CLINICAL THORACIC SURGERY

Fifth Stage – Group B (#7) – April/2018

Contents
Session 1 ....................................................................................................................................................................1
Pneumothorax (Causes, Rx, Tension type) ................................................................................................................1
Common Medications used in ward: .........................................................................................................................3
Session 2 (Out-patient) .............................................................................................................................................3
Session 3: Thoracotomy (GERD operation) ...............................................................................................................4
Session 4 ....................................................................................................................................................................4
Tube thoracotomy (Indications, Site, Old Sites & Risks, Contraindications, Complications, Criteria of Removal) ...4
Hemothorax (Etiology, Presentation, Rx) ..................................................................................................................6
Contusion ...................................................................................................................................................................7
Session 5 ....................................................................................................................................................................7
Acute limb ischemia (6Ps, Causes, Diagnosis, Treatment, Amputation Levels) ........................................................8
Session 6 ....................................................................................................................................................................9
Peripheral pulses .......................................................................................................................................................9
Chronic limb ischemia (Presentation, Investigations, Management) .................................................................... 11
Session 7 Dr-Rafid (X-Rays).................................................................................................................................... 12
General Notes (Profile, Technical, Hidden areas, Normal Things, Tips) ................................................................. 12
X-Rays Cases (Multiple) .......................................................................................................................................... 13
Session 8 ................................................................................................................................................................. 17
Bilateral leg swelling & Unilateral leg swellings: .................................................................................................... 18
Deep venous thrombosis (Risk factors, Investigations, Treatment)....................................................................... 18
Exams Questions..................................................................................................................................................... 19

MODIFIED AT: APRI 30, 2018

HDD-PC
MICROSOFT OFFICE WORD 2016
Session 1
• If you don’t know direction of X-ray, use aortic knob as a hint.
• If combined air and fluid, according to history:
◦ Trauma: say hemopneumothorax
◦ Malignancy or infection: hydropneumothorax

Pneumothorax
• Pneumothorax signs in X-ray: white edge of lung, and absence of
bronchovesicular markings.
• Spontaneous (No history of trauma), occurs during activity, but can occur in rest
also.
1. Primary: idiopathic (slim, tall, athletic) and have congenital bulla (> 1 cm) or
bleb (< 1 cm and near visceral pleura) that ruptures.
2. Secondary: underlying lung disease:
▪ Asthma
▪ COPD (chronic bronchitis and emphysema)
▪ Tumor (primary and secondary): usually cause pleural effusion but can
cause pneumothorax.
▪ Suppurative lung disease (bronchiectasis)
• Notes: Occur in conditions like cystic fibrosis, Young’s syndrome
(bronchiectasis, infertility and sinusitis).
▪ Infection (any type of pneumonia, it makes lung tissue more friable)
• Acquired: history of trauma:
1. Stab wound, penetrating trauma, bunt trauma, RTA
2. Iatrogenic especially in CVA insertion whether in subclavian below clavicle or in
jugular above clavicle.
• Also occurs commonly when needle is inserted in the back for pleural
effusion, but when lung expand it hits the needle and pneumothorax
develops.
• Note: recesses in chest are posterior, lateral, and anterior. Deepest is
posterior because diaphragm attachment posteriorly at 12th rib, laterally
at 10th rib, anteriorly at 6th rib.
• Note: there is always associated hemothorax even if mild, with any
pneumothorax.
• In Barotrauma
• Rx of pneumothorax :
1. Conservative: Asymptomatic, air < 15%
▪ Observation and follow up with X rays.
▪ Enhance absorption of air by putting patient on oxygen. To decrease
nitrogen in blood so pneumothorax will be absorbed into blood.

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 2. Thoracentesis: aspiration of air by needle, but very rarely used, and need
special blunt needle to avoid lung injury.
3. Chest tube: Symptomatic, dyspneic, air > 15%.
▪ Note: never underestimate severity by looking to size of injury even if
very small.
▪ Make patient blow in a balloon to enhance lung expansion.
▪ Indications of chest tube in pneumothorax:
• Air > 15 %
• Other associated pathology like hemothorax
• Severe dyspnea
4. Thoracotomy: Last step.
▪ Indications in pneumothorax
1. Recurrent pneumothorax
2. Massive pneumothorax
3. Large bullae
4. Pneumonectomized patient
5. Distant living place
6. Occupations: like divers, pilots 👨‍✈️.
5. Alternative to thoracotomy: VATS (video assisted thoracoscopic Surgery)
• Criteria of removal of chest tube:
1. Clinical criteria: No symptoms clinically, Good air entry on auscultation.
2. Radiological criteria: X-ray show full expansion and no obliteration of
costophrenic angle.
3. Mechanical criteria:
▪ Nature of drained fluid become serous or serosanguinous.
▪ No swinging or minimal when patient coughs.
• Tension pneumothorax:
o Diagnosed Clinically: (X-ray not allowed, because it is an emergency)
1. Hyper resonant on percussion
2. Severe dyspneic
3. Dilated neck vessels
4. Tachypnea, tachycardia with hypotension (obstructed shock, due
kinking of IVC and SVC)
5. Severely pale, and severe cyanosis.
6. Absence of air entry on auscultation
7. Deviated trachea in palpation.
o Rx: needle in 2nd intercostal space.

• After RTA, alternative to supine X ray is CT scan

o MRI is slow
o If there is backache also, do CT spine in addition to CT chest.

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• In CT chest:
o Pulmonary window: show lung parenchyma
o Mediastinal window: show heart
o In hemothorax: blood accumulate in paravertebral gutter, no need to look to
costo-phrenic space anymore.
o In pneumothorax: air is found anteriorly.
• Tips in stab wound patients:
o Do not confuse with scapula border as pneumothorax in X-ray.
o Respiratory difficulty can be due to muscle pain not pneumothorax.

Common Medications used in ward:

• Enoxaparin: routine to prevent DVT
• Ranitidine: routine to prevent stress ulcer
• Tramal & Paracetamol: for pain and fever
• Dexamethasone
• Amitriptyline: phosphodiesterase inhibitor.
• Antibiotics;

Session 2 (Out-patient)
• In Chest X ray, after resolution of pneumothorax, you might find black lines in chest
wall, these are surgical emphysema.
• In X-ray the tube is covered with opaque line to visualize it in X-Ray easily, in the
last segment there is interruption in the opaque line and this is the side last hole of
chest tube.
• In suturing the chest tube within the chest wall, first stitch should be only one
ligature, to facilitate its removal later, the last stitch can be lighted multiply to secure
it.
• Sudafate®️: best analgesia (paracetol+tramal+voltaren)
• In COPD patients, Oxygen either high flow (>6L) interrupted, or low flow(2L)
continuous.
o Because high O2 causes a decrease in CO2 in blood and respiratory depression
later on.
• Lung contusion is a cause of hypoxia, its X-ray haziness cannot be differentiated
from pneumonia without history.
• Mild hemothorax (less than 100cc), is not an indication for chest tube.
• Medication for trauma of back or chest: Olfen®️ (voltaren gel) + anti spasm.
• Signs of osteoarthritis: sclerosis of rims of vertebra + low intervertebral disk space
+ osteophytes
• Post DVT syndrome: swelling due to destruction of venous valves.
• Central venous line is difficult in dehydrated patients like burns.
• Oxygen saturation oximeter falsely decrease in cold limbs.

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Session 3: Thoracotomy (GERD operation)
• Medications used in gastro esophageal reflex disease.
o Antacid
o H2 inhibitor
o PPI
o Pro kinetic (metoclopramide)
o Surgery (resistant, bleeding, heartburn).
• Type of operation is fundoplication (270 degree).
• First muscle in lateral chest wall is latissimus dorsi, innervated by thoracodorsal
(C6-C8). Followed by serratus anterior.
• Nerve over heart? is phrenic nerve (C3-C5)
• Shiny white part of diaphragm? is central tendon.
• Black lumps inside thoracotomy? are lymph nodes.

Session 4
Tube thoracotomy:
• Surgical procedure during which we insert a drain into the thoracic cavity. Usually
carried out under local anesthesia.
o Note: swinging means drain is inside plural cavity
• Indications:
o Any type of fluid and / or air inside pleural cavity.
o Post-operative, to evacuate any remnants / entered air.
• Site: Perfect site is fifth intercostal space, anterior to mid axillary line.
o At upper border of sixth rib, because intercostal neovascular bundle pass at
lower border of each rib.
o If after a thoracotomy operation, place it any site.
o Safety triangle:
▪ Anterior border: pectoralis muscle.
▪ Posterior border: latissimus dorsi.
▪ Base of triangle: upper border of sixth rib.
• Old sites & their risks:
o For pneumothorax: at 2nd intercostal space mid clavicular line. Risks are injury
to axillary artery & vein and brachial plexus injury (and injury to muscular
branch of pectoralis major muscle in muscle-builder guys). It still can be done
only by thoracic surgeon if it is very needed. (Q/ structures injured in mid
clavicular line)
▪ Anatomy Note: subclavian artery ends at lateral border of 1st rib, axillary
artery ends at lateral border of teres major.

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 o For hemothorax: 8th intercostal space at posterior axillary line. Risk of injury to
diaphragm, liver or spleen.
• Distance of tube insertion:
o In thin male: 12
o In female: + 3
o In obese: +3 to +5
o Exceptions: neonate 4cm, half year 6cm (‫)عينك ميزانك‬
• Contraindications to chest tube:
o Absolute:
▪ Bulla (air cyst inside the lung itself)
▪ Diaphragmatic hernia (bowel inside chest, and multiple air fluid level)
o Relative: (those are also contraindication for CV line, but if lifesaving we can
ignore them):
▪ Infection
▪ Bleeding tendency.
• A way to solve this is by making the wound small and the tube
wide to compress the vessels in chest wall.
• Complications:
1. Bleeding: from viscera (heart, aorta, lung, liver, spleen)
2. Injury to intercostal vessels and nerves, especially in obese patients.
3. Injury to mediastinal structures.
4. Perforation: liver, spleen, bowel, stomach. (Not pancreas, not kidneys, not
ovaries, not bladder!)
5. Infection: like empyema (infection inside pleural cavity)
▪ Not Pleurisy, pleurisy is an inflammation due to systemic disease (SLE,
RA).
6. Mechanical:
▪ Kinking
▪ Obstruction due to clots/ debris.
7. Mal position: tube in wrong site
• Extra-pleural
• Subcutaneous
• Intra-cardiac
• Intra-pulmonary
• Intra-abdominal
▪ Rx: it is major mistake, tube should be removed and new tube is inserted
correctly.
8. Inappropriate position: tube away from site of pathology. Due to wrong direction
(for pneumothorax should be upward, for hydrothorax should be downward)
▪ Rx: it can be corrected by manual redirection of tube.
9. Iatrogenic:
▪ Surgical emphysema

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 10. Re-expansion pulmonary edema:
▪ Caused be rapid evacuation of large amounts of effusion.
• Not (or minimally) occur in pneumothorax.
▪ Avoided by making gradual compression through a valve/clump on the
tube, and close and open it intermittently.
11. Pain and anxiety.
• Criteria of removal of chest tube:
1. Mechanical criteria:
a. Swinging: should be not significant.
b. Fluid type not bloody.
• Serious fluid = yellow. Serosanguinous = brownish
2. Clinical criteria:
a. Not dyspneic
b. Good air entry in auscultation
3. Radiological criteria:
a. Resolution of pathology.
b. Lung fully expanded.
c. No collection of fluid in costophrenic.

Q/ differences between malposition and inappropriate position.

Hemothorax:
• Etiology
o Spontaneous
1. AV malformation
2. Torn of pleural adhesion
3. Malignancy
4. Pleural endometriosis (catamenial)
5. Blood dyscrasia (leukemia, hemophilia, drugs)
6. Hemoperitoneum (rupture of spleen, through openings of diaphragm,
and assisted by positive intra-abdominal pressure vs negative thoracic
pressure)
7. Intra thoracic pathology (aortic dissection and aneurysm rupture)
o Acquired:
1. Traumatic (penetrating and blunt)
2. Iatrogenic
• Presentation;
o Dyspnea
o Chest pain
o Signs and symptoms of Hypovolemic shock.
• Rx:
o Conservative: If just obliteration of costophrenic angle (200cc)

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 o Indication of chest tube:
▪ > 200 cc (theoretical)
▪ Associated pneumothorax
▪ Ongoing bleeding.
▪ Severely symptomatic patient.
o Indication of thoracotomy
▪ Massive hemothorax > 1500 ml initially.
▪ Ongoing lose of 200 ml/hour for 2-4 hours.
o No role for needle aspiration! (blood is thick material cannot be aspirated).
o No role for VADS!

Contusion: hemorrhage inside lung parenchyma (pulmonary edema). Treated

conservatively. Major cause of death in RTA due to severe hypoxia. Cannot be
differentiated from pneumonia (haziness in X ray).
• It is non-cardiogenic pulmonary edema and more dangerous than cardiogenic
one.

Q/Difference between contusion and hemothorax.

Session 5
• Asthmatic patient during exacerbation, air may be entrapped inside the alveoli, and
those alveoli may rupture and leads to pneumothorax or to pneumomediastinum with
emphysema to the neck.
• Inhaled corticosteroid is better than injectable to avoid the side effects like:
hyperglycemia, hypertension, osteoporosis, stria in skin, delayed healing of wounds,
infections like UTI, bruises, adrenal shutdown, cushioned features (neck hump,
plethora face, telangiectasia, slim proximal limbs).
o But inhaled corticosteroid can cause fungal infection in mouth and pharynx and
can predispose to TB.
• Rib fractures if not displaced is not an indication for chest tube.
• Salmeterol ®️: is long acting beta blocker.
• Type of suture in young female patient is subcortical, to reduce scar formation.
• Swelling at site of operation is due to seroma. It resolves spontaneously.
• Any surgery near stomach can cause nausea and vomiting for 7-10 days. Maybe due
to neuropraxia of vagus nerve due to manipulation and congestion of the area.
• Swelling at site of cannula is called Superficial thrombophlebitis.
• Hiatal hernia is 4 types, first one is common, the other 3 are very rare.
• Diaphragmatic hernia is common congenital, types are: Bochdalek occurs in left
hemithorax, while Morgagni in parasternal or right hemithorax.

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 o The presentation is multiple air-fluid or cystic lesions in the hemithorax with
deviation of the heart and lungs, usually in neonate.
Acute limb ischemia
• 6 Ps (pain, Pulselessness, pallor, paresthesia, paralysis, poikilothermia)
• Causes
o Distal thromboembolism 90%
▪ Heart source
• AF
• Dilated Cardiomyopathy
• Infective endocarditis
• Mitral valve problem
• Prosthetic valve and stopping taking warfarin
• Myocardial infarction
▪ Aortic aneurysm (due to turbulence of blood flow)
o Local
▪ Aortic dissection (tear in intima and then tunica media)
• Caused by hypertension and atherosclerotic.
• The resulted false lumen will compress the other branches of aorta
and cause arterial insufficiency.
• The tear can extend and crosses the adventitia and causes internal
bleeding.
▪ Atherosclerosis
• Rupture of atherosclerotic plaque, and exposure of sub endothelial
and collagen material (high thrombogenic material) and causes
thrombosis-in-situ.
o This is the same mechanism in MI that should be treated by
PCI to remove thrombus and fix plaque.
▪ Prosthetic conduit.
▪ Compartment syndrome.
▪ Direct arterial injury (bullet, fracture, stab wound)
• Diagnosis is clinically. But other investigations can be done for follow up and
determine the cause of ischemia:
o ECG (For heart causes).
o Liver and Renal function test.
▪ Due to myoglobin (dangerous on kidney) and lactate and H2 ion (causes
acidosis) and potassium (causes cardiac arrest)
o RBS
o Platelet count, especially in heparin.
▪ Half-life of heparin is 90 minutes
▪ It functions indirectly by increase anti-thrombin 3 and inhibit factor 2 and
10.

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 ▪ It can cause Heparin induced thrombocytopenia.
▪ Alternative is heriodine (most potent natural anticoagulant 🐜) or
heparin.
• Treatment:
o Admission
o Heparin IV Bolus 10,000 unit.
o Analgesia (opioids)
o IV fluid to correct dehydration
o Foley catheter to monitor renal function
o Embolectomy (because most common cause is distal emboli)
o If cause is local thrombus, then management toward thrombolysis and PCI and
balloon dilatation.
▪ The cause usually can be differentiated from history and examination.
o If delayed presentation, amputation should be done.
o Lifelong anti-coagulant.
• Amputation Levels:
o Level is determined by distal pulse positive site.
▪ Digital disarticulation if at metacarpophalangeal joint or
metatarsophalangeal joint.
▪ Ray excision if phalanges + whole metacarpal or metatarsal joint.
▪ Modified ray if phalanges + part of metacarpal or metatarsal joint.
▪ Mid metatarsal operation.
▪ Syme amputation at ankle joints.
▪ Below, through or above knee, wrist, elbow.
▪ Hip or shoulder disarticulation.
o If distal pulse is negative, amputation should be made proximally at positive
pulse site even if far above the site of gangrene.
▪ But if collaterals can be obtained, then amputation can be minimized.

Session 6
• When a patient is on chest tube and coughs, absence of bubbles means that air
leak is sealed.
• Swinging means lung is not fully expanded.
• Single rib fracture is not an indication for admission normally, except in chronic
cases like COPD that makes any simple injury is an indication.

Peripheral pulses:
Notes:
• Always compare after examining each artery.
o If you said that pulse of one side is weak, this is vague. Because maybe both are
week due to hypotension/hypovolemia.

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• You can start from bottom upward, or from up downward.
• Never say shortcuts/abbreviations.
• Examination is by 3 fingers

• Dorsalis pedis
o Between first and second metatarsal bones, lateral to extensor hallucis longus
tendon.
o It is direct continuation of anterior tibial artery, separated from it by imaginary
line between medial and lateral malleolus’s,
• Posterior tibial artery
o Behind and below medial malleolus, or midway between medial malleolus and
achilles tendon/heel of ankle.
o Direct continuation of popliteal artery,
o Larger than anterior tibial artery.
• Popliteal artery
o Put thumbs side-by-side on tibial tuberosity, insert fingers in the depth of
popliteal fossa between medial and lateral heads of gastrocnemius muscle,
usually lateral to the midline of knee.
• Femoral artery
o It is the common femoral artery.
o Determining the anterior superior iliac spine point: from posterior part of
flank follow the iliac crest until you find the bony prominence (ASIS, it site of
attachment of inguinal ligament and sartorius muscle)
▪ Longest muscle: sartorius (muscle of tailors)
▪ Strongest muscle: gluteus muscle
▪ Strongest ligament: iliofemoral
▪ Strongest tendon: achilles tendon
o Determining the symphysis pubis: from umbilicus move downward till finding
a bony prominence.
o Ask patient to externally rotate the leg to make it easier.
o Site of artery is 1 inch/2 cm below the midpoint between those two points.
o This is mid inguinal point, it differs from mid-point of inguinal ligament which is
between ASIS and pubic tubercle which is the site of deep ring of inguinal
canal.
• Radial artery
o Ulnar is larger than it, but radial is more superficial and can be compressed on
solid bone.
o Examination is done in prone position to make it more comfortable to patient.
But description is given according to the normal supine anatomical position.
o Site: brachioradialis (inserted into base of styloid process of radial bone)
laterally, and flexor carpi radialis tendon (inserted into base of 2nd/3rd
metacarpal bone) medially.

Page 10 of 19
• Brachial artery
o Right side is examined by right thumb (ipsilaterally), and vice versa.
o Determine the tendon of brachial biceps muscle. The artery is located medial to
it.
▪ Medial to this artery is median nerve (‘TAN mnemonic’)
▪ Ulnar nerve is located posterior to medial epicondyle.
• Below clavicle is axillary artery (not required)
• Subclavian artery is above clavicle (not required)
• Common carotid artery
o Right side is examined by left thumb, and vice versa.
o Site: anterior triangle of neck (bordered by anterior border of
sternocleidomastoid muscle, midline of neck, lower border of mandible),
between larynx and sternomastoid muscle.
▪ Bifurcates at C3-C4 to internal (brain) and external (external parts of
head) branches. At superior border of thyroid cartilage.
• External carotid artery can be ligated.
• Common carotid artery cannot be ligated (leads to CVA). If injured
should be bypassed surgically in 2 minutes.
▪ Cricoid cartilage is at C6.

Chronic limb ischemia

• Most common cause is atherosclerosis
o Hypertension, DM, dyslipidemia, obesity, sedentary life style, smoking, male
gender, old ages.
• Presentation
o Asymptomatic (week pulses).
o Intermittent claudication.
▪ Exercise/work makes blood insufficient for muscles, becoming anaerobes
and producing lactic acid, H2, CO2 that cause pain. Relieved when those
material are washed out during rest.
o Rest pain
▪ Especially during night.
▪ If becoming more severe, occurs during day also.
o Ischemic ulceration (called minor tissue loss)
o Frank gangrene (called major tissue loss)
• Investigation
o Doppler
o CT angiography (cannot be used in renal problems)
o MRA
o Reduced ABI (Ankle-Brachial index/ratio of blood pressure)
• Management
o Conservative

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 ▪ Life style modification
▪ Regular exercise (enhancing collateral)
▪ Control hypertension (by Ca blockers because it is also vasodilator), DM,
lipid level.
▪ Smoking cessation
o Pharmacological
▪ Gold standard is pentoxifylline and cilostazol. They are vasodilator,
remodeling RBCs decrease viscosity and enhance blood flow to distal
parts.
▪ Antiplatelets like aspirin
▪ Anticoagulant.
▪ Oral anticoagulant (warfarin).
o Surgery
▪ PCI
▪ Bypass graft surgery
• Synthetic or natural.
▪ Endarterectomy
▪ Amputation

Session 7 Dr-Rafid (X-Rays)

General Notes:
• Stand in front of X-ray, face to face.
• Profile:
o Site of X-Ray (e.g. chest)
o View (e.g. posterior anterior view (Don’t say PA or abbrevations))
o Named (And better to mention the name & number of patient)
o Dated (And better to mention the date)
o Labeled (And better to say labeled to right or left)
o Determine age by appearance of ossifications in bones:
▪ Head of humerus = 1 year
▪ Greater tuberosity = 3 years
▪ Lesser tuberosity = 5 years
▪ Fused epiphysis at 16 years
▪ Lateral epicondyle fuse at 13 years
o Determine sex if possible
• Technical Considerations:
o Full inspiration if 9-10 posterior ribs are visible.
o Good penetration if intervertebral disk of upper thoracic vertebra just seen
(not in details).
o No Rotation
▪ Vertebra spine is at equal distances from both medial ends of clavicles.
▪ Any child has to be rotated
▪ If rotated, say grossly or slightly

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• Hidden areas in chest x-ray
• Hila (contain bronchus, vessels, lymph nodes)
o Size
o Shape (normally concave)
o Density
• Lung apex
• Costophrenic angle
• Retrocardiac space.

• Normal findings
• End on vessels and End on bronchus
• In pediatric, thymus is largest organ

• Tips:
• When you find chest tube, mention its side and site (site is based on intercostal
space of tip) and direction (upward or downward)
• In pediatric, thymus is largest organ (don’t confuse with mediastinal
enlargement).

X-Rays Cases:
• Case: Extra-pulmonary air-fluid level:
o Empyema
o Hydrothorax
o Hemopneumthorax
o Ruptured viscous
o Post pneumonectomy
o Hernia
o Broncho pleural fistula
o Ruptured hydatid cyst

• Case: cavitary lesion inside the lung with

air fluid level:
• Ddx:
o Lung abscess
o Ruptured hydatid cyst
o Tumor (If old Age)
o Infected bulla or bronchiectasis

• How to Confirm that the mass is inside the lung:

o Check angle of the lesion, it should be acute (if obtuse angle (wide neck) =
mass is outside the lung, maybe pleural or mediastinal)
o Check where is the bulk of the mass if in the lung or not.
• Case: diaphragmatic henria
o Bochdalek is emergency, from posterior left side.

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 o Morgagni is not emergency, usually at anterior right side.

• Case: RTA with 6 findings

o Blunted costophrenic angle
o Chest tube (bilateral, their tips at 4th, 6th intercostal spaces)
o Non-homogeneous opacifications in hemithorax, mostly contusion (because
there is history/signs of trauma)
o CV line (Accepted position is till the site of entrance of SVC to right atrium)
o Overlapped ribs = Fracture ribs mostly.
o

• Case: hemorrhage + contusion

• Case: Left upper zone, homogenous mass/opacity.

o Mass Features:
▪ Size, site.
▪ Calcification (like TB) = benign feature if in lung (calcification in brain
also benign).
▪ Cavitation = can be aggressive feature.
▪ Fluid level, Boundaries, Homogeneity
▪ Tissue destruction
▪ Contact with mediastinum
▪ Angle is acute or obtuse
▪ Associated hilar hypertrophy
▪ Intra or extrapulmonary
o Ddx:
▪ Benign Tumor
▪ Malignant tumor
▪ Hydatid cyst
▪ TB granuloma
▪ Metastasis
▪ Round pneumonia
▪ Contusion
▪ Hematoma
▪ Hamartoma
▪ Mucous entrapment.

• Case: Air fluid level three must-say DDx:

• Diaphragmatic hernia
• Diaphragmatic injury
• Empyema

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• Case: chest tube with apparent left
diaphragmatic elevation + shifted
mediastinum
• Diaphragmatic injury +- Hernia ->
• Diaphragmatic hernia
• Phrenic nerve injury and Diaphragmatic
eventration.
• Diaphragmatic hump (normal variant)

• Case: Cystic lesions in right middle lobe = Bronchiectasis

• Case: Non-homogenous mass + Hilar hypertro

phy
• = Malignant tumor.

• Case: Kinking chest tube + Malposition

• Case: air under diaphragm, pneumoperitoneum

• Ddx:
o Perforate viscous
o Post laparotomy/laparoscopy
▪ Q/how long it takes to absorb air in peritoneum/pleura ?

• Case: unilateral mastectomy + axillary enlarged lymph node hypertrophy.

• Case: cardiomegaly + pulmonary edema

• Case: moderate pleural effusion (Meniscus Sign)

• Case: Pediatric fracture clavicle

• Case: scoliosis + calcified emphysema + collapsed lung

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• Case: foreign body in neck
• Round opacity in upper mediastinum
• Usually needs lateral view
• But here the trachea is clearly patent,so the
lesion is in esophagus

• Case: enfolding aorta

• Aging process
• (‫)عباية ساين‬

• Case: collapse of upper right lobe

of lung
1. Ddx are of mass (mentioned
above)

• Case: eventration of diaphragm

• Other Ddx:
o Collapse
o Consolidation

• Case: duplicated X-rays (Artifcat)

• Pneumothorax

Q/ last bone to ossify in human.

Page 16 of 19
Session 8
• After removal of chest tube and ligate the opening, don’t forget to make perfect
dressing to ensure no air leaks inside.
• Arabic terms for reports
o Hemothorax : ‫صباب الجنب‬
o Pneumothorax: ‫استرواح الجنب‬
o Pleural effusion: ‫استسقاء الجنب‬
o But in general, try not to use them and write the simple description.
• Medications:
o Montelukast: leukotriene receptor antagonist, not initially effective but in
long term is useful as prophylactic for allergic conditions.
o Co- amoxiclav (augmentin), mainly anti staph
▪ Clavulanic acid (anti penicillinase, called suicidal inhibitor, its
component is 125mg always)
▪ Amoxicillin
o Cefotaxime (3rd generation cephalosporins)
o Inhaler salmeterol + cortisol (side effect is tachycardia and tremor)
o Phylloquinone (another broncho-dilator)
o PPI
▪ Peptic ulcer: loss of mucosal continuity, it is general term for all
duodenal, gastric, esophageal ulcers.
▪ Zollinger ellison syndrome is type of peptic ulcer at unusual sites
(like 2nd part of duodenum) due to hyper secretion of gastric acid
(gastrinoma).
• Case: bilateral gynecomastia in male:
o Causes:
▪ Chromosomal (Klinefelter syndrome)
▪ Hormonal disturbance (hyperprolactinemia)
▪ Drugs (digoxin, spironolactone, cimatidine)
▪ Prostate treatment.
o It is done for plastic/cosmetic, so incision should be just below areola and
very small (<2cm).
o There is no recurrence.
o Benefit of tight bandage
▪ Make compression on the area to prevent seroma or swelling due to
any dead spaces.
• Post operative fever:
o First day = reactionary
o 3-5 days = wound infection
• Contraceptive pills should be stopped before any operation to prevent DVT

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Bilateral leg swelling:
• Drugs (ca channel blockers)
• Over fluid
• Heart, renal, liver failure
• Hypoalbuminemia

Unilateral leg swellings:

• Deep venous thrombosis
• Lymphedema (swelling due to pathology in insufficient lymphatic drainage)
• Cellulitis
• Rupture of baker 👩‍🍳 cyst (gelatinous material with fluid, at time of surgery)
• Insect bite
• Snake bite
• Superficial thrombophlebitis
• Revascularization of limb ischemia
o Reaction of newly perfused blood oxygen with anaerobic metabolite at
ischemic part, with resultant oxygen radicals.
• Post thrombotic and syndrome (late complication of DVT, due to destruction of
venous valves)
• Trauma (soft tissue trauma or deep trauma)
• Pelvic tumor.

Deep venous thrombosis

• Defined as thrombosis in the deep veinous system (limbs, or even neck ‘internal
jugular vein’).
o Most common sites are lower limb (stasis due to gravity)
o But upper limbs are also common, due to indwelling catheter and double
lumen cannula.
• Old Signs (not used, because sensitive but not specific, cans can cause
pulmonary embolism)
o Hoffman sign: dorsi-flexion of ankle
o Brad sign; compression of calf muscles
• Risk factors:
o From lecture
o MCQ: major surgery not minor surgery.
• Investigation:
o Doppler ultrasound (gold standard investigation). It is a must.
o D-dimer (fibrin degradation product), positive in early stage. (It is not
specific). If negative may exclude DVT.
o Venography (invasive and rarely used).

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• Treatment:
• Specific
o Injectable anticoagulant
▪ Unfactioned heparin
▪ LMWH (enoxaparin)
▪ Mechanism: potentials antithrombin 3 for 1000 times to inhibit facto
2 and 10
o Oral anticoagulant
▪ Warfarin: inhibit factor 2,7,9,10 (‘1972’).
▪ Mechanism:
• Carboxylase enzyme activates factor 2,7,9,10. It needs vitamin
k as a coenzyme for this process by giving his H ion and get
oxidized. Vitamin K then needs to be reduced again by epoxied
reductive enzyme. The latter is inhibited by warfarin.
o Duration of treatment
▪ Overlap of injectable and oral warfarin till INR became 2 or for 10
days
▪ Then warfarin for 6 months
▪ For 12 months if associated with pulmonary embolism
▪ If with irreversible risk factor, duration is lifelong.
• Non-specific
o Bed rest
o Leg elevation
o Elastic stockings (after resolution of swelling)
o Stop of causing
o Analgesia and opioids.
o NO massage or manipulation
o Rehydrated, because dehydration cause viscosity and decrease response to
treatment
• Treatment of comorbidities.
• Prophylactic (Read in lecture)
Exams Questions
o Q/mechanism of anticoagulants
o Q/ pneumothorax
o Q/ hemothorax
o Q/ pleural effusion
o Q/ acute limb ischemia Good Luck &
o Q/ DVT
o Q/ chronic limb ischemia
Sorry for any
o Q/ Lymph edema
o Q/ anything related to chest tube
mistakes ^^
o Q/ Baker cyst
o Q/ CV line sites and complications
o Q/ Burger Disease

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