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the wicked are in confusion and madness.
kuwa dambiilayaasha ah baadi iyo fogaansho yay ku suganyihiin.

and who wander in the abyss of confusion.
ee ah kuwa xumaantooda (baadinimadooda) ku dhexhilmaansan.

so leave them in their confusion for a time.
ee isagaga tag halmaanshahooda dhexdiisa tan iyo muddo.

did he not cause their war to end in confusion,
miyaan eebe ka yeelin dhagartoodii wax dhumay.

who are within a flood [of confusion] and heedless.
ee ah kuwa xumaantooda (baadinimadooda) ku dhexhilmaansan.

they said, “by god, you are still in your old confusion.”
waxayna dheheen adugu wali waxaad ku sugantahay gafkii hore, (jacaylkii yuusuf).

those who (flounder) heedless in a flood of confusion:
ee ah kuwa xumaantooda (baadinimadooda) ku dhexhilmaansan.

they have misled many, so do not increase the wrongdoers except in confusion.”
waxayna dhumiyeen dad badan ee eebow ha kordhinnin daalimiinta waxaan baadi ahayn.

but they denied the truth when it came to them, so they are in a state of confusion.
waxaybase beeniyeen xaqii markuu u yimid, waxayna ku suganyihiin xaal qasan.

in fact, they have rejected the truth that has come to them, thus, they live in confusion.
waxaybase beeniyeen xaqii markuu u yimid, waxayna ku suganyihiin xaal qasan.

some individual humans used to seek power through some individual jinn, but they only increased them in confusion.
waxayna ahaayeen kuwo insiga ka mid ah inay magangalaan kuwo jinniga ka mida markaasna u kordhiyeen kibir (iyo xad gudub).

if we took compassion on them and removed the affliction they are in, they would only wander lost in confusion.
haddaan u naxariisanno oon ka faydno waxa haya oo dhib ah waxay ku madax taagi xumaantooda iyagoo ku indho la'.

nay, they rejected the truth when it came to them, so they are (now) in a state of confusion.
waxaybase beeniyeen xaqii markuu u yimid, waxayna ku suganyihiin xaal qasan.

even if we had sent down an angel as messenger he would have appeared in the garb of a man and filled them with confusion, like the one they are filled with.
haddaan ka yeello malagna waxaan ka yeeli lahayn nin, markaasaan iskaga dari lahaydeen xaalka siday isaga dari jireen.

and those who disbelieve are protectors one of another - if ye do not so, there will be confusion in the land, and great corruption.
kuwa gaaloobay qaarkood waa sokeeyaha qaar haddaydaan saas falinna (ogaanna) fidmaa ahaan dhulka iyo fasaad wayn.

if we had made it an angel, we should have sent him as a man, and we should certainly have caused them confusion in a matter which they have already covered with confusion.
haddaan ka yeello malagna waxaan ka yeeli lahayn nin, markaasaan iskaga dari lahaydeen xaalka siday isaga dari jireen.

and pharaoh said: suffer me to kill moses, and let him cry unto his lord. lo! i fear that he will alter your religion or that he will cause confusion in the land.
wuxuu yidhi fircoon, i daaya aan silo muusee hana uyeedho eebihiisa, waxaan ka cabsan inuu idinka badalo diinta ama uu ka muujiyo dhulka fasaad.

work not confusion in the earth after the fair ordering (thereof). and call on him in fear and hope. lo! the mercy of allah is nigh unto the good.
hana fasaadinina dhulka inta la wanaajiyey ka dib, baryana eebe cabsi iyo doonidba naxariista eebana waxay u dhawdahay kuwa samaha fala.

emergency symptoms include difficulty breathing, persistent chest pain or pressure, confusion, difficulty waking, and bluish face or lips; immediate medical attention is advised if these symptoms are present.
quwa aan sidaa u baahsanayn, calaamadaha neefsiga ee sare sida hindhiso, san duuf leh ama cunaha oo xidhma ayaa dhici karta in la arko.

acknowledgment ................................................................................................................... i table of contents .................................................................................................................. ii chapter one: shock ............................................................................................................. 1 introduction ................................................................................................. 1 classification .............................................................................................. 1 patho physiology of shock ......................................................................... 2 management of shock ................................................................................ 3 complications of shock .............................................................................. 4 chapter two: fluid and electolytes ..................................................................................... 5 introduction ................................................................................................. 5 normal distribution of body fluids .............................................................. 5 disturbances of fluid and electrolytes ........................................................ 7 acid – base balance ................................................................................... 12 review questions ....................................................................................... 15 references .................................................................................................. 16 chapter three: blood transfusion ....................................................................................... 17 indications for blood transfusion ............................................................... 17 compatibility tests ...................................................................................... 17 component therapy ................................................................................... 18 review questions ....................................................................................... 21 references .................................................................................................. 22 chapter four: pre-operative and post-operative care ...................................................... 23 introduction ................................................................................................. 23 general consideration ............................................................................... 23 assessment and minimization of surgical risks ........................................ 24 post-operative care, complications and their treatment ......................... 26 post operative intestinal obstruction ......................................................... 31 hematoma, abscess and seromas ............................................................ 33 review questions ....................................................................................... 34 references .................................................................................................. 35 chapter five: aseptic and antisepic techniques ................................................................ 36 introduction ................................................................................................. 36 choice of antiseptic ................................................................................... 37 review questions ....................................................................................... 41 references .................................................................................................. 42 chapter six: suture materials and suturing ......................................................................... 43 types of suture materials ........................................................................... 43 suturing techniques ................................................................................... 44 iii chapter seven: wounds- wound healing and care ........................................................... 47 introduction ................................................................................................. 47 wound healing ............................................................................................ 47 wound assessment and classification ....................................................... 49 wound management ................................................................................... 50 crush and avulsion wounds ....................................................................... 53 wound complications ................................................................................. 55 review questions ....................................................................................... 57 key to the review questions ..................................................................... 59 references .................................................................................................. 60 chapter eight: surgical infections ........................................................................................ 61 introduction ................................................................................................. 61 classification .............................................................................................. 62 pathogenesis .............................................................................................. 62 specific types of infections ........................................................................ 64 review questions ....................................................................................... 73 key to the review questions ..................................................................... 75 references .................................................................................................. 76 chapter nine: trauma .......................................................................................................... 77 introduction ................................................................................................. 77 treatment priorities ..................................................................................... 78 road traffic accidents ................................................................................ 79 firearm injuries ........................................................................................... 80 burn injuries ......................................................................................... 81 review questions ....................................................................................... 84 references .................................................................................................. 85 head and spinal injuries ............................................................................ 86 head injury .................................................................................................. 86 brain injuries ............................................................................................... 87 spinal cord injuries ..................................................................................... 90 review questions ....................................................................................... 92 references .................................................................................................. 93 chapter ten: orthopedic surgery ........................................................................................ 94 introduction ................................................................................................. 94 infections of bones and joints .................................................................... 94 fractures ..................................................................................................... 97 dislocations ................................................................................................. 102 amputations ................................................................................................ 103 review questions ....................................................................................... 105 references .................................................................................................. 106 chapter eleven: anesthesia................................................................................................. 107 pre-anesthetic patient evaluation and preparation .................................... 107 iv cardiopulmonary resuscitation .................................................................. 111 systemic (general) anesthesia .................................................................. 115 regional anesthesia ................................................................................... 118 review questions ....................................................................................... 124 references .................................................................................................. 125 systemic surgery chapter one: the thyroid gland ......................................................................................... 126 thyroid enlargement: goiter ....................................................................... 126 neoplasms of the thyroid ........................................................................... 130 review questions ....................................................................................... 132 references .................................................................................................. 133 chapter two: the breast ..................................................................................................... 134 introduction ................................................................................................. 134 anatomy ..................................................................................................... 134 breast lumps .............................................................................................. 135 carcinoma of the breast ............................................................................. 137 review questions ....................................................................................... 140 references .................................................................................................. 141 chapter three: the chest ................................................................................................... 142 introduction ................................................................................................. 142 upper airway obstruction ........................................................................... 142 tracheostomy ............................................................................................. 143 chest injuries .............................................................................................. 146 pneumothorax ............................................................................................. 149 hemothorax ................................................................................................. 149 tube thoracostomy (chest tube) .............................................................. 150 empyema and lung abscess ..................................................................... 152 lung abscess .............................................................................................. 154 review questions ....................................................................................... 156 references .................................................................................................. 157 chapter four: gastrointestinal tract .................................................................................... 158 introduction ................................................................................................. 158 upper gastrointestinal bleeding ................................................................. 159 colorectal tumors ....................................................................................... 164 common perianal conditions ..................................................................... 166 anal fissure (fissure in ano) .................................................................... 170 hemorrhoids (piles) .................................................................................... 171 references .................................................................................................. 175 acute abdomen ........................................................................................... 176 intestinal obstruction .................................................................................. 177 sigmoid volvulus ......................................................................................... 179 v appendicitis ................................................................................................. 180 peritonitis .................................................................................................... 183 hepato biliary diseases .............................................................................. 185 hydatid cyst of the liver ............................................................................. 187 diseases of gall bladder and biliary tree .................................................. 189 obstructive jaundice................................................................................... 193 review questions ....................................................................................... 197 abdominal wall hernias ............................................................................. 198 introduction ................................................................................................. 198 risk factors for abdominal wall hernia development ............................... 199 specific types of hernia ............................................................................. 200 review questions ....................................................................................... 204 references .................................................................................................. 205 stomach and duodenum ............................................................................ 206 introduction ................................................................................................. 206 peptic ulcer disease ................................................................................... 206 gastric cancer ............................................................................................ 211 review questions ....................................................................................... 213 dysphagia ............................................................................................. 214 introduction ................................................................................................. 214 dysphagia ................................................................................................... 214 carcinoma of the esophagus...................................................................... 215 review questions ....................................................................................... 218 references .................................................................................................. 219 chapter five: urology .......................................................................................................... 220 introduction ................................................................................................. 220 urinary symptoms and investigations of urinary tract problems .............. 220 acute renal failure (anuria/oliguria) ......................................................... 222 disorder of the kidneys and ureters ........................................................... 223 urinary tract infection ................................................................................. 224 renal tuberculosis ..................................................................................... 226 urinary bladder ........................................................................................... 230 bladder cancer ........................................................................................... 231 benign prostatic hyperplasia ...................................................................... 231 the urethra and penis ................................................................................ 233 urethral stricture ......................................................................................... 234 review questions ....................................................................................... 238 references .................................................................................................. 239 1 chapter one shock learning objectives at the end of this chapter, each student should be able to: • state the clinical definition of shock • list the chief characteristics and causes of all types of shock • describe the clinical symptoms and signs that are indicative of shock • list the immediate treatment measures to prevent complications introduction shock is a life-threatening condition which occurs when the circulatory system fails to deliver oxygen and nutrients to the body tissues and becomes unable to remove waste products from the body. it is a descriptive term based on the symptoms and signs secondary to one or more of a wide range of problems. if not recognized and corrected as early as possible, shock may rapidly progress to an irreversible state with subsequent multi-organ failure and death. definition shock is defined as a pathological state causing inadequate oxygen delivery to the peripheral tissues and resulting in lactic acidosis, cellular hypoxia and disruption of normal metabolic condition. classification shock is generally classified into three major categories: 1. hypovolemic shock 2. cardiogenic shock 3. distributive shock distributive shock is further subdivided into three subgroups: a. septic shock b. neurogenic shock c. anaphylactic shock hypovolemic shock is present when marked reduction in oxygen delivery results from diminished cardiac output secondary to inadequate vascular volume. in general, it results from loss of fluid from circulation, either directly or indirectly. 2 e.g. ▪ hemorrhage 􀂃 loss of plasma due to burns 􀂃 loss of water and electrolytes in diarrhea 􀂃 third space loss (internal fluid shift into inflammatory exudates in the peritoneum, such as in pancreatitis.) cardiogenic shock is present when there is severe reduction in oxygen delivery secondary to impaired cardiac function. usually it is due to myocardial infarction or pericardial tamponade. septic shock (vasogenic shock) develops as a result of the systemic effect of infection. it is the result of a septicemia with endotoxin and exotoxin release by gram-negative and gram-positive bacteria. despite normal or increased cardiac output and oxygen delivery, cellular oxygen consumption is less than normal due to impaired extraction as a result of impaired metabolism. neurogenic shock results primarily from the disruption of the sympathetic nervous system which may be due to pain or loss of sympathetic tone, as in spinal cord injuries. patho physiology of shock shock stimulates a physiologic response. this circulatory response to hypotension is to cons
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