الدرة الجامعة للفرقة الرابعة

2 ::.. للفرقة الرابعة .. اجلامعة ة ر الد ..:: حممود شعيب – حمفوظة احلقوق مجيع ©

ة الجامعة ر الد

للفرقة الرابعة

جامعة طنطا – كلية الطب

1429


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فإن اخلافقات هلا سكون .. إذا هبت رياحك فاغتنمها

فال تدري الفصيل ملن يكون .. وإن ولدت نياقك فاحتلبها

: قال حكيم من احلكماء

ملا كنت حدثا كنت أتصور أن الرعد هو الذي يقتل الناس

لما كربت علمت أن الربق هو الذي يقتل ف

وهلذا عزمت من ذلك احلني على أن أقل من اإلرعاد وأكثر من اإلبراق


بسم اهللا الرمحن الرحيم

املقدمة

احلمد هللا على توفيقه وامتنانه، وعظيم نعمه، وتتابع إحسانه، وأشهد أن ال إله إال اهللا وحده ال شريك

أن حممدا عبده ورسوله، اللهم صل وسلم عليه وعلى آله وأصحابه ومن تبعهم بإحسان إىل يوم له، وأشهد

. لقائه

فقط ولكنه على غري مثال سابق أو تأليف إضافة جديد - ذا الكتاب - ي ع د أ فإين ال : أما بعد

وأرجوه سبحانه أن هللا، قصاصات متفرقة وأفكار شاردة رأيت مجعها يف كتاب واحد ليعم النفع ا إن شاء ا

. وأن ينفع به، وهو سبحانه ويل اهلداية والتوفيق يكلل هذا العمل باإلخالص لوجهه الكرمي،

ه يف النهاية على أن الرسالة حباجة إىل مزيد عمل، ولكن خيرج األمل دائما خارج دائرة و ن وال يفوتين أن أ

خراج إبداعام الطالب إل اليت تشعل مهم رارة مبثابة الش مر القصري، ولكن قد يكون هذا الكتاب ع ال

. ستخالص الفوائد من املواد الطبية، ونرى من بعده كتبا تفوقه مادة وإخراجا وجهودهم يف ا

وكتب شعيب حممود

1429 مجادى اآلخرة 27

طنطا

وكان االنتهاء من مراجعته يف1429 رمضان 19 - اجلمعة


فهرس

7 ................................................ اجلوهرة يف األنف واألذن واحلنجرة . 1

22 ............. ......................... شرعي والسموم إزالة اهلموم يف عملي الطب ال . 2

23 ...................................................... الطب الشرعي : القسم األول •

44 .............................................................. السموم : القسم الثاين •

58 ....... ........................... ........ وشهادة الوفاة تتبع اجلناة يف التقرير الطيب . 3

70 ................................................ القطر والربد خالصة يف عملي الرمد . 4

93 .................................................. كشف االفتراء عن علم اإلحصاء . 5

6 . 98 ........................................................... .......... واستبيان ختام


هرة و لج ا

في األنف واألذن والحنجرة


جتميعات ) 1 (

EXPRESSIONS

• Boxer’s ear → Haematoma of the auricle.

• Cauliflower ear → Pericondritis of the auricle.

• Ramsey‐Hunt syndrome→ Herpes zoster oticus.

o A triad of:

1. Herpes zoster oticus.

2. Facial nerve palsy.

3. Sensori‐neural hearing loss & vertigo.

• Wet newspaper → Otomycosis of the EAC.

o The lumen of the canal contains a whitish mass with black spots.

• Post auricular abscess →Mastoiditis.

o An external fluctuant abscess behind the auricle.

1. Zygomatic abscess → In front & above the auricle.

2. Bezold’s abscess → Deep to sternomastoid.

3. Citelli’s abscess → Deep to posterior belly of digastric.

• +ve reservoir sign →Mastoiditis.

o Discharge is mucopurulent, excessive & reaccumulates rapidly after removal.

• Griesinger’s sign → Lateral spread to the mastoid emissary veins → tender post‐auricular edema.

• Empty delta sign → CT with contrast → due to failure to visualize the contrast in the lumen of the

sinus.

..:: BOTH IN lateraL sinus thrombosis or thrombophlebitis ::..


• Kernig’s sign +ve → Hip flexion limits knee extension.

• Brudziniski’s sign +ve → Neck flexion causes flexion of hips & knees.

..:: BOTH IN meningitis ::..

• Paracusis willshii → Hearing is better in noisy areas due to the loud voices used against the

background noise.

• Schwartz sign (rare) → Flamingo red tinge seen through the TM due to active vascular bone on the

promontory.

..:: BOTH IN otosclerosis ::..

• Hitzelbeger’s sign → Numbness of the posterior concha & post‐auricular area associated with

compression of facial nerve in the CPA by acoustic neuroma.

• Eagle’s syndrome→ Elongated styloid process stretching the glosso‐pharyngeal nerve as it winds

around it.

• Miculicz cells → Large foamy cells having a central nucleus & vacuolated cytoplasm (containing the

Frisch bacilli).

• Russell bodies → Transformed plasma cells having an eccentric nucleus & deep eosinophilic

cytoplasm.

• Tapir nose → Adhesions & stenosis distort the normal anatomy & an external nasal deformity may

appear.

..:: ALL IN rhinoscleroma ::..

• Grape like → Ethmoidal polypi.

o Bilateral multiple polypi arising mainly from the middle meatus.

• Bull’s neck → Diphtheria.

o Enlarged tender cervical lymph nodes.

• Koilonychias → Plummer‐vinson syndrome.

o Spooning of the nails.


• Killian’s dehiscence → A potentially weak area on the posterior surface of the pharynx, between the

upper oblique fibers (thyro‐pharyngeus) & lower circular fibers (crico‐pharyngeus) of the inferior

constrictor muscle.

• Retort‐shaped appearance → Barium swallow X‐ray shows retort‐shaped (pear‐shaped) appearance.

..:: BOTH IN pharyngeal pouch ::..

• Dumbbell shaped→ Large tumors are centered on the spheno‐palatine foramen with:

1. One part in the nose & naso‐pharynx.

2. The other in the pterygo‐palatine fossa.

• Frog face deformity → Broadening of the external nose & proptosis.

..:: BOTH IN naso‐pharyngeal angiofibroma ::..

• moure’s sign +ve → Post Cricoid Carcinoma.

o In normal persons, there is a click felt when the larynx is moved from side to side over the vertebral

column.

o This sign is absent in patients with PCC (moure’s sign +ve).

• Omega‐shaped epiglottis → Laryngomalacia.

o Long tapering epiglottis & folded ary‐epiglottic folds (Infantile type of the larynx).

• Thumb nail sign → Acute epiglottitis (supra‐glottitis).

o Lateral view X‐ray neck → markedly thickened epiglottis.

• Arnold‐chiari malformation→ Congenital vocal cord paralysis.

o Stretch at skull base in meningioceles & hydrocephalus.

• Parrot peak appearance → Achalasia of the cardia.

o Barium swallow X‐ray shows dilated esophagus with narrow lower part.

• Rat tail appearance → Carcinoma of esophagus.

o Barium swallow X‐ray shows an irregular filling defect and/or shouldering.


THE COMMONEST

• The commonest congenital anomaly of the auricle → Protruding (bat) ears.

• The commonest cause of rupture TM → A blow on the ear (indirect trauma).

• The commonest operation to treat all types of chronic suppurative OM→ Tympanoplasty.

• The commonest complication of suppurative OM→Mastoiditis.

• The commonest tumor of the inner ear & CPA → Acoustic neuroma.

• The commonest cause of:

• CHL →Wax.

• Progressive CHL in young adults in middle age → Otosclerosis.

• Deafness in children → OM with effusion.

• Deafness in elderly people → Presbyacusis.

• The commonest benign tumor of the skin of the external nose & vestibule → SC papilloma.

• The commonest malignant tumor of the nasal cavity & paranasal sinuses → SCC.

• The commonest fungus affection of the throat →Moniliasis (candida albicans).

• The commonest benign tumor of the naso‐pharynx → Naso‐pharyngeal angiofibroma.

• The commonest malignant tumor of the naso‐pharynx → Naso‐pharyngeal carcinoma.

• The commonest malignant tumor of the hypo‐pharynx in EGYPT → PCC.

• The commonest laryngeal granuloma in EGYPT → Laryngoscleroma.

• The commonest cause of vocal cord paralysis → Surgical trauma (25%).

• & the commonest surgery → Thyroid surgery.

• The commonest neoplasm causing vocal cord paralysis → Bronchogenic carcinoma.


• The commonest laryngeal congenital anomaly → Laryngomalacia (80%).

• The second commonest laryngeal congenital anomaly→ Vocal cord paralysis (10%).

• The commonest benign tumor of the larynx → Papilloma.

• The commonest type of cancer larynx → SCC.

• The commonest site of cancer larynx → Glottis (60%).

CAUSATIVE ORGANISMS

• ASOM:

1.Beta haemolytic streptococci.

2.Streptococcus pneumonia.

3.Staphylococcus aureus.

4.Haemophilus influenza.

5.Moraxilla catarrhalis.

6.Viral infection paves the way for secondary bacterial infection.

• Common cold (acute coryza):

1.Adenovirus.

2.Rhinovirus.

3.Respiratory syncytial virus (RSV).

4.Para‐influenza.

• Rhino‐scleroma (& laryngo‐scleroma):

Ø Klebsiella rhino‐scleromatis (gram –ve Frisch bacillus).

• Acute sinusitis:


2.Haemophilus influenza (type B).

3.Moraxilla catarrhalis.


• Diphtheria:

Ø Coryne‐bacterium diphtheria.

• Vincent’s angina:

1.A fusiform bacillus.

2.A spirochete (borrelia vincenti).

• Moniliasis:

Ø Candida albicans.

• Acute tonsillitis:

1.Beta haemolytic streptococci.


3.Haemophilus influenza.

• Acute simple (non specific) laryngitis in adults or in children:

Ø Usually mixed viral & bacterial.

• Acute epiglottitis (supra‐glottitis):

Ø Haemophilus influenza (type B) is the most common pathogen.

• Acute laryngo‐tracheo‐bronchitis:

Ø Viral infection of the mucosal lining of the mucosal lining of the whole respiratory tract.

• Tuberculosis of the larynx:

Ø Mycobacterium tuberculosis.

• Syphilis of the larynx:

Ø Treponema pallidum.


احملاضرات زيادات ) 2 (

OPERATIONS

• Waldeyer’s ring

o A ring of lymphoid tonsils which lies in the pharyngeal submucosal CT layer (the pharyngeal

aponeurosis).

o It surrounds the upper part of the aero‐digestive tract.

o It consists of:

Ø One pharyngeal (naso‐pharyngeal) tonsil

Ø 2 tubal tonsils.

Ø 2 palatine tonsils.

Ø 2 lingual tonsils.

• In any operation you should know:

1.Aim = principle = rationale, e.g.:

Ø Caldwell‐luc operation (radical antrum) Ø FESS

o To remove all diseased mucosa.

o To promote ventilation & drainage through an

artificial opening in the most dependant part of

the sinus.

o To restore function & patency of the natural

ostium of the sinus.

o To provide normal ventilation & drainage.

2.Indications.

3.Contra‐indications.


• Indications of radical antrum:

1.Chronic sinusitis with irreversibly damaged mucosa.

2.Dentogenic sinusitis.

3.Benign tumors & cysts.

4.Recurrent antro‐choanal polyp.

5.FB sinus (ethmoid & maxillary).

6.Fracture orbital floor.

7.As a step in other operations to reach the spheno‐palatine fossa:

o Vidian neurectomy.

o Ligation of spheno‐palatine artery in severe epistaxis.

• Indications of submucous resection (SMR):

= clinical picture of deviated nasal septum (DS).

GLAND DISEASE COMPLICATION OF OPERATION

(Injury of …)

o Parotid g. o Pleomorphic adenoma. o Facial n.

o Submandibular salivary g. o Chronic sialadenitis due to

calculus.

o Hypoglossal n.

o Thyroid g. o Simple nodular goiter. o recurrent laryngeal n.

INVESTIGATIONS

• In X‐ray & CT scan you should mention 3 words, e.g.:

Ø X‐ray Ø CT

Poster‐anterior, X‐ray, On the chest. Coronal, CT, On the paranasal sinuses.


DISEASES

PHARYNGEAL MEMBRANES

• FALSE:

1.Diphtheria.

2.Vincent’s angina.

3.Acute pharyngitis of blood disease:

o Agranulocytosis.

o Leukemia.

o Infectious mononucleosis (glandular fever).

• TRUE:

1.Moniliasis.

2.Acute membranous tonsillitis.

AIDS

1.Hairy leukoplakia.

2.Kaposi sarcoma.

3.Recurrent candidiasis.

4.Recurrent herpetic ulcer.

ORAL ULCERS

1.Aphsous.

2.Traumatic.

3.Syphilitic.

4.Herpetic.

5.Neoplastic (malignant tumors).


VELO‐PHARYNGEAL INCOMPETENCE

v Causes

§ Structural:

o Cleft palate (partial or complete).

o Oro‐nasal fistula.

§ Functional:

o Palatal paralysis.

v Clinical picture:

1.Defective swallowing.

2.Nasal regurgitation of fluid or sometimes food.

3.Defective speech (rhinolalia aperta ‐ hyper nasality of speech).

v Complications:

§ OM with effusion due to ET affection.

v Treatment:

§ For structural defect:

o Closure.

§ For functional defect:

o Augmentation.

o Pharyngoplasty.

DEVIATION RULE

10 th (vagus n.) + 7 th (facial n.) 12 th (glosso‐pharyngeal n.) + 5 th (trigeminal n.)

Deviation to the healthy side Deviation to the diseased side


Formulate a treatment plan for ?

1. Conservative ttt→ observe for … (e.g. C/P),

o If resolved → discharge the patient.

o If progress → step 2

2. Surgical ttt.

State the rationale (principle of ttt) of ?

• A malignant tumor e.g. Post‐cricoid carcinoma or pyriform fossa carcinoma:

1. To remove the tumor completely (structural rationale), so as to minimize the possibility of:

o Local recurrence.

o Regional or systemic metastasis.

2. To preserve the function (functional rationale).

• An infectious disease:

1. Eradication of disease (antibiotics).

2. Relief of symptoms.

• Allergic rhinitis:

1. Avoidance: to avoid exposure or intake of the offending antigen.

2. Modulation of Ag‐Ab reaction → immune‐therapy (desensitization) by slow injection of Ag that

forms IgG instead of IgM.

3. Suppression of mast cells (prevention of release of mediators) → chromoglycates.

4. Combating the released mediators → anti‐histaminics.


اآلالت ) 3 (

INSTRUMENT USED IN

1. Head mirror. • ENT examination.

2. Aural speculum. • Examination of the ear.

3. Siegle (pneumatic) speculum. • Examination of the ear (magnification, test drum mobility,

fistula test).

4. Straightmetallic tongue depressor. • Examination of the oral cavity and oropharynx.

5. Curvedmetallic tongue depressor.

6. Wooden tongue depressor.

7. Laryngeal mirror. • Examination of the larynx (indirect laryngoscopy).

8. Post‐nasal mirror. • Examination of the posterior part of the nasal cavity and

nasopharynx (posterior rhinoscopy).

9. Dressing forceps. • Dressing of the ear or nose.

10. Probe (cotton applicator). • Cleaning the ear canal.

11. Tuning fork. • Tuning fork tests.

12. Scalpel handle. • All surgical operations e.g. SMR, Tonsillectomy,

Tracheostomy.

13. Towel forceps. • Used to fix the towels in any surgical operation.

14. Tonsil Holding forceps. • Tonsillectomy operation.

15. Straight tonsillar artery forceps.

16. Curved tonsillar artery forceps.

17. Tonsillar scissor.

18. Toothed tonsillar dissector.

19. Combined dissector and retractor.

20. Tonsillar snare.


21. Davis Boyle Mouth gag. • Tonsillectomy and adenoidectomy operations.

22. Tonsillar compression forceps. • Post‐tonsillectomy hemorrhage.

23. Adenoid curette. • Adenoidectomy operation.

24. Nasal snare. • Polypectomy.

25. Local anesthesia syringe. • SMR operation.

26. Short bladed nasal speculum. • Examination of the nose (anterior rhinoscopy).

27. Long bladed nasal speculum. • SMR and Turbinectomy.

28. Luc’s forceps.

29. Nasal dressing forceps.

30. Nasal scissor.

31. Self retaining nasal speculum. • SMR and septoplasty operations.

32. Septal dissector.

33. Swivel knife.

34. Chisel. • SMR and Caldwell Luc’s operations.

35. Hummer.

36. Antral burr. • Intranasal inferior antrostomy.

37. Ethmoid Curette. • Intranasal ethmoidectomy operation.

38. Periosteal elevator. • Mastoidectomy and Caldwell Luc’s operations.

39. Metallic sucker (suction tip). • SMR, turbinectomy and other nasal operations.

40. Walsham’s forceps. • Reduction of fracture nasal bones.

41. Ash forceps. • Reduction of fracture nasal septum.

42. Anterior nasal pack. • Management of anterior epistaxis.

43. Posterior nasal pack. • Management of posterior epistaxis.


44. Myringotomy knife. • Myringotomy operation.

45. Mastoid curette. • Mastoidectomy operation.

46. Gland forceps. • Thyroidectomy and submandibular sialadenectomy.

47. Alice forceps. • Tracheostomy and other neck operations.

48. Kocher forceps.

49. Mosquito forceps.

50. Tissue retractor.

51. Non‐toothed forceps. • Tracheostomy and other neck operations.

(hold delicate structures).

52. Toothed forceps. • Tracheostomy and other neck operations.

(hold tough structures).

53. Tracheal dilator. • Tracheostomy operation.

54. Tracheostomy tube

(single lumen, silicon, cuffed).

) ** بنفس الترتيب املوجود هنا ( انظر عرض اآلالت **

Instruments‐modified.ppt


الهموم إزالة

في عملي الطب الشرعي

وم والسم


القسم األول

الشرعي الطب


IDENTIFICATION

UPPER LIMB

• The specimen is left humerus aged less than 14 years (if male),

because trochlea & capitulum are not united (unites at 14 years in males).

• The specimen is left humerus agedmore than 20 years (if male),

because the head is united with the shaft (unites at 20 years in males).

• The specimen is right ulna aged less than 16 years (if male),

because the head is not united with the shaft (unites at 16 years in males).

• The specimen is right radius aged less than 17 years (if male),

because the head is not united with the shaft (unites at 17 years in males).

• The specimen is left ulna agedmore than 20 years (if male),

because the lower end is united with the shaft (unites at 20 years in males).

• The specimen is left radius agedmore than 20 years (if male),


LOWER LIMB

• Two opened humeri to demonstrate:

oMedullary cavity reached surgical neck (30 years if male).

oMedullary cavity reached anatomical neck (33 years if male).

• The specimen is left femur aged less than 16 years (if male),

because the lesser trochanter is not united with the shaft (unites at 16 years in males).

• The specimens are right tibia & fibula aged less than 18 years (if male),

because the lower ends are not united with the shafts (unite at 18 years in males).

• The specimen is left femur agedmore than 21 years (if male),



• The specimen is right tibia agedmore than 21 years (if male),

because the upper end is united with the shaft (unites at 21 years in males).

• The specimen is infant vault of skull aged less than 18months,

because the anterior fontanelle is still opened (closes at 18‐24 months).

• The specimen is skull.

o The parietal eminences are not prominent.

o The superciliary ridges are less marked.

o The fronto‐nasal junction is smoothly arched.

o The mastoid processes are short & small.

o The occipital condyles are short (or small) & broad.

üBasioccipital, basisphenoidal, sagittal, coronal & lambdoid sutures are closed (close at 23, 30, 40 & 50

years respectively in males).

(epiphyseal union is earlier in females by 2 years).

o Y‐shaped fissure fracture in the posterior part of the right parietal bone (about 4 cm in length)

extending through the occipito‐mastoid suture (diastatic) towards the base causing fracture base at

the level of basioccipit‐basisphenoid.

Ø The specimen is female skull agedmore than 48 years with fracture base.

• The specimen is skull.

o The parietal eminences are prominent.

o The superciliary ridges are prominent.

o The fronto‐nasal junction is angular.

o The mastoid processes are long & big.

o The occipital condyles are long & narrow.

üBasioccipital, basisphenoidal, sagittal, coronal & lambdoid sutures … (from above).

Ø The specimen ismale skull agedmore than 50 years.


• The specimen is sternum.

o It is short & narrow.

o The length of the body is less than double length of the manubrium sterni.

o The xephoid process is united with the body (unites at 38 years in females).

o The manubrium is not united with the body (unites at 58 years in females).

Ø The specimen is female sternum agedmore than 38 & less than 58 years.

• The specimen is most probablymale vault of skull (prominent parietal eminences), aged less than 25

years,

because the sagittal suture is still opened (closes at 25 years in males).

• The specimen is child hip bone aged less than 6 years,

because the pubic ramus is not united with the ischial ramus (unite at 6 years).

• The specimen is left hip bone.

o Iliac crest is highly arched.

o Body of pubis is triangular in shape.

o Pubic arch is narrow (forms an acute angle).

o Greater sciatic notch is narrow & deep.

§ Preauricular sulcus is ill defined.

§ Ilio‐pectineal line is sharp & well defined.

o Obturator foramen is oval.

o The epiphysis of iliac crest is united (unites at 23 years in males).

Ø The specimen is left male hip bone agedmore than 23 years.


• The specimen is left hip bone.

o Iliac crest is less arched.

o Body of pubis is quadrangular in shape.

o Pubic arch iswide (forms an obtuse angle).

o Greater sciatic notch iswide & shallow.

§ Preauricular sulcus iswell defined.

§ Ilio‐pectineal line is smooth & ill defined.

o Obturator foramen is triangular.

o The epiphysis of iliac crest is united (unites at 23 years in males).

Ø The specimen is left female hip bone agedmore than 21 years.

• The specimen ismale sacrum because:

o The body is long & narrow with homogenous curve & projecting sacral promontory.

o The auricular surface with illium extends to the third sacral segment.

• The specimen is female sacrum because:

o The body is short, wide & curved only in its lower part.

o The auricular surface with illium extends only to the second sacral segment.

• The specimen is adult male mandible agedmore than 18 years (in the middle life).

o The chin is square.

o The angle region is everted.

o The angle between the body & ramus is nearly right.

oMandibular foramina aremidway between the upper & lower borders of the mandible.

o All the permenant teeth including wisdom teeth are erupted (18‐25 years).


BALLISTICS • The specimen is empty (fired) cartridge of sporting gun (non‐rifled weapon).

o It is empty, fired (dimple in the percussion cap).

o It is long, made of cardboard with brass base.

o Powder is smokeless or black.

o The complete cartridge contains internal wad, external wad & small rounded shots inbetween.

• The specimen is complete (full) (not fired) cartridge of sporting gun (non‐rifled weapon).

o It is complete, not fired (no dimple in the percussion cap).

o It is long, made of cardboard with brass base.

o Powder is smokeless or black.

o Inside the cartridge, there are internal wad, external wad & small rounded shots inbetween.

• The specimen is outer (external) wad of non‐rifled weapon.

o It is thin (1 mm in thickness), rounded (1 cm in diameter), made of cardboard & white in color.

o It is present in sporting gun & greener gaffer gun.

• The specimen is inner (internal) wad of non‐rifled weapon.

o It is thick (1 cm in thickness), rounded (1 cm in diameter), made of felt & brown in color.

o It is present in all non‐rifled weapons (sporting & gaffer gun).

• The specimen is inner (internal) wad of recent types of sporting gun.

• The specimen is empty (fired) cartridge of non‐automatic service rifle.


o It is non‐automatic (rim near the base).

o It is long, made of brass & there is faint shoulder near its empty upper end.

o Powder is smokeless.


• The specimen is complete (full) (not fired) cartridge of automatic service rifle.


o It is automatic (groove near the base).

o It is long, made of brass & there is faint shoulder near its empty upper end.


o The bullet is long, point ended & jacketed.

• The specimen is deformed fired bullet of service rifle weapon.

o It is long, point ended & jacketed.

o It is fired as shown from the presence of primary rifling marks.

o It is also deformed.

• The specimen is fired bullet of short rifled weapon.

o Weapons are either automatic pistol or new revolver.

o It is short, blunt ended & jacketed (A) copper jacket (B) nickel jacket.

o It is fired as shown from the presence of primary rifling marks.

• The specimen is empty (not fired) cartridge of greener gaffer gun (non‐rifled weapon).

o It is empty, not fired (no dimple in the percussion cap).

o It is long, made of brass & has a rim at its base.


o The complete cartridge contains internal wad, external wad & large rounded shots inbetween.

• The specimen is shots of sporting gun (non‐rifled weapon).

o They are machine made (small, spherical, regular & equal in size & shape).

o They are made of lead (lead balls).

• The specimen is shots of greener gaffer gun (non‐rifled weapon).

o They are machine made (large, spherical, regular & equal in size & shape).

o They are made of lead (lead balls).


• The specimen is empty (fired) cartridge of automatic pistol (short rifled weapon).


o It is short, made of brass & has a groove at its base.


• The specimen is complete (full) (not fired) cartridge of automatic pistol (short rifled weapon).


o It is short, made of brass & has a groove at its base.

o The bullet is short, blunt ended & jacketed.


• The specimen is complete (full) (not fired) cartridge of new revolver (short rifled weapon).


o It is short, made of brass & has a rim at its base.

o The bullet is short, blunt ended, jacketed (new type) & shows a trial of extraction.


• The specimen is smokeless powder.

Ø Composition: It consists of nitrocellulose 60%, nitroglycerine 35% & mineral gel 5%.

Ø Shape: It may be in various shapes & colors.

Ø Type of weapon: It is present in sporting gun, greener gaffer gun, service rifle, automatic pistol &

new revolver.

Ø Amount of gases: One volume gives 900 volumes of gases.

• The specimen is black powder.

Ø Composition: It consists of carbon 15%, sulphur 10%, potassium nitrate 75%, fine powder.

Ø Shape: Black amorphous powder.

Ø Type of weapon: It is present in sporting gun, Schneider, remington & old revolver.

Ø Amount of gases: One volume gives 300 volumes of gases.


FETUS • The specimen is fetus aged:

oMore than 3months due to formation of placenta & umbilical cord.

o Less than 4months because there is no sex differentiation.

• The specimen is fetus aged:

oMore than 4months because there is sex differentiation.

o Less than 5months because no ossific center appeared in calcaneum.

• The specimen is fetus aged:

oMore than 7months because Ossific center appeared in talus.

o Less than 8months because no ossific center appeared in lower end of femur.

• The specimen is longitudinal section of the right thigh, leg & foot of full term fetus due to:

o Appreciable subcutaneous fat deposition.

Ø Ossific center of calcaneum (appear at 5 th month gestation), its relative big size is due to its

appearance since 5 months.

• The specimen is longitudinal section of the left thigh, leg & foot of full term fetus due to:

o Appreciable subcutaneous fat deposition.

Ø Ossific center of calcaneum (appear at 5 th month gestation), its relative big size is due to its

appearance since 5 months.

Ø Ossific center of talus (appear at 7 th month gestation).

Ø Ossific center of lower end of femur (appear at 8 th month gestation).


• The specimen is full term fetus.

o Length 45‐50 cm, weight 3‐3.5 Kg.

o Placenta is about 30 cm in diameter & 600 gm in weigth.

o Umbilical cord length 45‐50 cm.

§ Testes descended in the scrotum.

§ Nails are growing beyond the tips of the fingers & reach the ends of the toes.

o Head circumference is 13 inches (or 33 cm).

o Scalp hair length is 3 cm.

o Posterior fontanelle is closed while anterior fontanelle is still opened (closes at 12‐18 months).

§ Dark meconium is present in rectum.

Ø Ossific center in lower end of femur is 0.5 cm in diameter.

Ø Ossific centers in cuboids, upper end of tibia & head of humerus.


VISCERA 1) The specimen is a piece of scalp.

o It shows curved contused wound with less marked regular edges (simulating cut wound).

o It is about 7 cm in length.

o It is caused by heavy blunt instrument.

o The possible cause of death is shock, hemorrhage or brain injuries (concussion or compression).

Ø The specimen is a piece of scalp showing contused wound.

3 و 2 اكتبهم في

o It is about 2 cm X ½ cmwith regular edges & 2 acute angles.

o It is caused by sharp point ended instrument (elliptical wound).

o The possible cause of death is shock or cardiac tamponade (collection of blood in the pericardial sac).

2) The specimen is opened heart & overlying skin.

o It shows stab penetrating wound in the heart & overlying skin.

Ø The specimen is stab penetrating wound in the heart & overlying skin.

3) The specimen is heart & overlying chest wall.

o It shows stab penetrating wound in the left ventricle of the heart & overlying chest wall.

Ø The specimen is stab penetrating wound in the left ventricle of the heart & overlying chest wall.

6 و 5 و 4 اكتبهم في

o The causative instrument is sharp edged.

o The possible cause of death is shock, hemorrhage or injury to a vital organ.

4) The specimen is a piece of skin.

o It shows stab wound with regular edges & 2 acute angles with tailing of the ends (stab wound with

dragging).

o It is about 5 cm in length.

Ø The specimen is a piece of skin showing stab wound.


5) The specimen is kidney & overlying skin of the back.

o It shows multiple stab non‐penetrating wounds, with regular edges, about 2 cm in length.

o The wounds are non‐penetrating because the posterior surface of the kidney is retroperitoneal.

Ø The specimen is kidney & overlying skin of the back showing multiple stab non‐penetrating wounds.

6) The specimen is a piece of liver & overlying skin.

o It shows multiple stab penetrating wounds in the anterior surface of the liver & overlying skin with

regular edges & acute angles.

o Their length ranges from 2‐15 cm.

Ø The specimen is a piece of liver & overlying skin showing multiple stab penetrating wounds.

9 و 8 و 7 في اكتبهم

o The causative instrument is rifled weapon (fires bullets).

o Absence of powder marks denotes far firing.

7) The specimen is a piece of skin of anterior chest wall.

o It shows 2 injuries with loss of substance that means firearm injuries.

1.One is circular (about 2 mm in diameter) due to perpendicular firing.

2.The other is oval (slit like) (about 5 mm in diameter) due to oblique firing.


Ø The specimen is a piece of skin of anterior chest wall showing 2 inlets of bullets.

8) The specimens are 4 pieces of skin.

o They show injuries with loss of substance that means firearm injuries.

o The injuries are rounded (about 0.5 cm in diameter).

1.2 injuries are inlets with regular & inverted edges.

2.The other 2 are exits with irregular & everted edges.


Ø The specimens are 4 pieces of skin showing 2 inlets & 2 exits of bullets.


9) The specimen is liver & overlying skin.

o It shows an injury with loss of substance that means firearm injury.

o The injury is a small circular hole (about 0.5 cm in diameter).

o The edges are everted indicating that it is an inlet of firearm wound (because it is in fatty area of

anterior abdominal wall).

o Notice the circular appearance of the inlet in the liver.

o The possible cause of death is shock or injury to a vital organ (liver).

Ø The specimen is liver & overlying skin showing inlet of a bullet.

10) The specimen is human heart.

o It shows 2 injuries with loss of substance that means firearm injuries.

1.One in the right ventricle of the heart with regular & inverted edges (about 1.5 X 0.5 cm).

2.The other in the left ventricle of the heart is rounded with irregular & everted edges (about 2 cm).

o The causative instrument is rifled weapon (fires bullets).

o The possible cause of death is shock or hemorrhage.

Ø The specimen is human heart showing inlet & exit of a bullet.

11) The specimen is a piece of neck.

o It shows a ligature mark of hanging.

o It is high up in the neck (notice hair line).

o It is complete.

o The mark is in the form of a depression with abrasions & contusions at the edges.

o The possible cause of death is cerebral anoxia, congestion, asphyxia or reflex vagal inhibition.

Ø The specimen is a piece of neck showing a ligature mark of hanging.


HEAD INJURIES كله الجملة دي إال إذا ذكر غير ذلك

Ø Age & sex:most probably male skull (prominent parietal eminences) aged more than 50 years

(closed lambdoid suture).

Ø EDH= extradural haematoma.

Ø SSA= striking surface area.

Ø FF= fissure fracture.

1) Diagnosis: The specimen is a transverse section in the brain & skull showing EDH.

• The specimen is a transverse section in the brain & skull.

• Age & sex: …

• Lesion:

ü There is separation of dura from the skull bone (an evidence of EDH) in the right parieto‐temporal

bone (about 10 X 4 cm).

• The cause of death: brain compression.

2) Diagnosis: The specimen is skull vault with dura matter showing localized depressed fracture with

partial comminution & EDH.

• The specimen is skull vault with dura matter.

• Age & sex:most probably female skull (less prominent parietal eminences) aged more than 48 years

(closed lambdoid suture).

• Lesion: It shows localized depressed fracture with partial comminution in the left parietal bone

(about 5 cm in diameter).

ü There is separation of dura from the skull bone (an evidence of EDH).

• The causative instrument: heavy blunt with localized SSA & moderate force.

• The cause of death: brain compression.


3) Diagnosis: The specimen is skull vault showing localized depressed comminuted fracture with

radiating FF.

• The specimen is skull vault.

• Age & sex: …

• Lesion: It shows localized depressed comminuted fracture in the right parietal bone with radiating FF

extending in the right temporal bone.

• The causative instrument: heavy blunt with localized SSA & high force.

• The cause of death: concussion, compression or brain laceration.

4) Diagnosis: The specimen is skull vault showing 2 localized depressed fractures one with partial

comminution & the other comminuted with 3 radiating FFs & EDH.

• The specimen is skull vault with dura matter.

• Age & sex: …


(about 3 X 1.5 cm) with 2 radiating FFs:

1.One extends in the frontal bone (4 cm in length).

2.The other extends in the left parietal bone & crosses the sagittal suture to the right parietal bone (6

cm in length) to meet the other localized depressed comminuted fracture in the right parietal bone

(about 5 X 3 cm) with radiating FF in the right temporal bone.



• The cause of death: compression or brain laceration.


5) Diagnosis: The specimen is skull vault showing localized depressed fracture with 2 radiating FFs.


• Age & sex: …

• Lesion: It shows rounded localized depressed fracture in the left fronto‐parietal bone (about 2 cm in

diameter) just behind the coronal suture with 2 radiating FFs:

1.One extends in the frontal bone (8 cm in length).

2.The other extends in the left parieto‐temporal bone (8 cm in length) passing through the coronal

suture.

• The causative instrument: heavy blunt with small rounded localized SSA & low force.


6) Diagnosis: The specimen is skull vault showing localized depressed fracture with partial

comminution & radiating FF.


• Age & sex:most probably female skull (less prominent parietal eminences) aged more than

48 years (closed lambdoid suture).


(about 5 cm in diameter) & radiating FF in the left temporal bone (1.5 cm in length).

• The causative instrument: heavy blunt with localized SSA & moderate force.


7) Diagnosis: The specimen is skull vault showing localized depressed comminuted fracture with sign of

healing in the form of smoothening of the edge & radiating FF.


• Age & sex: …

• Lesion: It shows rounded localized depressed comminuted fracture (about 3 cm in diameter) in the

left parietal bone & radiating FF in the left temporal bone (0.5 cm in length).

o There is sign of healing in the form of smoothening of the edge.


• The cause of death: brain abscess or epilepsy.


8) Diagnosis: The specimen is skull vault showing 2 FFs & a trephine hole.


• Age & sex: …

• Lesion: It shows 2 FFs:

o One extends in the right frontal & parietal bones crossing coronal suture (7 cm in length).

o The other crosses the coronal suture & extends in the right temporal bone until it meets the first one

(3.5 cm in length).

o There is regular bone defect in the right temporal bone (a trephine hole) (1cm in diameter).

• The causative instrument: heavy blunt with wide SSA & low force.


9) Diagnosis: The specimen is a part skull vault with dura matter showing comminuted facture with

EDH & nibbling.

• The specimen is a part of skull vault with dura matter.

• Lesion: It shows comminuted facture.


• The causative instrument: heavy blunt with wide SSA & high force.

• There is evidence of surgical interference in the form of nibbling.


10) Diagnosis: The specimen is skull vault showing localized depressed comminuted fracture with

radiating FF.


• Age & sex: …

Lesion: It shows localized depressed comminuted fracture (about 3 cm in diameter) in the frontal bone

with radiating FF (1 cm in length).




11) Diagnosis: The specimen is complete skull showing cut comminuted facture with trephine &

nibbling.

• The specimen is complete skull.

• Age & sex: …

Lesion: It shows cut comminuted facture in the fontal & left parietal bones (about 12 X 6 cm) with

trephine & nibbling.

o There is regular bone defect in the left parietal bone (a trephine hole) (1cm in diameter).

• The causative instrument: heavy sharp edged.


12) Diagnosis: The specimen is skull vault showing cut comminuted facture with sign of healing in the

form of partial membrane formation with radiating FF.


• Age & sex: …

Lesion: It shows cut comminuted facture in the right parietal bone (L‐shaped) (about 6 cm in length)

with radiating FF extending towards the frontal bone (5 cm in length).


• The cause of death: brain abscess or jaksonian epilepsy.

13) Diagnosis: The specimen is skull vault showing cut comminuted facture with sign of healing in the

form of smoothening of the edge.


• Age & sex: …

• Lesion: It shows cut comminuted facture in the right parieto‐temporal bone (about 5 cm in length).





14) Diagnosis: The specimen is a part skull vault showing cut & cut comminuted factures with radiating

FFs & chipped fracture.

• The specimen is a part skull vault.

• Age & sex: …

Lesion: It shows:

o Cut fracture in the right parietal bone (about 8 cm in length) with radiating FF passing towards the

sagittal suture causing its separation (diastatic).

o Cut comminutes fracture in the left parietal bone with radiating FF passing towards the sagittal suture

(diastatic).

o Chipped fracture in the right parietal bone (about 3 cm in diameter).

• The causative instrument: heavy sharp edged which was directed:

o Perpendicularly causing cut & cut comminuted fractures.

o Tangentially (removing the outer table) causing chipped fracture.


15) Diagnosis: The specimen is skull vault showing cut & cut comminuted factures with radiating FFs,

trephine & nibbling.


• Age & sex: …

Lesion: It shows:

o Cut comminuted fracture in the right side of the frontal bone (about 8 cm in length) with trephine,

nibbling & 2 radiating FFs:

1.One extends to the left side of the frontal bone (2cm in length).

2.The other extends to the right side (1 cm in length).

o Cut fracture extending in both parietal bones on both sides of the sagittal suture about 1 cm behind

the coronal suture with trephine & 2 radiating FFs:

1.One extends to the right parietal bone (4 cm in length).

2.The other extends from the left end of the fracture (2 cm in length).




16) Diagnosis: The specimen is a part skull vault showing chipped facture.

• The specimen is a part of skull vault.

• Lesion: It shows chipped facture.

• The causative instrument: sharp edged passing tangentially (removing the outer table).

• The cause of death: concussion or brain compression.

17) Diagnosis: The specimen is skull vault showing inlet & exit of a bullet.


• Age & sex: …

• Lesion: It shows:

o A bone defect (about 0.5 cm in diameter) in the right temporal bone with internal beveling (the

opening in the inner table is larger).

o Another bone defect (about 1.5 cm in diameter) in the left temporal bone with external beveling (the

opening in the outer table is larger) & 2 radiating FFs:

1.One extends in the left temporal bone (5 cm in length).

2.The other extends in the left parietal bone (4 cm in length).

• The causative instrument: rifled firearm weapon.

• The cause of death: concussion or brain laceration.


18) Diagnosis: The specimen is skull vault showing 2 healed inlets of bullets.


• Age & sex:most probably male skull (prominent parietal eminences) aged more than 25 &

less than 30 years (sagittal suture is closed from inside only).

• Lesion: It shows 2 rounded bone defects in the posterior part of both right & left parietal bones:

o The one in the right (about 1 cm in diameter) lies just beside sagittal suture & about 1 cm from

lambdoid suture.

o The one in the left (About 0.5 cm in diameter) is about 1.5 cm from sagittal suture & about 2 cm from

lambdoid suture.

o Both bone defects show internal beveling (the opening in the inner table is larger).


• The causative instrument: rifled firearm weapon.


19) Diagnosis: The specimen is skull vault showing inlets of shots.


• Age & sex: …

• Lesion: It shows 2 bone defects in the left frontal bone:

o The 1 st is about 0.5 X 0.5 cm.

o The 2 nd is about 1 X 0.5 cm, indicating inlets of firearm injuries.

o Both bone defects show internal beveling (the opening in the inner table is larger).

o There is deposition of lead shots in the substance of the skull in the frontal bone.

o There are rounded non‐penetrating bone defects in the left frontal bone (each is about 5 mm).

• The causative instrument: non‐rifled firearm weapon (fires shots).

o The distance of firing is more than 2 meters (dispersion).

• The cause of death: concussion or brain laceration.


اني القسم الث

السموم


GENERAL • Diagnosis: Syrup of ipecac.

• Dose:

o 30 ml for adults, 15 ml for children & 5‐10 ml for children between 6 months & 2 years.

o If vomiting does not occur after 30 minutes, the dose is repeated.

o If still no vomiting, gastric lavage should be carried out to remove ipecac from the stomach (as it is

toxic).

• Contra‐indications:

o SUBSTANCES:

1.Convulsants.

2.Corrosives (inorganic).

3.Hydrocarbons.

4.Sharp objects (needle or pin).

o PATIENTS:

1.Unconscious or comatosed.

2.Decreased gag reflex.

3.Under 6 months of age (gag reflex not well developed).

4.Severe CVS disease, emphysema or respiratory distress.

5.Recent surgical intervention.

6.Haemorrhagic tendencies.

7.Previous significant vomiting before this moment.

8.Pregnancy.


• Diagnosis: Gastric lavage tube.

• Indications:

1.When emesis is conta‐indicated.

2.Failure of induction of emesis.

3.Ingestion of life threatening amount of poison within one hour.


o ABSOLUTE:

1.Corrosives (except carbolic acid).

2.Froth producing substances (liquid soap or shampoo)

o RELATIVE:

1.Comatosed patients.

2.Convulsions.

3.Petroleum distillates.

4.Chronic poisoning.

5.Poisoning more than 6 hours.

6.Oesophageal varices & haemorrhagic diathesis.

• Diagnosis: Activated charcoal.

• Dose:

o Activated charcoal : poison ratio = 10 : 1

o 1‐2 mg/kg mixed with 60‐90 ml water.


1.Corrosives.

2.Hydrocarbons.

3.Intestinal obstruction, perforation or ileus.


• Diagnosis: Deferoxamine.

• Target poison: Iron toxicity.

• Mechanism: It combines with iron → excreted via kidney.

• Dose:

o For serious toxicity: 10‐15 mg/kg/hr up to 6 gm IV.

o For mild toxicity: 50 mg/kg up to 1 gm IM.

• Route: IV or IM.

• Diagnosis: Naloxone.

• Target poison: Opiate toxicity.

• Mechanism: It competes with & displaces drugs from Mu, Kappa & Delta opoid receptors.

• Dose: 0.4‐2 mg repeated every 2 minutes up to 20 mg.

• Route: IV.

• Diagnosis: Flumazenil.

• Target poison: Benzodiazepine toxicity.

• Mechanism: It competes with enzodiazepine at enzodiazepine receptor.

• Dose: 0.2 mg repeated every 2 minutes up to 2 mg.

• Route: IV.

• Diagnosis: N‐acetyl cysteine.

• Target poison: Acetaminophen toxicity.

• Mechanism:

o It enhances detoxification of active intermediate metabolite.

o It either binds directly to the toxic metabolite rendering it non‐toxic or enhances hepatic synthesis of

glutathione & sulphate.

• Dose:

o Loading dose: 140 mg/kg.

o Further doses: 70 mg/kg/4hr for 17 doses.

• Route: Oral.


• Diagnosis: Atropine.

• Target poison: Organophosphate toxicity.

• Mechanism: It antagonizes muscarinic & CNS effects of organophosphate.

• Dose: 1‐2 mg/15 minutes till dryness of bronchial secretion.

• Route: IV.

• Diagnosis: Oximes (toxogonine).

• Target poison: Organophosphate toxicity.

• Mechanism:

o Reverse phosphorylation of cholinesterase enzyme.

o Detoxify organophosphate molecule.

o Anti‐cholinergic effect.

• Dose:

o Toxogonine: 250 mg for adults.

o Pralidoxime: 1‐2 gm in 100 ml saline for adults.

• Route: IV.

• Diagnosis: Sodium bicarbonate.

• Dose: 1‐2 ml Eq/Kg.

• Indications:

o Treatment of acidosis.

o Urine alkalinization:

§ To enhance elimination of certain acidic drugs (e.g. salicyaltes).

§ In cases of rhabdomyolysis.

o In cases with wide QRS complex (e.g. propoxyphen, one of opoids).


• Diagnosis: Phenol.

• Mechanism of action:

o Local: coagulation of protein.

o Systemic:

§ CNS: Transient stimulation then depression.

§ Heart:Myocardial depression.

§ Kidney: Acute glomerulonephritis & uremia.

• Antidote: No specific antidote.

• Diagnosis: Oxalic acid.


o Local:Weak corrosion on stomach & skin.

o Systemic: It changes ionized calcium to non‐ionized Ca‐oxalate that cannot be utilized by the

body leading to fatal hypo‐calcemia.


• Diagnosis: Caustic potach.


o Tissue injury by liquifactive necrosis.

o Fats & proteins are saponified resulting in deep tissue destruction.

o Further injury is caused by thrombosis of blood vessels.


• Diagnosis: Naphthalene.


o It is an oxidative agent accelerating O2 consumption in patients with G6PD deficiency .

o So RBCs cannot meet O2 demand due to oxidative deamination of haemoglobin leading to cell lysis.



• Diagnosis: Carbamate.


o It inhibits cholinesterase enzyme which is reversible within 24‐48 hours.

• Antidote: Atropine.

• Diagnosis: Airway devices (oro‐pharyngeal).

o Placed in the mouth to lift the tongue & push it forward in comatosed patient or patient with

depressed or absent gag reflex.

• Diagnosis: Endo‐tracheal tube.

o Used in comatosed patient and/ or absent gag reflex.

• Indications:

o To protect the air way.

o Allow for mechanical ventilation.

o To give some emergency drugs as naloxone.

• Diagnosis: Diazepam.

• Indications:

o Anxiety, agitation or convulsions.

o Alcohol or sedative‐hypnotic withdrawal.


HAIRS Diagnosis: Human hair. Animal hair.

Description: o Cuticle: regular & thin.

o Cortex: thick (no transverse striations).

oMedulla: very thin (may be absent or

interrupted).

o Cuticle: irregular & thick.

o Cortex: thin (with transverse striations).

oMedulla: thick (may be continuous or

segmented).

DD: Animal hair. Human hair.

FIBERS Diagnosis: Wool fiber. Jute fiber. Cotton fiber. Silk fiber. Linen fiber.

Description: o Serrated

fiber.

o Surface

covered with

imbrications.

o Large air

cavities.

o Longitudinal

striations.

o Tape like.

o Flattened.

o Twisted.

o Translucent

cylinders.

o Clear margin.

o Refracting

light.

o No surface

markings.

o No twists.

o No swellings.

o Bamboo like.

o Segmented

with

projections

(may be

swollen at

joints).

DD: DD أما تكتب واحد منهم٬ اكتب الباقي في الـ

Wool fiber لو العينة : مثال

DD : Jute, cotton, silk & linen fibers الـ يبقى


SEEDS Diagnosis: Castor oil seed. Croton oil seed.

Description: o Oval large.

o 1 cm in diameter.

o Grey in color with light brown spots &

mosaic lustrous appearance.

o Oval large.

o 1 cm in diameter.

o Dull brown in color.

Active

principle:

Ricin (present only in seeds). Crotin (present in seeds & oil).

Antidote: No specific antidote.

DD: Croton oil seed. Castor oil seed.

• Diagnosis: Nutmeg seed.

• Description:

oMore or less like a date.

o Slightly furrowed surface.

o 3‐4 cm in length.

o Used as a flavoring agent.

o In medicine: used as a gastric stimulant and abortifacient.

• Active principle:Myristicin (hepatotoxic)


• Diagnosis: Strychnus nux vomica seed.

• Description:

o Hard, rounded, button‐shaped with a compressed concavo‐convex center & raised edges.

o It has a central hilum at the middle with radial extendings to the microphyl of the edges.

o 2 cm in diameter.

o Ash grey in color.

o Intense bitter taste & no odor. ∆

• Active principle: Strychnine, brucine alkaloids & loganin glucosides.

• Antidote: Diazepam.


Diagnosis: Datura Fastiosa

seed.

Capsicum seed. Sesam seed. Egg plant seed.

Description: o Kidney‐shaped

with double

convex border.

o Finely

mamillated

surface.

o 4 mm in length.

o Light brown in

color.

o Bitter taste. ∆

o Rounded with

pointed end.

o One sharp

convex border.

o Flattened

smooth surface

(non

mamillated).

o 2‐3 mm in

length.

o Pale yellow in

color.

o Pungent taste.

∆

o Ovoid &

biconvex.

o Non

mamillated.

o 2‐3 mm in

length.

o Light yellow in

color.

oMore or less rounded.

o Finely mamillated

surface.

o 2‐3 mm in diameter.

o Yellowish brown in

color.

Active

principle:

Atropine, traces of

hyoscine &

hyoscyamine.

Capsicin.

Antidote: physostigmine. No specific antidote.



Diagnosis: Datura Stramonium seed. Onion seed. Black pepper seed.

Description: o Kidney‐shaped with

double convex border.

o Finely mamillated

surface.

o 3‐4 mm in length.

o Black in color.

o Irregular with elevated

protrusions (dibble).


o Black in color.

o Rounded.

o Roughly mamillated.


o Black in color from

outside & yellowish white

in cut section.

o Sharp pungent smell. ∆

Active

principle:

Atropine, traces of

hyoscine & hyoscyamine.

Antidote: physostigmine. No specific antidote.



REINSCH TEST test اكتبهم في كل

• Principle: Some metals precipitate on cupper foils giving certain colors.

• Value: +ve for soluble inorganic metals & ‐ve for insoluble organic metals.

• Diagnosis: Container contains cupper foils with grey to black deposit indicating that it is either

arsenic or bisthmus (+ve reinsch test). It must be followed by sublimation stage to differentiate both.

• Diagnosis: Container contains cupper foils withmirror‐like deposit indicating that it is eithermercury

or silver (+ve reinsch test). It must be followed by sublimation stage to differentiate both.

• Diagnosis: Container contains cupper foils with violet deposit indicating that it is either antimony or

tin (+ve reinsch test). It must be followed by sublimation stage to differentiate both.

• Diagnosis: +ve reinsch test for arsenic.

• Result: Sublimation tube contains octa & tetra hedral crystals of arsenic.

• Diagnosis: +ve reinsch test formercury.

• Result: Sublimation tube contains black spherical globules of mercury.

• Diagnosis: +ve reinsch test for antimony.

• Result: Sublimation tube contains black amorphous powder of antimony.


TESTS 2 و 1 اكتبهم في

• Principle: It depends on the presence of peroxidase enzyme.

• Value: The stain may be blood (it is a preliminary test).

1) Diagnosis: Phenol phthalein test.

• Result: Pink color.

2) Diagnosis: Guiacum test.

• Result: Greenish blue color.

3) Diagnosis: Teichmann test.

• Principle: It depends on the formation of special crystals of haemoglobin derivatives after addition of

specific chemicals to the blood (haemin crystals).

• Result: Small regular brown rhombic crystals of acid haematin.

• Value: The stain is blood (it is a confirmatory test).

4) Diagnosis: Takayama test.

• Principle: زي اللي فوقه بس غير اللي بين القوسين (haemochromagen crystals).

• Result: Needle salmon pink feathery‐shaped crystals of alkaline hematin arranged in clusters or

rosettes.

• Value: The stain is blood (it is a confirmatory test).

5) Diagnosis: Florence test.

• Principle: It depends on the formation of brown rhombic crystals of choline periodide.

• Result: Brown rhombic crystals of choline periodide (larger than haemin crystals & disappear after ½

hour).

• Value: The stain may be semen (it is a preliminary test).


6) Diagnosis: Barberios test.

• Principle: It depends on the formation of yellowish green neddle crystals of spermine picrate.

• Result: Needle yellowish green feathery‐shaped crystals of spermine picrate.

• Value: The stain may be semen (it is a preliminary test).


تتبع الجناة

التقرير الطبي وشهادة في

الوفاة


) أوال (

التقرير الطيب الشرعي األويل

: نوع اإلصابة •

. سحجات . 1

. كدمات . 2

. جرح رضي . 3

. جرح قطعي . 4

. جرح قطعي متهتك . 5

. جرح طعين . 6

. بتر . 7

). فتحة خروج – فتحة دخول ( طلق ناري . 8

: عددها •

. واحدة . 1

. اثنان . 2

. متعددة . 3


: أبعادها •

o الطول X العمق ال يذكر ) " سم ( العرض ."

o يف حالة وجود إصابات متعدة حندد طول أصغرها وأكربها .

: موضعها من اجلسم •

o يذكر بعد اإلصابة عن عالمات تشرحيية واضحة anatomical landmark ) احلاجب – السرة – احللمة –

). املفصل

o أمثلة :

. اجلهة الوحشية من الفخذ األمين §

. ة الوحشية من الكتف األيسر اجله §

. اجلفن السفلي من العني اليسرى §

. اجلبهة §

. فروة الرأس §


: اآللة املستخدمة يف إحداث اإلصابة •

Scratch abrasion . سحجات : آلة راضة ذات طرف مدبب . 1

Brush abrasion . سحجات : آلة راضة ذات سطح خشن . 2

. جرح رضي – كدمات : آلة راضة . 3

. جرح طعين – جرح قطعي : آلة حادة . 4

. بتر – جرح قطعي متهتك : آلة حادة ثقيلة . 5

: قذيفة نارية / مقذوف . 6

). فتحة واحدة ( bullet : سالح ناري مششخن §

). فتحات متعددة ( shots : سالح ناري غري مششخن §

: اإلصابات املشتبه يف مصاحبتها لإلصابة األصلية •

ü يف األنسجة حتت اجللد .

ü يف األوعية الدموية واألعصاب .

ü وتار والعضالت يف األ .

. ال يوجد : سحجات . 1

... تك يف : جرح رضي – كدمات . 2

... قطع يف : جرح قطعي . 3


: اإلصابة بالرأس . 4

o اشتباه كسر يف عظام اجلمجمة .

o اشتباه ارجتاج باملخ .

o اشتباه نزيف باألغشية الداخلية للمخ .

: نوع العالج الذي أجري •

. مصل ضد التيتانوس – مضاد حيوي – غرز : سحجات . 1

. عرض أشعة عادية وأشعة تليفزيونية – مضاد حيوي – كمادات : كدمات . 2

. عرض أشعة عادية وأشعة تليفزيونية – مصل ضد التيتانوس – مضاد حيوي – غيار – غرز : جرح رضي . 3

. مصل ضد التيتانوس – مضاد حيوي – غيار – غرز : جرح قطعي . 4

: جرح طعين أو طلق ناري . 5

o عرض أشعة عادية وأشعة تليفزيونية .

o ائب جراحة القلب والصدر عرض على ن .

o دخول مستشفى إلجراء عملية استكشاف .


): فوق احلاجب ( جرح رضي بالرأس . 6

o مصل ضد التيتانوس – مضاد حيوي – غيار – غرز .

o ساعة 48 دخول مستشفى ويوضع حتت املالحظة ملدة .

o عرض أشعة عادية على الرأس .

o عرض على نائب جراحة املخ واألعصاب .

: فاء الوقت الالزم للش •

). جرح رضي أو قطعي يف مكان غري الرأس – كدمات – سحجات ( يوم ما مل حتدث مضاعفات 20 أقل من . 1

). بتر ( يوم مع ترك عاهة مستدمية 20 أقل من . 2

). open fracture يف حالة ظهور كسر يف العظام من خالل اجللد ( يوم 20 أكثر من . 3

). يف الرأس جرح رضي ( دخول مستشفى والتقرير النهائي عند اخلروج . 4

). طلق ناري – جرح طعين ( دخول مستشفى والتقرير النهائي عند اخلروج ومناظرة الطب الشرعي . 5


) ثانيا (

شهادة الوفاة

: بيانات املتوىف •

o االسم الكامل :

o النوع :

o الديانة :

o املهنة :

o اجلنسية :

o السن :

o احلالة العائلية :

o عنوان حمل اإلقامة :

o القرية واملدينة واحملافظة ( حمل اإلقامة اجلهة اإلدارية اليت يتبعها :(

o الرقم وجهة الصدور وتاريخ الصدور ( البطاقة :(

o تاريخ وحمل امليالد :

o حمل القيد بالسجل املدين :


o جهة الوفاة :

o مكان الوفاة :

o السنة / الشهر / اليوم / الساعة ( تاريخ الوفاة :(

: بيانات املبلغ •

o االسم الكامل :

o تاريخ الصدور الرقم وجهة الصدور و ( البطاقة :(

o عنوان حمل اإلقامة :

o عالقته باملتوىف :

: شهادة الوفاة الطبية •

: السبب املباشر للوفاة ) أ ) 1 (

: نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

: نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ج

: فاة وليس هلا عالقة باملرض األصلي ساعدت على الو ) إن وجدت ( أحوال مرضية ) 2 (

: .. التاريخ : ... التوقيع : ... اسم الطبيب


أمثلة لشهادة الوفاة

. احنزاف رئوي : السبب املباشر للوفاة ) أ ) 1 (

. جلطة بأوردة الساق : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

. الرقود لفترة طويلة بالفراش : ها السبب املباشر للوفاة نشأ عن ) إن وجدت ( أحوال مرضية ) ج

. ال يوجد : ساعدت على الوفاة وليس هلا عالقة باملرض األصلي ) إن وجدت ( أحوال مرضية ) 2 (

. احنزاف رئوي هوائي : السبب املباشر للوفاة ) أ ) 1 (

. عملية إجهاض : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

. ال يوجد : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ج


. احنزاف رئوي دهين : السبب املباشر للوفاة ) أ ) 1 (

. كسر يف عظمة الفخذ : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب




. ) رق، أسفكسيا إصابية الغ الشرق، اخلنق، أسفكيا : أو ( أسفكسيا اخلنق باليد : السبب املباشر للوفاة ) أ ) 1 (

. ال يوجد : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب



. التهاب يف الربيتون : اشر للوفاة السبب املب ) أ ) 1 (

. انفجار املثانة البولية : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

. ضربة أسفل البطن : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ج

. ال يوجد : صلي ساعدت على الوفاة وليس هلا عالقة باملرض األ ) إن وجدت ( أحوال مرضية ) 2 (

. نزيف يف الغشاء البلوري : السبب املباشر للوفاة ) أ ) 1 (

. انفجار األورطى الصدري : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

. انكسار الضلوع : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ج

. ال يوجد : على الوفاة وليس هلا عالقة باملرض األصلي ساعدت ) إن وجدت ( أحوال مرضية ) 2 (


. قئ دموي : السبب املباشر للوفاة ) أ ) 1 (

. انفجار قرحة معدية : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

. قرحة معدية مزمنة : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ج

. ال يوجد : ساعدت على الوفاة وليس هلا عالقة باملرض األصلي ) إن وجدت ( مرضية أحوال ) 2 (

. قئ دموي : السبب املباشر للوفاة ) أ ) 1 (

. دوايل املرئ : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

. البلهارسيا : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ج


. إصابات الصدر : السبب املباشر للوفاة ) أ ) 1 (

. ارتطام بعجلة القيادة : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

. حادثة سيارة : ة نشأ عنها السبب املباشر للوفا ) إن وجدت ( أحوال مرضية ) ج


. انضغاط املخ : السبب املباشر للوفاة ) أ ) 1 (

. نزيف يف املخ : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

. ضربة على الرأس : املباشر للوفاة نشأ عنها السبب ) إن وجدت ( أحوال مرضية ) ج



. كسر يف قاع اجلمجمة : السبب املباشر للوفاة ) أ ) 1 (

. إصابة بالرأس : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

. ال يوجد : نشأ عنها السبب املباشر للوفاة ) ن وجدت إ ( أحوال مرضية ) ج


. احنزاف يف شرايني املخ : السبب املباشر للوفاة ) أ ) 1 (

. القلب البكتريي التهاب بطانة : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب

. محى روماتزمية بالقلب : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ج


. ) طلق ناري انتحاري صعق كهربائي، : أو ( ضربة مشس : السبب املباشر للوفاة ) أ ) 1 (

). الرصاص، الزرنيخ : أو ( أول أوكسيد الكربون تسمم ب

. ال يوجد : نشأ عنها السبب املباشر للوفاة ) إن وجدت ( أحوال مرضية ) ب


. ال يوجد : األصلي ساعدت على الوفاة وليس هلا عالقة باملرض ) إن وجدت ( أحوال مرضية ) 2 (


القطر والبرد

في عملي الرمد خالصة


cataract فكلمة .. إىل املعىن احلريف للكلمة يف اللغة اإلجنليزية cataract رمبا ترجع تسمية عتامة عدسة العني بالـ

إن الفرق الواضح هو يف درجة شفافية املاء .. املتحركة دوء أو الراكدة والشالل ولكن ما الفرق بني املياة " .. شالل " تعين

!! وتصادم جزيئاته ببعضها .. حيث يفقد املاء شفافيته عند حتركه بسرعة كبرية ..

متاما .. blurred لظهرت الصورة مشوشة .. للمنظر الطبيعي املوجود يف أسفل الصورة من خلف شالل ت نظر فلو أنك

!! فكأنه ينظر من خلف شالل .. بعد أن فقدت عدسته شفافيتها .. cataract رى مريض الـ ي


CLINICAL OPHTHALMOLGY TESTS كارت اخلاصني بامتحان العملي 17 يشمل هذا اجلزء شرح الـ

حيتوى على موضوعات أكثر sheet لكن الــ

1. History.

2. Visual acuity.

3. Eyelids examination.

4. Examination of the upper conjunctiva.

5. Fluorescein test.

6. Regurge test.

7. Corneal light reflex.

8. Corneal sensation.

9. Examination of the anterior chamber.

10. Iris shadow.

11. Examination of the pupil.

12. Ocular movements in cardinal directions.

13. Assessment of abduction & adduction.

14. Color test.

15. Projection of light.

16. Confrontation test.

17. Digital examination of intraocular pressure.


1. HISTORY

1. PERSONAL H.:

o Name.

o Sex.

o Age.

o Occupation.

o Marital status.

o Children.

o Habits.

o Address.

E.g.:

Ø A male patient named …, aged … years old, living in … (نواج مركز طنطا غربية).

He is married with 3 children & works as a … (e.g. famer) & he is a smoker.

Ø A female patient named …, aged … years old, living in … ( طنطا – آخر ش محب ).

She is single & works as a … (e.g. house wife) with no special habits.

2. COMPLAINT:

o The patient own words.

E.g.:

• Diminution of vision.

• Defective vision.

• Double vision.

• Photopsia.

• Colored haloes around lights.

• Field defects.


• Pain.

• Discharge.

• Disfigurement.

• Red eye or redness.

• Watering of the eye.

• Dryness of the eye.

3. PRESENT H.:

o Analysis of the complaint, as regards (DOC):

1. Duration: Short or long.

2. Onset: Sudden, rapid or slow.

3. Course: Progressive, regressive or stationary.

4. PAST H.:

o Local or general disease.

o Trauma or surgery.

o Taking medications.

5. FAMILY H.:

o Especially diabetes & hypertension.


2. VISUAL ACUITY

1. CHARTS FOR DISTANT VISUAL ACUITY:

• LANDOLT’S CHART (BROKEN RINGS):

o 7 lines of broken rings, the uppermost is the largest & is seen by a normal eye at a distance of 60

meters, the next lines at 36, 24, 18, 12, 9 & 6 meters respectively.

o METHOD:

1. The patient is seated at a distance of 6 meters from the chart (for light rays to reach the eye parallel

with relaxation of accommodation).

2. The smallest line seen by him should be found out.

3. Right eye is tested separately with left eye covered & then left one.

o RESULT:

1. If the patient sees the smallest line, his V/A = 6/6.

2. If the patient only sees the second line from below, his V/A = 6/9 & so on 6/12. 6/18, 6/24, 6/36 &

6/60.

3. If the patient cannot see the uppermost line (of 6/60), he is brought closer the chart at a distance of

5, 4, 3, 2 & 1 meter (5/60, 4/60, 3/60, 2/60 & 1/60).

4. If the V/A is less than 1/60, vision will be respectively:

Ø Counting fingers (CF): At 90 cm … & till 10 cm.

Ø Hand movement (HM).

Ø Perception of light (PL). “in a dark room”

Ø No perception of light (no PL). “in a dark room”

• SNELLEN’S CHART (LETTER TYPES).

2. TEST CARDS FOR NEAR VISION:

1. By cards with graded sizes of letters or words.

2. The smallest type the patient can read at a distance at which he is accustomed to read (or for near

work) is the measure of his near vision.


3. EYELIDS EXAMINATION

1. LID POSITION:

o Upper lid covers upper 1/6 of cornea.

o Lower lid just touches lower limbus.

E.g. of abnormality:

Ptosis.

2. LID FUNCTION:

o Closure & opening.


1. Lagophthalmos.

2. Lid lag (delayed movement of upper eye lid during downward pursuit of the eye).

3. Blepharospasm.

3. LID MARGIN:

o Rounded anterior & sharp posterior margin resting on the globe.


1. Trichiasis.

2. Entropion.

3. Ectropion.

4. Madarosis.


LEVATOR FUNCTION o METHOD:

1. Hold your thumb firmly against the patient’s brow (to negate frontalis muscle action).

2. Ask the patient to look down.

3. Align the zero point of the transparent millimeter ruler with patient’s upper eye lid margin.

4. Ask the patient to look up as far as possible & record the new location of the upper eye lid margin.

5. The difference between the 2 measurements = levator function.

o RESULT:

• Normal: 15 mm or more.

• Good: 12 mm or more.

• Fair: 5‐11 mm.

• Poor: 4 mm or less.


4. EXAMINATION OF THE UPPER CONJUNCTIVA o By eversion of the upper lid using:

1. The index & thumb of the left hand.

2. A glass rod in the right hand.

o To examine the upper fornix:

§ By double eversion of the upper lid using lid retractor.

E.g. of abnormality: follicles, papillae, discharge, PTDs or FB.

5. FLUORESCEIN TEST

1. FLUORESCEIN STAINING:

(For determination of discontinuity of corneal epithelium)

1. Surface anaesthesia (novesine 0.4% drops).

2. The conjunctiva above upper limbus is touched with a glass rod dipped in 2% sodium fluorescein

solution.

3. Conjunctiva) irrigation with saline.

4. Areas of greenish stain indicate corneal ulceration.

5. Sterile fluorescein strips or single use disposable units of 2% drops are used nowadays instead of

fluorescein solution, as the later may be contaminated.

2. DYE (FLUORESCEIN) TEST:

(For investigation of epiphora)

1. Fluorescein drops 2% in the conjunctival sac and after 2 minutes, the patient blows his nose.

2. If the nasal secretion is not stained green, obstruction in the lacrimal drainage system is present.


6. REGURGE TEST 1. Pull the eye lids out and feel the medial palpebral ligament.

2. Press backwards and medially on the sac with cotton‐tipped glass rod.

3. Note regurgitation from punch:

o Positive test → regurge in lower (nasolacrimal duct) obstruction.

o Negative test → no regurge in upper (canallicular) obstruction.

7. CORNEAL LIGHT REFLEX o The patient is asked to look at a source of light at a distance of 0.5 meter & the position of the

corneal reflex is noted:

• Central corneal reflex: In the fixing eye.

• Eccentric corneal reflex: In the squinting eye (it is situated on the temporal side of the cornea

in convergent strabismus and on the nasal side of the cornea in divergent strabismus).

§ Its position indicates the angle of strabismus as follows:

1. Angle 15 o : If at the pupillary margin.

2. Angle 30 o : If midway between the pupillary margin and limbus.

3. Angle 45 o : If at the limbus.

N.B.: Every 1 mm away from the centre of the pupil equals 7 o .


8. CORNEAL SENSATION o A cotton wisp to cornea → closure of eye lids.

o Avoid the patient’s line of vision & without touching the eye lashes.

E.g. of abnormality: impaired corneal sensitivity, in:

1. Herpetic keratitis (simplex & zoster).

2. Neuroparalytic keratitis.

3. Anaesthetic eye drops.

4. Corneal edema.

5. Corneal dystrophy (lattice, granular & macular).

6. Glaucoma (acute & absolute).

7. Leprosy.

9. EXAMINATION OF THE ANTERIOR CHAMBER (AC)

o METHOD:

1. Hold a pen light near the temporal limbus & keep the bean parallel to the plane of the iris.

2. While facing the patient, observe the medial aspect of the iris.

o RESULT:

1. Normal: The iris is completely illuminated.

2. Shallow AC: 2/3 of the nasal portion of the iris is in shadow.


FEATURES 1. Depth:

• Normally: 2.5 mm (should be compared with the other side).

• Absent AC in:

1. After IO operation.

2. Perforated corneal ulcer, injury or fistula.

• Shallow AC: Causes of absent AC +

1. Acute g glaucoma.

2. Intumescent cataract.

3. High hypermetropia.

• Deep AC in:

1. Buphthalmos.

2. Ectatic cornea.

3. Megalocornea.

4. Aphakia.

5. Hypermature cataract.

6. High myopia.

2. Regularity: Irregular in:

1. Lens subluxation.

2. Anterior synechia.

3. Iris bombé.

4. Leucoma adherent.

5. Anterior staphyloma.

3. Contents: Abnormal contents may be:

1. Turbid aqueous: Aqueous flare.

2. Sterile pus: Hypopyon.

3. Blood: Hyphaema.


4. Lens matter: After cataract.

5. Lens: Anterior dislocation.

6. Intraocular Iens: AC‐IOL.

7. Foreign body: IOFP.

8. Mass: Tumour of the iris.

9. Vitreous: Dislocation or subluxation of the lens.

10. IRIS SHADOW

o METHOD:

1. Hold a pen light obliquely at 45 o to iris surface.

2. While facing the patient, a dark crescent of iris shadow is seen on the pupil at the side of light (in

case of immature cataract), because there is clear lens matter between the opaque lens and iris.

o VALUE:

1. TO DIAGNOSE immature cataract.

2. ASSES ITS PROGRESS as it becomes smaller & narrower as it approaches maturity.


11. EXAMINATION OF THE PUPIL

o Normally:

1. Slightly nasal to the centre of the cornea.

2. 3‐4 mm in diameter.

3. Rounded.

4. Regular.

5. Reactive.

6. Color:

o Black in young age.

o Grey in old age.

PUPILLARY REACTIONS 1. LIGHT REFLEX (LIGHT REACTION)

o When light stimulates the retina → contraction of the pupil:

§ On the same side (direct light reflex).

§ On the opposite side (consensual light reflex).

** Absent in lesions of OPTIC NERVE & RETINA **

o Stimulus: Light.

o Receptors: Rods and cones in the retina.

o Pathway:

• Afferent path: Rods and cones in the retina → optic nerve → optic chiasma (the nasal fibers cross to

the opposite side) → optic tract (its anterior 2/3) → midbrain (relay in the pretectal nucleus) → new

intercalated neurons to Edinger‐Westphal nucleus on both sides.

• Centre: Edinger‐Westphal nucleus (constrictor part of the third nerve nucleus) on both sides.

• Efferent path: Third cranial nerve → nerve to inferior oblique → relay in the ciliary ganglion (or in

another accessory ganglion) → 6‐10 short ciliary nerves → sphincter pupillae on both sides.

N.B.: The consensual reaction is due to crossing of the fibers in the optic chiasma and in Edinger‐

Westphal nucleus of the midbrain.


2. ACCOMMODATION REFLEX (NEAR REACTION)

o Fixing a near object with both eyes → 3 associated movements:

1. Accommodation (by contraction of the ciliary muscle).

2. Convergence (by contraction of the medial recti).

3. Miosis (by contraction of the sphincter pupillae).

** Absent in lesions of 3 rd NERVE **

ABNORMAL PUPILLARY RESPONSES 1. Argyll Robertson's pupil:

o Cause: Neurosyphilis (commonest cause).

o Site of lesion: Intercalated neurones at aquiduct of Sylvius in the mid brain.

o Clinically: Small pupil, usually bilateral and unequal → not react to light but reacts to

accommodation.

2. Horner's syndrome:

o Cause: Damage to sympathetic pathway from hypothalamus to the dorsal part of the spinal cord

and then up to the eye.

o Clinically:Miosis, ptosis, enophthalmos and anhydrosis (same side of lesion).

3. Marcus‐Gunn pupil (Paradoxical pupil – Relative Afferent pupillary defect):

o Cause: Unilateral or asymmetric damage to anterior visual pathway (optic nerve & retina).

o Clinically: Pupil remains dilated on exposure to light or constricts on withdrawal of light.


CAUSES OF MYDRIASIS & MIOSIS

MYDRIASIS (Dilatation of the pupil)

MIOSIS (Constriction of the pupil)

1. Drugs:

• Mydriatics. • Miotics.

2. Physiological:

• Dark adaptation.

• 2nd and 4th stages of anaesthesia.

• Emotion (sympathetic).

• Light and accommodation reflexes.

• 3rd stage of anaesthesia.

• Senile miosis.

3. Ocular disease:

• Traumatic mydriasis.

• Acute glaucoma.

• Traumatic miosis.

• Acute iritis.

4. Neurological disease:

• As 3rd nerve paralysis. • Horner's syndrome(Sympathetic paralysis).

• Argyll Robertson's pupil.

• Pontine haemorrhage.

• Unequal size of pupils (anisocoria):

1. Congenital.

2. Acute iritis (miosis).

3. Acute glaucoma (mydriasis).

12. OCULAR MOVEMENTS IN CARDINAL DIRECTIONS o It is examined in the 6 cardinal directions using a fixation object at a distance of 50 cm.

13. ASSESSMENT OF ABDUCTION & ADDUCTION o The same as previous, except that it is done in 2 directions only (out & in).


14. COLOR TEST

o Importance of testing of color vision:

1. Gives an idea about the macula in mature cataract.

2. Important in occupations as in drivers.

o Testing of color vision:

1. Ishihara test: A series of plates containing colored figures.

2. Color matching test:With colored beads (mainly in children).

3. Colored glass discs: Red, green and blue colored discs.

15. PROJECTION OF LIGHT 1. It is done if the patient cannot see at a distance of 33 cm.

2. By using a small beam of dim light from above, below, right & left sides.

3. Right eye is tested separately with left eye covered & then left one.

o Good projection of light: Patient can see light in all directions.

o Bad projection of light: Patient cannot see light in one or more directions.


16. CONFRONTATION TEST ** Testing of the VISUAL FIELD **

1. CONFRONTATION TEST: (Rough test)

1. The examiner sits at a distance of 60 cm from the patient.

2. The patient is told to look straight into the examiner's left eye.

3. The patient's left eye is covered and the examiner's right eye is closed to compare the right field of

the patient with the left field of the examiner, and vice versa.

4. The examiner moves his finger from above, below, right & left sides keeping his hand in plane half‐

way between the patient and himself.

5. If the patient sees the moving finger as soon as the examiner sees it, his field of vision is normal.

2. PERIMETRY: (By the perimeter)

1. Old kinetic methods:

• Simple (arc) perimeter.

• Goldmann's perimeter.

• Campimetry (scotometry).

2. New static automated perimeter (field analyzer):

3. PROJECTION OF LIGHT.

THE NORMAL FIELD OF VISION 1. PERIPHERAL FIELD OF VISION:

o Is 50° upwards, 60° nasally, 70° downwards and more than 90° temporally.

2. CENTRAL FIELD OF VISION:

o Extends 30° in all directions from fixation point (corresponds to fovea).

o Contains physiological blind spot of Mariotte (corresponds to optic disc):

1. Temporal to the fixation point.

2. Below the horizontal meridian.

3. Negative (the patient is unaware of it).


17. DIGITAL EXAMINATION OF INTRAOCULAR PRESSURE ** Testing of the INTRAOCULAR PRESSURE (TENSION) **

1. DIGITAL PALPATION: (Rough test)

o Value: To test the tension of sclera (rigidity).

o Method:

1. The patient looks downwards.

2. The examiner's index fingers are placed on upper eye lid.

3. Gentle pressure is applied with each finger successively downwards and backwards.

4. The sensation of tension is recorded:

• Normal tension: Tn.

• High tension: T+, T++ or T+++.

• Low tension: T‐1, T‐2 or T‐3.

2. TONOMETRY: (By a tonometer)

1. Indentation (Schiotz) tonometer.

2. Applanation tonometer.

3. Non‐contact tonometer.


CAUSATIVE ORGANISMS 1. ULCERATIVE BLEPHARITIS.

2. STYE (HORDEOLUM EXTERNUM).

3. INFECTED CHALAZION (HORDEOLUM INTERNUM).

o STAPHYLOCOCCUS AUREUS.

4. ANGULAR BLEPHARITIS.

o MORAX‐AXENFELD DIPLOBACILLUS.

5. CHRONIC DACRYOADENITIS.

o SPECIFIC:

• Syphilis, tuberculosis & trachoma.

o NON‐SPECIFIC:

• On top of acute dacryoadenitits.

6. ACUTE DACRYOCYSTITIS.

o Pneumococci.

o Staphylococcus.

o Streptococcus.

7. CHRONIC DACRYOCYSTITS.

o SPECIFIC:

• Syphilis, tuberculosis & trachoma.

o NON‐SPECIFIC:

• Pneumococci.

• Morax diplobacilli.


8. MUCOPURULENT CONJUNCTIVITIS (MPC).

1. KOCH‐WEEKS BACILLUS.

2. Staphylococcus.

3. Streptococcus.

4. Pneumococci.

9. PURULENT CONJUNCTIVITIS (PC).

Pyogenic organisms:

o GONOCOCCI (80%):

1. Epidemic type: in summer.

2. Genital type: infected is transmitted from the genital tract (ophthalmia neonatorum).

o Other pyogenic organisms:

1. Staphylococcus.

2. Streptococcus.

10. MEMBRANOUS CONJUNCTIVITIS.

o DIPHTHERIA BACILLI.

11. CHRONIC CATARRHAL CONJUNCTIVITIS.

o LOW VIRULENCE ORGANISMS.

12. TRACHOMA.

o CHLAMYDIA TRACHOMATIS (serotypes A, B & C) which can be considered as gram –ve bacteria.

13. SUPERFICIAL KERATITIS (CORNEAL ULCER).

1. BACTERIA attacking intact corneal epithelium:

o GONOCOCCI.

o DIPHTHERIA BACILLI.

(OTHER bacteria usually need a corneal abrasion).

2. FUNGI: Follow corneal trauma.

3. VIRUSES: As HS virus.


14. HYPOPYON ULCER.

o Typical hypopyon ulcer (80%):

• PNEUMOCOCCI.

o Atypical hypopyon ulcer (80%):

1. BACTERIA: As Morax bacilli.

2. FUNGI: Aspergillus fumigates.

15. DENDRITIC (HERPETIC) ULCER.

o HS virus.

PREDISPOSING FACTORS 1. SQUAMOUS BLEPHARITIS.

2. ULCERATIVE BLEPHARITIS.

3. ANGULAR BLEPHARITIS.

4. STYE (HORDEOLUM EXTERNUM).

5. INFECTED CHALAZION (HORDEOLUM INTERNUM).

o GENERAL: Diabetes, malnutrition & smoking.

o LOCAL:

• Dust, smokes & chemicals.

• Errors of refraction (if uncorrected).

6. CHRONIC DACRYOCYSTITIS.

o Obstruction of the lacrimal passages (with stasis of tears).

o Then >> infection of stagnant tears (precipitating factor).

7. MUCOPURULENT CONJUNCTIVITIS (MPC).

8. PURULENT CONJUNCTIVITIS (PC).

• Flies.

• Dirty towels.

• Bad personal hygiene.


9. CHRONIC CATARRHAL CONJUNCTIVITIS.

o GENERAL: Alcoholism & constipation.

o LOCAL:

• Exposure to dust & smokes.

• On top of acute conjunctivitis.

10. TRACHOMA.

11. PHLYCTENULAR CONJUNCTIVITIS (PHLYCTENULOSIS).

o Bad environment.

o Bad general health.

12. SPRING CATARRH (VERNAL CONJUNCTIVITIS).

13. PINGUECULA.

14. PTERYGIUM.

o CHRONIC IRRITATION: Ultraviolet (sun) rays, heat & dust.

15. SUPERFICIAL KERATITIS (CORNEAL ULCER).

16. HYPOPYON ULCER.

o GENERAL:

• MALNUTRITION: Vitamin A deficiency.

• GENERAL ILL HEALTH: Diabetes, gout or debility.

o LOCAL:

1. Corneal trauma: FB, rubbing lashes or PTDs.

2. Xerosis: Keratomalacia.

3. Exposure: Lagophthalmos.

4. Loss of sensation: Neuroparalytic keratits.

17. DENDRITIC (HERPETIC) ULCER.

18. HERPES SIMPLEX (HS).

o Fevers (mainly common cold & influenza). o Menses.


ف االفتراء كش

اء عن علم اإلحص


..:: PRESENTATION OF DATA ::..

1. NUMERICAL METHODS

v Measurements of central tendency:

• MEAN:

o Computed by dividing the sum (∑) of all observations in the series (∑X) by their number (N).

o The most commonly used measurement of central tendency.

• MEDIAN:

o The value that divides the series into 2 equal groups (after all values have been ordered) so that:

§ Half of the values are greater than &

§ Half are less than the median.

• MODE:

o The value most frequently occurring in the series.

o The series may have no or several modes.

v Measurements of dispersion:

• RANGE:

o The difference between the highest & lowest values in the series.

• INTER‐QUARTILE RANGE:

o The difference between:

§ The value at the third quartile (Q3) &

§ The value at the first quartile (Q1).


• VARIANCE (V):

• STANDARD DEVIATION (SD):

• COEFFICIENT OF VARIATION (COV):

2. TABULAR PRESENTATION (FEQUENCY TABLES)

v Single variable (one dimension):

• For qualitative variables (nominal & ordinal).

• For quantitative variables (interval & ration).

1. Range.

2. W =

§ W= width of the class.

§ R= range.

§ K= desired number of class interval ( 5 عادة ) وده إحنا اللي بنجيبه من عندنا

v Two dimensional (contingency tables).


3. GRAPHICAL PRESENTATION

1&2 are qualitative 3&4 are quantitative

1. Pie chart:

o For summarizing data arranged in categories & on percentage

basis.

o 1% of distribution = 3.6 o of central angle.

2. Bar chart:

o Various categories are represented on one axis (usually the

horizontal).

o Frequencies or percentages of each category on the other axis

(usually the vertical).

3. Histogram:

o A special form of bar chart.

o Represents categories of quantitative variable.

4. Frequency polygon:

o More useful then histogram because several frequency

distributions can be:

§ Plotted easily &

§ Compared on one graph.

5. Scatter diagram:

o Each individual or unit measured is entered as a point.


..:: THE NORMAL DISTRIBUTION CURVE ::.. • CHARACTERS:

1. Bell shaped.

2. Symmetrical.

3. Area Under Curve (AUC) = 100%.

4. Mean = Median = Mode.

5. Mean determines its → location.

6. SD (or dispersion) determines its → shape.

o SD = 1,2,3,‐1,‐2,‐3

o Z =

o Z= mean بعد الرقم أو النقطة عن الـ

o X= ) 75 مثال ( الرقم أو النقطة

o SD= standard deviation.


ختام واستبيان

ه واملعني عليه، وما كان فيه من خطإ فمن اهللا فهو املوفق ل من صواب ما كان فيما قرأت وختاما، ف

ة الطاعنني، فلقاريه لسهام الراشقني، وغرضا ألسن قد نصب نفسه هدفا كاتبه وها هو ، فمين ومن الشيطان

". من ألف فقد استهدف : " ، وقدميا قالوا مه ر مه، وعلى مؤلفه غ ن غ

وأنس ، ولطيف عباراتكم ، تكم بارع مالحظا : أنتظر بشغف أشكر لك اقتناء كتايب، ولكين ولذا فإين

دم، وت ق كلماتكم، اليت تبين أكثر ما و أكثر ما تؤمل، فمشكور من أخذ من وقته دقائق معدودة ملأل هذا م

. اهللا خريا م االستبيان، وأرجو إرساله على الربيد اإللكتروين أو تسليمه باليد، وجزاك

شعيب حممود


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