Orders will be used on all patients. Radiographic evidence of unstable cervical fracture or dislocation (i.e. atlantococciptal dislocation, bilateral subaxial facet dislocation,..) and/or Clinical or radiographic evidence of spinal cord injury All field collars should be changed out to a permanent rigid collar (Aspen or Miami-J) within 6 hours of admission. Admission location and monitoring criteria for patients with documented cervical fractures without radiographic evidence of dislocation (i.e. transverse foramen fractures, spinous process fractures,.. ) and without clinical or radiographic evidence of spinal cord injury is left to the discretion of the admitting ...

1.An eight year old boy presented to the casualty with high fever, pruritic erythematous rash, joint pain and lymph node enlargement. There is a history of upper respiratory tract infection for which he was on cefaclor – 8 days completed of a 10 day course. The most likely diagnosis is? A. Serum sickness like illness B. HSP C. Type III hypersensitivity D. Kawasaki disease Correct answer : A. Serum sickness like illness Serum sickness like reaction can occur following the use of certain drugs, especially cefaclor in children. It presents with an urticarial / purpuric rash, arthritis, lymphadenopathy and fever. But unlike true serum sickness (a type III hypersensitivity response), it is not caused by circulating immune complexes. 2.A one year old child presented to the OPD with the history of short stature, tiredness and constipation. Examination revealed a palpable goitre. Serum T4 was decreased and TSH levels were ...

Title Page Book 1 GRIP FOR FINAL YEAR Medicine 1 Medicine 2 Paedetric Medicine Backcover Title Page Book 2 GRIP FOR FINAL YEAR GENERAL SURGERY SPECIAL SURGERY GYNAECOLOGY OBSTETRICS Backcover "GRIP" COMPREHENSIVE HELPING STUFF FOR ALL MEDICAL STUDENTS... IT GUIDES THE STUDENTS WHAT TOPICS THEY HAVE TO STUDY , MARKS DISTRIBUTION OF EACH UNIT AND NO OF MCQS ,SEQS FROM EACH UNIT ... SYLLABUS , TOS ...... UHS POOL OF SEQs  AND MCQs , MOST REPEATED QUESTIONS AND TOPICS EXTRACTED FROM PAS T PAPERS OF EACH SUBJECT.... Author : DR. HAFIZ BASHIR AHMAD NOOR Published by : Allied book company aminpur bazar faisalabad price : Rs 400 only edition : 1st Copies: 1000 Available now only in FAISALABAD at ALLIED BOOK COMPANY AMINPUR BAZAR BOOK will be distributed in lahore , sargodha , rawalpindi , multan , bahawalpur after Eid vacations ... most probably on saturday . process for home delivery described earlier ... value paid post by Pakistan post for booking in advan...