Dr.

Talat’s OSPE Sets SMDC

Set I & V: Abuhurayrah Sabir
Set II,III,IV: M. Usman Khan

Let us know if there are any mistakes.

SET I
Fracture of Sternum
Row 1: Extradural hemorrhage, Extradural Hemorrhage, Bilateral Extradural hemorrhage,
Depressed Scalp fracture occipital region, Hematoma
Row 2: Depressed Scalp fracture (first from left), Subdural hematoma (fourth from left)
Row 3: brain abcess,

Aortic Dissection
 Hydropneumothorax
Opaque shadow on left side of chest with dark area (air) above, air fluid level. And
tracheal shift can be seen.

Treatment: Chest tube intubation (2 tubes, one for fluid, directed downwards. Other
for air, directed upwards)
 ?????

Pneumothorax (Right sided) and surgical emphysema.

CT Chest showing Surgical emphysema (arrow), blood under
posterior surfaces of lungs (prominent on right of this CT)
 Intestinal Obstruction,
X-ray abdomen (erect). Showing air fluid levels
Fig 1 (Normal), Fig 2 (Obstruction)
Investigation: Barium enema
Diagnosis: Deverticulosis
Barium Swollow showing Zankers Diverticulum
ERCP Showing Cholidocholithiasis
MRCP Showing Cholilithiasis and cholidocholithiasis
CT Axial View, Pancreatic Pseudocyst (in body of pancrease)

Pancreatic Pseudocyst (Not Confirm)

Trauma to liver (subcapsular hematoma)

Metastatic liver disease

Metastatic liver disease (CA colon)

Gastric Outlet obstruction (Not Confirm)

CT axial view, Splenic Trauma (Hematoma)

Pancreatic Pseudocyst
Hydatid liver disease
SET II
Description: Air under diaphragm
Diagnosis: Enteric Perforation (most likely duodenal)
Management:
Resuscitation:Fluid & electrolytes, Antibiotics, NG tube insertion, catheteriation
Open or laproscopic Repair
Description: Pneumothorax (Left Sided) on Chest Xray
Management:
ATLS
Chest Tube Intubation
Upward directed under water seal
Description: Hydropneumothorax (Right sided) on X-ray Chest
Treatment:
ATLS
Chest Tube Intubation
Downward directed underwater seal
Description & diagnosis: Apple core appearance (Colorectal CA)
DUKE’s classification:
A: Confined To the bowel wall
B: Through the bowel wall
C: Lymph node Involvement
Treatment:
Extended right hemicoloectomy
Tranverse hemicoloectomy
1- X-ray abdomen Erect showing Multiple air fluid levels
2-Diagnosis: Bowel obstruction
3- Management:
Fluid & electrolyte replacement, catheterization, Antibiotics
NG aspiration,
Treatment of cause of obstruction(adhesions,volvulus)
If gangrenous segment present (resection)
Description: ERCP showing filling defects
Management:
ERCP+Stone Removal+Cholecystectomy
choledohocotomy+T-tube insertion+Cholecystectomy

MRCP showing cholelithiasis and choledoholithiasis

Management:
Therapeutic ERCP with stone extraction
laparoscopic cholecystectomy
Exploration of CBD
Description: Multiple hypo-echoic lesions in the liver on axial section of CT possibly due to Stage IV
colorectal CA metastatic deposits
Different Planes of CT-sections:
Axial, Coronal, Sagittal

Splenic rupture
Treatment: Causes of splenectomy:
ATLS TRAUMA (Blunt,Penetrating,Iatrogenic)
Blood trasnfusion RBC disorders: Hereditory spherocytosis, Sickle cell disease,
laparotomy, slenectomy, Thalassemia
Conservative management: IN children, if stable WBC disorders: Lymphomas, leukemias(AML,CML)
Splenoraphy if damage is small. Platelet disorders: ITP, TTP
Pancreatic pseudocyst
Treatment:
Endoscopic or Surgical: Cystogastrostomy, Cystoduodenostomy

Eule of 2
Location: 2 feet proximal to ileocecal
junction
Incidence: 2%
Age: less than 2 years
Male/female: 2:1
2 types of tissues (gastric, ileal)

Meckel’s diverticulum (eventually diverticulitis)

Investigations: X-ray, Endoscopy, Technetium Scan, Contrast Studies. Angiography
Treatment:
Diverticulectomy
 Intussusception (ileo-colic)
Types:
Ileo-ileal
Ileo-cecal
Ileo-colic
Colico-colic
Investigations:
Barium Enema (Claw sign)
Ultrasound
CT-Scan Abdomen
Treatment:
Resuscitation
Hydrostatic Reduction
Milking
Cope’s Method
right hemicolectomy (If non-viable
gangrenous segment)

Philadelphia (cervical) collar opening in the front

Indications:
Neck stabilization
Cervical Spine Trauma
Suspected Neck Inuries
Emergency Tracheostomy
Cervical Spondylitis
Heniated Disc
Neck of femur fracture

pic n/A
Pelvic fracture
TILES Classification :
Type A: Stable Fractures
Type B: Rotationally Stable Fractures
Type C: Vertically Stable Fractures

Management:
- ATLS
-Control Hypertension & Bleeding
- External Fixators
- Assessment Urethral Injuries & their Management
Open-book pelvic fracture

Description:
Ulcer above the angle of the mouth
Diagnosis: basal cell carcinoma (beaded edges)
Investigation: Skin Biopsy
Treatment:
Local Excision with disease-free margins
 1- BCC 2-SCC
Above the angle of mouth Below the angle of mouth
beaded edges Everted edges
Locally aggressiveRodent ulcer(rolled edges) Metastatic
Types: Types:
Nodular Ulcerative
Pigmented Proliferative
Superficial Ulcero-proliferative
Cystic Investigation:
Infiltrative Wedge Biopsy & FNAC adjacent lymph nodes
Investigation: Wedge Biopsy Treatment:
Treatment: Surgical Excision
Surgical Excision with disease free margin (2 mm) Radiotherapy
Lymph node dissection(Sec mets.)

Description: Dupuytrens contracture

Causes:
Collagen disorders
CLD
Hypothyroidism
Management:
Z-plasty and release
Malignant ulcer on planter aspect of the foot
Causes of Malignant Ulcers:
Melanoma
Basal Cell carcinoma (locally malignant) Rodent Ulcer
Squamous cell carcinoma  Marjolin Ulcer

Management of Melanoma:
Surgical excision & lymph node biopsy
Adjuvant Chemotherapy (Interferon Alpha)
Ulcer & wound Care
Distal toe ischemic ulcers
Fontaine presentations of limb Ischemia:
-Grade I: Asymptomatic
-Grade II: termittent claudication
-Grade III: pain at rest
-Grade IV: ulcer/gangrene

Neurofibromatosis
Treatment: Surgery, Radiation, Chemotherapy
Diagnosis: Ranula (frog belly appearance)
Treatment: Surgical Excision (cyst & affected sublingual gland)
 Bilateral cervical Lymphadenopathy
Common causes:
Lymphoma
TB
Secondary Deposits

1- Transillumination Test
2- Diagnosis: Hydrocoele
3- Management:
- Herniotomy (Children)
-Lord’s plication (Adults)
Description: angular- Dermoid Cyst at the angle of the eye
Treatment: Incision

Neurotrophic Diabetic Foot Ulcer

Treatment:
Routine workup(Xray Foot)
Control Blood Sugar (oral hypoglycemic & insulin)
Wound Debridement
Amputation (Gangrene/Bone Involvement)
Description: Venous ulcer at distal aspect of leg
bluish discoloration  healing
healthy granulation tissue
sloping edges

Treatment:
Leg elevation
Compression stockings
Treat the cause
Antibiotics
Other:
Pentoxifylline
Skin Grafting
Description:
Bright BI-CONVEX shaped Opacity on CT- Scan Brain
Midline shift
Effacement of anterior horn of left lateral ventricle
Scalp fracture & hematoma
Diagnosis:
Extradural hemorrhage and scalp hematoma
Management:
- ATLS
-Burr Hole Craniotomy
(Mannitol Contraindicated in EDH)
Description:
Crescent shaped density
Midline shift
Effacement of ventricles
Scalp fracture & hematoma
Diagnosis:
Subdural hemorrhage (crescent shaped)
Treatment:
- ATLS
- Burr hole craniotomy (small clot)
-Open Craniotomy (large clot)
Bilateral frontal Extradural hemorrhage and hematoma

Clavicle fracture Management:

segmental comminuted fracture
Neurovascular status: INTACT
Non-operatively, Broad Arm SLING (3-6
weeks)
Neurovascular status:
DAMAGED/COMPROMISED
Open reduction & Internal fixation
Decription & diagnosis: Mediastinal widening most likely due to Aortic dissection
Further Investigations:
CT-Scan/CT-Angiogram
Echocardiogram
Treatment:
Type A (DeBakey Type I & II)  Median sternotomy, Cardiopulmonary Bypass, Aorta Cross Clamped &
AORTIC GRAFT
Type b (Debakey Type III)  Conservative management: ANTIHYPERTENSIVES, surgery if size is increasing on
serial X-rays
1- Presence of Air in subcutaneous tissue & Gingko lead sign (in extensive surgical emphysema)
Possibly, right sided radiolucent lung field with lack of vascular markings
2- Surgical emphysema (subcutaneous emphysema)
3- Chest tube intubation if there is hemopneumothorax (Conservative when there isn’t)
Diverticulitis
management:
uncomplicated: bed rest, antibiotics, barium enema
complicated:
Resection of diverticular segment
In case of peritonitis: Resection and Hartmans procedure
Description:
Small Gut(JEJUNAL) Obstruction on X-ray Supine showing Valvulae Conniventes (stacked coin appearance)
passing across the width of bowel at regular intervals
Investigation: X-ray Abdomen SUPINE
Treatment:
Fluid & electrolyte replacement, catheterization, Antibiotics
NG aspiration,
Treatment of cause of obstruction(adhesions,volvulus)
If gangrenous segment present (resection)
Description: Barium Swallow showing Bird Beak Appearance
Diagnosis: Achlasia Cardia
Gold Standard Investigation: Manometry
Treatment:
Endoscopic Dilatation
Hellers Myotomy
Botulinum Toxin
Nifedipine (Ca Channel Blockers)
Desrciption: Barium swallow showing pouch-like extension
Diagnosis: Zenker’s Diverticulum
Investigations: Barium Swallow, Endoscopy
Treatment: Excision

1- ERCP showing Stone in CBD (Choledocholithiasis)

2- treatment: Therapeutic ERCP, Chloledochotomy
Description: Smooth space occupying lesions with several septa & floating membranes on CT- Scan
Diagnosis: Hydatid Cysts
Investigations:
Ultrasound
CT-Scan
Casoni test
Elisa for antibodies to hydatid antigen
Management:
Medical: Albendazole
Indications :
Low disease burden
Single cyst
Pre-operative, peri-operative & post-operative
Percutaneous treatment: few cysts
PAIR: Puncture, Aspiration, Injection(Protoscolicidal agent, Reaspiration
Surgical( Multiple cysts):
Conservative surgery with omental packing, Radical cystectomy, Pericystectomy
 SET III
Instruments/Sutures
Picture: Not avaialble
Silicon urinary catheter
Uses: Urinary retention, monitoring urine output, surgical procedures involving urogenital system
advantage: More pliable with less tissue trauma as compared to latex made catheter
complications: infections, stricture formation
?!

endorracheal tube with cuff

Tracheostomy Tubes

Bag Valve Mask (ambu bag)

advantages:
Ventillation in Respiratory Failure
Ventillation in failure on intubation
Disadvantages:
Aspiration
Hyperventialltion
Hypoventillation
 d
Laryngeal mask airway(LMA)
Indications/advantages:
Anesthesia
Failed Intubation
Conduit for Intubation (Endotracheal tube can be passed through it)
Alternative to mask anesthesia

Contraindications/disadvantages:
Can not open mouth
Complete airway obstruction
Plural effusion

1-Devors retractor
2- Retration of abdominal viscera
3- Advantage: Proper exposure of abdominal contents to surgeon
disadvantage: Damage to structures and viscera
balfour abdominal retractor
picture?
1- Hook: Connected to diathermy this instrument is the main dissector used in laparoscopic surgery
2- Laproscopic Grasper (holds tissues)
3-Needle Holder
4- Maryland Grasper (holds soft tissues)
Cauterization needles
Single ended Diathermy Needle
Double ended Diathermy Needle
Advantages:
Fine, precise incisions
Hemostasis
Disadvantages:
Potential explosion of combustible gases in anesthesia endogenous intestinal gas
Arrhythmias
Effect on pacemakers
SET IV
20 year old boy had RTA in which he fell on outstretched Rt. Hand. He was unable to move his shoulder. X-
rays of shoulder were taken:

60 year old female fell on her outstretched hand. After that she was unable to move her Rt. Wrist. X-rays of
the wrist are shown below:
1- Anterior dislocation of Rt. Shoulder
2- History, Examinations (particularly neurovascular status of the upper limbs) & X-rays
3- Early Reduction under General anesthesia via:
Kocher’s method (Traction, External rotation, Adduction, Rotation internal)
Hippocratic Method
Hanging Arm Gravitational Method
1- d/d:
Testicular Torsion
Acute epididymo-orchitis
2- PREHN’s Sign:
Testicular torsion: Pain not relieved
Acute epididymo-orchitis: Pain relieved
3.Management:
If viable: Orchidopexy (Bilateral fixation at 3 places)
If Gangrenous: Orchidectomy
a. Ringer’s lactate (not confirm source found)
b. Ringer Lactate:
Na: 130 meq/L
Cl: 109 meq/L
K:4 meq/L
HCO3 as Lactate: 28
c. Normal Saline(0.9% NaCl)
Na:150 meq/L
Cl: 150 meq/L
K: 0 meq/L
 a- BLS Steps:
1. Check pulse at carotid artery
2. If no pulse, start with 30 chest compressions on the lower half of the sternum between nipples
3. Open the airway and give 2 breaths.
4. Continue 5 SETS of 30 compressions and 2 breaths until the ambulance arrives to take over, the AED
(Automatic external defibrilator) arrives

b. Compression-to-ventilations ratio, 30:2

c. Depth: At least 2 in (5 cm)

NOTE:
 Compression method: Heel of one hand, other hand on top
 Allow complete chest recoil after each compression
 Compression rate: At least 100/min
 Continuous compressions if advanced airway present
 Rotate compressor every 2 minute

Anethesisa st#
a. Heimlich maneuver
b. Back Thrusting/blowing (blow between the person’s shoulder blades)
c .Unconcious/Pulseless patient
-Lower the person to the floor.
- Perform a Finger Sweep to try to remove any foreign body from the mouth. Only remove an object you can
see and easily extricate.
- Begin CPR
SET V
 Lipoma

Sebaceous Cyst
 Lipoma

Neurofibromatosis
 Left image: Retention Cyst
Right image: ranula

Lower motor neuron lesion of

Facial nerve (Right facial nerve) Bell’s palsy
Complete third nerve palsy

Parotid swelling
 Neck Swellings
Lymph node enlargement on right side of neck, left side of neck
and bilateral cervical lymphadenopathy
 Zenker’s diverticula

Neck Swellings

Image 1: Swelling in posterior triangle most probably tumor of thyrocervical trunk

Image 2, 3: Lymph node enlargement or carotid tumor

Dermoid cyst (Teratoma)
Image 1: Scrotal swelling, Image 2: Transilumination test,
Image 3: Epididymal cyst (third testis)
 Inguinal hernia

Testicular swelling, Transilumination positive (hydrocele)

 Testicular torsion

Basal cell carcinoma

 Rheumatoid hand

Dupetryn’s Contracture
Chronic limb ischemia and (ischemic ulcer???)

Trophic ulcer