Oral questions and answers in general surgery



Index:

Arterial disorders ----------------------------------------------------------1

Venous disorders ----------------------------------------------------------5

Lymph ------------------------------------------------------------------------8

Nerve injuries ---------------------------------------------------------------9

Thyroid diseases------------------------------------------------------------11

Breast-------------------------------------------------------------------------19

Face and neck---------------------------------------------------------------21

Salivary------------------------------------------------------------------------23

Skin ----------------------------------------------------------------------------24

Hernia and scrotum--------------------------------------------------------25

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Most important causes of acute ischemia?

●Embolism ●Thrombosis ●Injury

1st presentation of ischemia?

Paresis/paralysis, so the 1st thing to do in a patient with paralysis is to check pulse.

The surest sign of gangrene?

Loss of capillary circulation.

Why is Gangrene more common with aneurysms rather than arterial injury?

Showers of emboli from aneurysms obstruct the collaterals.

Bad general condition

1. 1st line in management of embolic acute ischemia?

Immediate heparinization

2. in immediate ttt of arterial injuries, heparinization is indicated only for patients with isolated vascular bleeding i.e free from any other source of bleeding!

3. If arterial injury is associated with fracture, correct fracture 1st, usually ischemia is corrected afterwards. If not ( open

4. Which is better, partial or complete division of an artery?

Partial division is better. (distal tissues remain viable and pulse maybe palpable)

5. On injection of short acting barbiturates for induction of anesthesia, if arterial spasm occurs, what will you do?

Don’t remove the canula; it’s an access to the artery through which you can inject vasodilators or heparin.

6. Most important investigation for abdominal aortic aneurysm?

Ultrasonography.

7. 2 types of Buerger’s disease?

Proximal and distal.

Feel Popliteal pulse, if present distal, if absent, proximal type with Claudication in calf muscles. (proximal type is the DD with atherosclerosis)

8. Frost bite?

Severe cold Freezing of tissues Thrombosis of arterioles.

9. trench (خندق) foot?

Severe cold to foot Spasm (VC)

Jobs predisposing to ischemia?

Vibrating machine.

10. Patient with Raynaud’s, 1st thing to do?

• Exclude raynaud’s phenomenon (it is 2ry to some occupations and diseases, revise them)

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11. What causes ischemia in UL?

1- Reynaud's phenomenon

2- Thoracic outlet syndrome

3- Injury

4- Embolism

5- Intra arterial injection of irritant material ex: addicts

12. Why upper limp is not affected by atherosclerosis (not to degree of ischemia)

Subclavian artery is a side branch from aorta, so its not subjected to trauma. (The main factor in atherosclerosis and formation of atheroma is TRAUMA, Because trauma produces injury of the intima of arteries facilitating depostition of lipids in subintimal layer and formation of atheroma. So coronaries are most affected due to trauma by heart beats)

13. why profunda femoris artery is not affected by atherosclerosis?

As it is deep artery and not subjected to trauma

14. claudication is from the name of the roman empror Claudis, it means to limp

15. pseudocluadication: due to neurospinal compression, exaggerated by lumbar lordosis and relieved by straightening the back.

16. How come some patients complain 1st of rest pain before claudication? Usually claudication preceeds rest pain, But sometimes rest pain may be the 1st presentation if the patient has angina and doesn't move much so he won’t complain from claudication and the 1st presentation is rest pain

17. How come patient complains of pain in one limb only, although the pathology is in both limbs? As the patient feels pain 1st in the more affected limb, so he stops before feeling pain in the other limb

18. A patient may have both intermittent claudication and rest pain, as they are different manifestations of different etiologies (not related)

19. Disappearing pulse: pulse that disappears with exercise

20. Whats the level of amputation in cases like tibioperoneal block, femoropopliteal block , iliofemoral and aortoiliac block? is never above knee, there is a rule saying that thigh never die so whatever the level of block gangrene will not affect the thigh at all and we do above knee amputation not higher than that

21. Why thigh never die?

Because in cases of aortoiliac block, collaterals develop between aorta proximally and between the deep femoral vein distally and these collaterals preserve thigh.

22. Why do you investigate for blood urea and renal functions in chronic ischemia? As renal arteries are commonly affected by atherosclerosis.

تحب تبص على ايه فى رجل العيان Beurger’sده؟

احب ابص على :

1-Gangrene

2- Taenia interdigitalis (fungal infection that has to be properly treated as minor trauma or infection predispose to gangrene)

23. In chronic ischemia, If the doctor asks you, what to do for management of this patient, you reply according to the patient’s category, so you have to know it well

24. Patient is feasible for surgery = proximal obstruction + patent distal run-off

25. Bypass operation above femoral: use synthetic graft, bypass operation below femoral: use long saphenous vein (size of long saphenous is compatible with femoral, popliteal arteries)

Berger's disease oral important

the most important point to know is that it affects small DISTAL arteries

Beurger’s causes early rest pain due to:

- Affection of distal vessels which have no collaterals

- It causes neuritis

Raynaud's disease oral important

Raynaud's phenomenon is secondary to a cause thus we treat it's cause first and no value of sympathectomy

In case of a patient with suspected raynaud's: exclude phenomenon at first to treat the causes

Vasomotor diseases oral important

Arteritis oral important

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1. After surgery, patient suffered unexplained fever and tachycardia, what do you have to exclude?

Asymptomatic DVT

2. Difference between thrombophlebitis, and phlebothrombosis:

• Thrombophlebitis: ↑↑↑↑local manifestations, ↓↓ risk of pulmonary embolism (inflammation→adherent thrombus)

• Phlebothrombosis: ↑ local manifestations. ↑↑ risk of pulmonary embolism

3. Types of venographies:

• Ascending venography (dye injected in dorsum of foot)

• Descending venography (Dye injected in IVC)

• Functional venography: to assess muscle pump, on contraction, it checks movement of blood vessels

4. Whats the first thing to do if you diagnose DVT? Immediate heparin

5. No anticoagulants after operations leaving large raw surface.

6. What if bleeding occurs to a patient receiving heparin? ttt by protamine sulphate 1 mg IV for every 100 IU heparin قيس على آخر امبول, if protamine sulphate is not available, use protamine zinc insulin + glucose

7. What are the pressure changes in superficial system during walking?

The pressure in superficial system drops due to movement of blood into the deep system

8. why in cases of ischemia V.V. is common?

Because there is sluggish circulation, Also due to loss of transmitted arterial pulsations to the veins thus decrasing VR.

9. why VV is more common in Lt side? As pressure is higher in the LT side in all individuals as LT common iliac vein is crossed by RT common iliac artery

10. what are sites of VV?

a- LL

b- Oesophagus

c- Spermatic cord

d- Anal canal ( ano rectal varices)

e- Caput medusae

f- Bronchial varices

11. when do you see VV in upper limb?

After A-V fistula of renal dialysis ( in renal failure pt we do him regular dialysis so we induce A-V fistula to take the blood from it to the machine)

12. what question you should ask the pt before injection ttt?

We must ask about use of pills

13. Precautions to avoid DVT during injection ttt of VV?

a) Only 1ml is injected

b) No injection is done above knees

c) Walking after injection

d) Tourniquet above knee

e) Not to be done in females taking OCPs or with predisposition to thrombosis

14. Substances injected: 5% ethanolaine oleate and 3% sodium tetradecyl sulphate

15. Why are the elastic stockings below knee, not above? As no complications occur above knee

16. Why ulcer bearing area is above medial malleolus?

• This area is drained by direct perforators

• Superficial system in this area is drained directly to deep system

• Pressure of deep system is transmitted directly to superficial system

17. Can complications of VV occur in lateral malleolus? Yes, some people have lateral perforators

18. Why is varicose ulcer a chronic ulcer? ●Due to anoxia, liposclerosis,

●chronic irritation by hemosiderin, ●superadded infection and periosteitis

19. Complications of varicose ulcer:

• malignancy,

• periosteitis (ulcer fixed to tibia),

• talipus equines (plantar flexion + inversion, as walking on toes relieves pain leading to contracture, ttt: physiotherapy )

20. Why there is chronic traumatic leg ulcer and there is no chronic traumatic forearm ulcer?

• Due to dependency in the leg.

• Ulcers in legs are more liable for repeated trauma.

• Ulcers in leg are more liable for repeated infections.

21. Margin is the most important for diagnosis of cause of ulcer; it’s the part that has the original disease, before sloughing of skin

22. How to know if this is healthy granulation tissue?

|Healthy granulation tissue |Unhealthy |

|Red |Pale |

|Finely granular, flat surface |Coarsely ranular, raised surface |

|Does not bleed easily |Bleeds easily |

|Minimal serous discharge |Profuse pus discharge |

|Painless |painful |

23. TB ulcer shows thin cyanotic margin as TB bacilli produce vasoconstricting substances.

1. Famous sites for chronic non-specific lymphadenopathy? Inguinal and cervical LNS

2. What to do in case of chronic non specific lymphadenopathy? Don’t say give antibiotics, because ttt has to be directed to original focus, nodes are not treated.

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3. Giant cell?

- It is multinucleated cells.

4. Famous giant cells in surgery?

- Langerhan’s giant cell. (TB, with horse shoe nucleus)

- Reed Sternberg cell. (in lymphoma)

- Giant cells of osteoclastoma.

- Giant cells of Granulomas.

5. Why is the name cold abscess a wrong name? because it is not hot like pyogenic abscess, but it is warm not cold, and, its not an abscess as it does not contain pus, it contains caseation

6. Management of cold absess is very important, revise from book.

7. Sites of primary T.B.?

- Lung.

- Intestine

- Tonsils

- Skin.

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8. In Hodgkin;s lymphoma, don’t describe LNS as rubbery, better say firm

9. When is staging laparotomy indicated? Stages I and II

10. Why? Because in stages I and II, after staging laparotomy I might discover that the patient is stage III, so chemotherapy is started early (improving prognosis). But if patient is diagnosed as stage III, he already receives chemotherapy and there will be no change in ttt.

11. Why is staging laparotomy not preferred in some centres?

• Risk of OPSI (overwhelming post splenectomy infection)

• High accuracy of non-invasive CT and MRI

12. Role of surgery in lymphoma?

- Staging laparotomy.

- Gastric or intestinal lymphoma.

13. Is it possible to find malignant LNS and not find the 1ry lesion? Yes, when? If the 1ry is in a hidden place and overlooked, as primaries in ear, hypopharynx, nasal sinuses, nasopharynx, bronchi, stomach, testis, cecum and thyroid.

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14. Preserved ankle crease in lymphedema?

- Skin at ankle is adherent to deep fascia and drained by deep lymphatics.

15. In complications of lymphedema ( on top of lymphedema, lymphangiosarcoma may occur (Stewart Trevus Syndrome)

16. Causes of chronic diffuse Limb swelling? ●Lymphedema ●Pospphlebitic ● elephantiasis neurofibromatosis ● congenital arteriovenous fistula (local gigantism)

17. How to differentiate between post-phlebitic limb and lymphedema limb?

|Post phlebitis |Lymphedema |

|Painful |Painless |

|History DVT |Lives in endemic area, not DVT history |

|Ankle crease not preserved |Ankle crease preserved |

|Pitting edema |Non-pitting edema |

|Skin shows uiceration and pigmentation |Recurrent attacks of streptococcal inflammation (cellulitis) |

18. Sistrunk operation in surgery?

- Lymphedema.

- thyroglossal cyst or fistula.

- Hypospadius

-

19. Filarial lymphedema is important oral

20. Varicose gland: cystic enlargement of lymph node 2ry to obstruction of lymph flow in LNS (worm remains is cortex of LNS)

21. Why do we give a Patient with active filariasis diethyl carbamazine? Not to cure the patient, but to prevent dissemination of disease by killing the worms

1. In axonotemesis, what is the expected time for regeneration?

From date of injury, 1 week lag + 1-3 mm/day

2. In diagnosis of nerve injury, sweating test may be done, what s the powder used? Quinizarine powder. It is blue and turns red on exposure to water, so it is used to map out areas of anhydrosis.

3. In diagnosis of nerve injury, what is the value of nerve conduction velocity? (NCV)? It is not impaired in cases of neuropraxia. (neuropraxia is concussion of nerves with rapid and complete recovery.)

4. In diagnosis of nerve injury, why do we do electromyography? Viable denervated muscles show spontaneous fibrillations. These fibrillations are lost if complete fibrosis occurs , and this muscle becomes no more suitable for reinnervation

5. what to do for repair of nerve injury if approximation of two ends is difficult? One of the following methods:

- flexion of the limb (position of maximum use of functions)

- mobilization of nerve proximally and distally

- stripping of unimportant anchoring branches

- transposition of nerve to shorten its course (ulnar course is behind medial epicondyle, bring it anterior, and radial N. course is behind lateral epicondyle, bring it anterior)

- bone shortening (shorter limb, bad results)

- nerve grafting, either by using less important nerves, or multiple strands of Cutaneous nerves are used as a bundle (cable graft)

6. what less important nerves? Sural and saphenous

7. sural nerve: is a branch of medial popliteal nerve (a branch from sciatic) accompanying short saphenous vein.

8. Saphenous nerve: a branch of femoral nerve, accompanying long saphenous vein.

9. Which is more important, Median or ulnar nerve? Median

يعنى اخد من الmedian اصلح ال ulnar وليس العكس

As median supplies opponens pollicis, so it is responsible for opposition of thumb, which is responsible for 50% of movement

10. When to seek orthopedic ttt? In a chronic patient, with failure to get the nerve to recover.

11. How? In other words, what to do for a chronic patient (in clinical exam)

(A) orthodesis: fixation of joint (e.g. in radial nerve paralysis which causes wrist drop)

(B) Tendon transplantation: e.g. flexor digitalis is sutured in extensors of wrist

• whats the carrying angle? Normally there is an angle between the long axis of forearm and that of the arm. It is larger in females

If supracondylar fracture occurred → improper healing → Cubitus valgus (wider carrying angle) → course of ulnar nerve become elongated and this causes delayed ulnar neuritis → we treat the condition by anterior transposition of ulnar nerve in front of medial epicondyle .

Application: in clinical ask pt with ulnar nerve injury to stand with extended elbow

The doctor will ask you why?Tell him that you are inspecting for wide carrying angle

• Neurofibromas: Important for Oral (عناوين)

1. All thyroid is very important oral

2. Thyroglossal cyst and fistula: important oral

3. Sites of ectoic thyroid?

●lingual ●mediastinal ●neck ●struma ovarii ●in the past,lateral aberrant thyroid before knowing its nature as enlarged deep cervical LNS [metastasis from thyroid] (last to be said)

4. How to know that this is thyroid tissue? Thyroid scan

5. How to manage ectopic thyroid ?

- DONT answer : we remove it sir

- say we should first make sure that this is not the only thyroid tissue present in his body , so we check for thyroid gland if present and working then we remove the ectopic one.

6. DD of any sinus

- chronic osteomylitis

- T.B.

7. All thyroid diseases are more common in females except

- anaplastic carcinoma (fatal disease)

8. in case of hypothyroid goitre, how come thyroid hormone are low while the gland is enlarged and hyperactive?

- it occurs in cases of severe iodine deficiency in which in spite of hyperactivity of the gland, there is no iodine to synthesize T3 and T4. therefore T3 and T4 are low and TSH will increase leading to more and more hypertrophy of the gland

9. euthyroid= normal T3 and T4

10. what does the patient complain of in case of diffuse hyperplastic goitre (physiological goitre) ?

- fullness in the lower part of front of neck = venus neck إلةالجمال فى الأساطير!

11. Colloid goiter

- Is a pathological diagnosis not a clinical one

- A phase between physiological goiter and S.N.G

12. How S.N.G. cause dyspnea?ازاى بيحصل dyspnea(يقصد ازاى بيدوس فيسببه)

- By pressure on trachea :

1- anteroposterior pressure especially in retrosternal cases

2- lateral kinking of trachea by unilateral goiter

3- compression from both sides in bilateral huge goiter (scabbard trachea خنجر )

4- prolonged compression of trachea results in resorption of cartilaginous rings ( tracheomalacia

13. Is knowing if there’s tracheomalacia before thyrtoidectomy important?

- Yes, as after gland removal ( trachea collapse so u must do a tracheostomy

14. how to diagnose tracheomalacia preoperative ?

- krocher's sign : bilateral compression of thyroid, if suffocation occurs, do not do surgery (tracheomalcia is a contraindication for thyrtoidectomy)

- الأحسن انه يعيش بhuge goiter عن انه يعيش ب tracheostomy

15. If thyrtoidectomy is wrongly done in case of tracheomalacia, what will you do? Tracheostomy is a must

16. Krocher's in surgery

1- Sign to diagnose tracheomalcia

2- forceps

3- reduction of shoulder dislocation

4- 2 incisions, in thyriodectomy & Subcostal incision in cholecystectomy

17. Trendlenberg in surgery

1- Test for VV

2- position ( head down )

3- valve

4- 2 operation in varicose vein & pulmonary embolism

5- Examination in hip joint

18. Waldeyers in surgery :

a) waldeyers ring in neck

b) waldeyers fascia between rectum and sacrum (delays direct spread of rectal carcinoma to sacrum)

19. consistency of SNG? Firm

20. when is it hard? In calcification, malignancy, reidl’s thyroiditis and tense cyst

21. when is it cystic? In cystic degeneration, hge or suppuration

22. whats berry’s sign? It occurs due to biding of malignancy on carotid ( absent carotid pulse.(بيحضنه )

as malignancy cant infiltrate carotid (there will be no signs of cerebral ischemia)

23. complications of SNG: v imp

24. What to be done preoperatively for any thyroidectomy?

a) Routine preoperative investigation & ECG

b) indirect laryngoscopy ( for medico legal purpose to be sure that that the recurrent laryngeal nerve was not already injured before operation )

25. what kind of injury can be commonly found? 3% of people have recurrent laryngeal nerve injury of an unknown cause, only explanation is that it is due to recurrent viral neuritis.

26. What are types of calcification in plain x-ray thyroid

a) Linear: around nodules بالطول

b) punctate : in papillary carcinoma نقط

c) patchy : in medullary carcinoma بطش

27. Why avoid thyriodectomy in patients below 25 years old ?

- As this patient is still young & will be subjected later on to stress especially if a female case facing stress of pregnancy and lactation having higher risk for recurrence

28. If you decide not to do surgery in a patient, what further management would you like to do?

- Give her L-thyroxine (trying to stop the progression of the pathology, which may even regress on this ttt)

29. Why manubruim is normally resonant on percussion?

- As trachea is behind it

30. What does autoimmune thyroiditis mean? Antibodies acting on thyroid instead of TSH, so response of thyroid will be longer and stronger.

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31. Which term is better thyrotoxicosis or hyperthyroidism?

- Thyrotoxicosis is better as some manifestation are due to autoimmune mechanism ( exophalmos & pretibial myxedema & thyroid acropathy &

32. What are the complications of 2ry toxic goiter?

- The same as SNG + heart failure

33. What is hashitoxicosis ?

- Thyroiditis & destruction of gland ( release of t3 & t4

- Cause hyperthyroidism early only but after complete destruction of the gland( fibrosis ( hypothyroidism

34. Who is the pt. with hyperthyroidism, & a low gland activity?

- Patient with thyroiditis

- N.B. we detect gland activity by iodine trapping

Iry toxic goiter

35. Evidence that toxic goiter is an autoimmune disease?

- Antibodies in serum of patients

- Lymphocytic infiltration in microscopy

- RES hyperplasia (so in general exam, you may find HSM)

36. What are the names of antibodies?

- LATS : long acting thyroid stimulators

- LATS -P : long acting thyroid stimulators protected

37. What are the grades of toxic goiter according to tachycardia?

- Milde: 80 – 90

- Moderate: 90- 110

- Severa: >110

38. DON’T diagnose toxic goiter if pulse is less than 80/min ECXEPT if under ttt.

39. In metabolic manifestations of toxic goiter, there is recent intolerance to hot weather

40. Where can you see tremors in thyrotoxic pt?

●outstretched hands, ●lightly closed upper eyelids ●protruded unsupported tongue

41. Sleeping pulse? While sleeping, or Sedated pulse, أهدى العيانه واقيسه

42. Can pretibial myxedema be unilateral? No, it is always bilateral, and always associated with true exophthalmos (أصلها immune)

43. diarrhea with goiter?

1- toxic goiter

2- medullary carcinoma

44. goiter with spleenomegally?

1- toxic goiter

2- lymphoma thyroid

45. thyroid with LNS?

1- thyroiditis

2- lymphoma

3- spread from carcinoma

4- not related

46. Why polyurea in toxic goiter?

1- high metabolic rate

2- glycosuria as thyroid hormone is diabetogenic

3- high blood flow to kidneys

47. Why isthmus should be removed in all thyroid operations?

- As recurrence will manifest early

48. And when reccurence occurs?

هيبقي عنده بليه في رقبته بتطلع و تنزل مع البلع

49. What is the difference between lobectomy & hemi thyroidectomy?

- In both we remove: Lobe + isthmus

- But in lobectomy, in addition we remove the medial part of the other lobe

50. Complications of thyroidectomy? Thyrotoxic crisis

a. Convulsions ⋄ give sedatives

a. Fever ⋄ ice pack

a. Dyspnea ⋄ oxygen

a. Tachy cardia ⋄ indral with monitor & ECG & give steroids

51. Why after thyroid operations there may be change of voice

a. Cocussion of nerve

a. Tracheitis

a. Laryngitis

52. Vessels supplying parathyroid:

- inferior thyroid artery

53. what will you do if you accidentally removed all parathyroid tissue ?

- Autotransplantaion in forearm muscles (it will take blood supply from the surrounding)

54. what is the 1st symptom of hypothyroidism ?

- Personality changes

55. keloid on thyrtoidectomy scar :-

- Why on sternum? A common place for development of keloid

- Why did the incision become on sternum? as patient’s neck is hyperextended, so incision might be done so low in the neck that after the operation when she flexes her neck, it will be on sternum

- How to avoid?

56. Why is it contraindicated to do surgery for severe 1ry thyrotoxicosis with recent progressive exophthalmos?

As sudden termination of toxicity causes higher incidence for developing malignant exophthalmos.

57. Why? There are some explanations saying that hypothyroidism (after surgery) stimulates piutuitary. And Exophthalmos Producing Substance (EPS) is produced from anterior pituitary.

58. What is malignant exophthalmos? It means it is progressive despite all lines of ttt.

59. Eye signs other than exophthalmos: very important (don’t forget to put your hands to stabilize patient’s head in all of them )

60. Difference between 1ry thyrotoxicosis and 2ry thyrotoxicosis? Revise table from book (10 points)

61. Thyroid function tests: oral, specially radioactive iodine studies (v imp)

62. In blood examination of thyrotoxicosis,

- there is hypercreatinema (creatine of myopathy), hypocholestrolemia (thyroid is the only hormone that lowers cholest.) and hyperglycemia (thyroid is diabetogenic)

63. Factors affecting line of ttt:

●type of goiter ●age ●pregnancy ●thyrocardiac condition

●recent exophthalmos ●high thyroid antibody titre (thyroiditis ( medical ttt only)

●type of thyrotoxicosis: if 2ry toxic goiter, surgery is always better, if toxic nodule, surgery or radioiodine

64. Cases in which u must know pre-operative preparations:

●toxic goiter (lugol’s iodine to ↓ vascularity ● intestinal obstruction ●pyloric obstruction ●obstructive jaundice ●shocked patient ●elective colonic surgery

65. How do treat thyrotoxicosis?

Start with this phrase: each patient is considered separately, and one measure or a combination of measures is chosen for him.

66. In thyrtoidectomy for ttt of SNG & thyrotoxicosis, how much of the gland should be left in the body?

According to the surgeon’s experience, but usually in SNG, 8 gm on each side, which is equal to distal phalynx of thumb. In toxic goiter, ½ or 1/3 this amount is left

67. Embryology of thyroid?

- Thyroglossal duct → follicles,

- neural crest → para-follicular cells (that produce calcitonin → ↓ serum ca

68. is fine needle aspiration useful in follicular adenoma?

No, its not reliable, as it doesn’t differentiate between adenoma and carcinoma. Because the only difference histologically is the presence of vascular or capsular invasion.

69. Malignant neoplasms of thyroid are very important oral.

70. You discovered a patient with medullary carcinoma, what would you like to do concerning his family?

Screening for calcitonin level, if proved to be high in one of them, prophylactic thyrtoidectomy is done.

71. Why? Because before malignancy develops, it passes through a phase of hyperplasia of parafollicular cells, which secrete calcitonin.

72. Medullary carcinoma is very imp oral

73. How does medullary carcinoma produce diarrhea?

- By production of serotonin (5-hydroxytryptamine) or PGs

74. What is the microscopic picture of medullary carcinoma?

●Sheets of Neoplastic cells ●in a hyaline sroma ●hyaline stroma may contain amyloid material

75. What is MEN? It is multiple endocrinal neoplasia syndrome

76. Types?

tYpe I: Wernes syndrome

●parathyroid hyperplasia ● pancreatic islets cell tumour (insulinoma, glucagoma, somatostatinoma) ●pituitary tumour

Type II: Sipple’s syndrome

IIa: ●parathyroid hyperplasia ●pheochromocytoma ●medullary carcinoma

IIb: IIa + neurological abnormalities, marfanoid facies and multiple neuromas

77. Patient with medullary carcinoma and pheochromocytoma, which will you treat 1st?

Pheochromocytoma 1st, although it is usually benign, but patient with pheochromocytoma can not tolerate the anesthesia required for thyrtoidectomy.

78. What is the 1st LN to be affected in thyroid carcinoma? Recurrent laryngeal node

79. Then? Then pretracheal and prelaryngeal (Delphic), and to lower deep cervical LNS

80. Which are more commonly affected, upper or lower deep cervical LNS? Lower

81. What are the characteristics of metastasis of thyroid tumour to bones?

- Painful, tender, pulsatile lump

- Pathological fracture

- Commonly in spine, skull and neck of femur. (so in clinical exam, check the patients scalp)

82. Can incision biopsy be done to investigate for thyroid malignancy?

No, its absolutely contraindicated, as it results in seedling of malignant cells. (Although it is allowed in breast, because if it proved to be malignant, mastectomy later on will remove the whole tract)

83. How do we scan for recurrence of thyroid tumour after TOTAL thyroidectomy? Thyroglobulin, as it is only produced from thyroid and tumour cells.

84. What would you like to give the patient post-thyroidectomy? L-thyroxine short of toxicity

85. Why? as Replacement and for suppression of metastasis.

86. What are the hormone dependant tumours?

●breast ●differentiated thyroid carcinoma

87. Criteria inoperability?

a) Extensive local spread

b) Extensive lymphatic spread

c) Blood spread

d) Unfit patient.

88. Prognosis of differentiated thyroid carcinoma?

These factors increase the risk: in this order

a) Age: males above 40 and females above 50

b) Sex: females have better prognosis

c) T: ●size (more than 5 sm) ●microscopic picture (vascular or capsular invasion) ●type

d) N: presence of LN metastasis

e) M: presence of distal metastasis.

89. Thyroiditis: imp oral

90. Subacute thyroiditis = De Quervain thyroiditis = granulomatous thyroiditis: probably a viral infection, iodine uptake of gland is ↓↓ in presence of slight ↑ of serum T4, ttt as any viral wih anti-inflammatory and prednisone.

91. Causes of chronic thyroiditis? TB and Syphilis

92. Autoimmune thyroiditis = hashimoto’s thyroiditis, investigations?

Serum titres of antimicrosomal, antimitochondrial and antithyroglobulin antibodies.

93. Reidle’s thyroiditis: probably a collagen disease, thyroid is hard (extensive fibrosis), differentiation from anaplastic carcinoma may need an open biopsy

94. Which part will you remove for biopsy? a wedge of isthmus is removed

95. Why? So that in addition to biopsy, trachea is relieved from obstruction. (remember, in all thyroid operations we remove isthmus, check Q 48)

96. Thyrtoidectomy is v imp oral

97. If trachea is injured during thyrtoidectomy, what will you do?

Immediate suturing, with prolene

98. How to avoid keloid formation on the scar?

Do incision in the lower neck 1 inch above suprasternal notch (so that scar will be in lower neck not on sterum, which is a known place for keloid)

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1. What are Cardinal symptoms and signs of pus formation?

• fever becomes hectic ( fluctuates about 1 C up and down but doesn't return to base line) not intermittent (return to base line)

• pitting edema

• throbbing pain

• Localization

• fluctuation: cavity containing pus

• Pointing

2. Areas in our bodies in which we don't wait for fluctuation to drain?!

• gluteal region

• perineal abscess

• hand infections

• Parotid gland (deep to deep fascia so you can't feel the fluctuation.)

• perinephric abscess

• ear lobule

3. If a case of duct papilloma and you feel a mass, what are the possibilities?

This is a retention cyst as the papilloma closes the duct partially and causes swelling of acini forming retention cyst

4. In case of Cystsarcoma Phylloides , How a mass causes skin ulceration?

a)Pressure necrosis in case of rapidly growing benign neoplasm

b) Infiltration of malignant neoplasm.

5. What are the types of biopsies in general?

a) Open biopsy: excision biopsy (remove all mass with safety margin) OR incisional biopsy (remove part of the mass).

b) Frozen section biopsy: rapid results within 20 minutes but not accurate as open biopsy

c) Needle biopsy: true cut biopsy OR fine needle aspiration biopsy

6. What is meant by Radical surgery?

= Removal of 1ry tumor with safety margin + draining LN in one block

7. Why Radical Mastectomy of Halsted isn’t radical?

✓ As he left the internal mammary LN

N.B.: the only true radical operation is extended radical who removed axillary and internal mammary LN

8. why Halsted removed Pectoralis major and minor?

To ensure removal of interpectoral LN of Rooter which was believed to be the main station of lymphatic spread

9. Why the skin ellipse included the nipple and areola?

To ensure removal of retroareolar plexus of sappy this was believed to be main station of lymphatic spread

10. What is extended radical?

= Halsted + internal mammary LNs removal

10. What is super-radical?

=Halsted + supraclavicular LNs removal ( not internal mammary)

11. Which is more risky early or late arm edema after operation?

Late as it is commonly due to recurrence of malignancy!

12. When incidence of breast carcinoma in male is equal to female?

In case of klienfilter syndrome

[pic]

1. How to differentiate between thyroglossal cyst and subhyoid bursitis?

✓ Thyroglossal cyst: Rounded

✓ subhyoid bursa: oval with transverse axis

2. What is step-ladder incision?

It is an incision used for ttt of congenital branchial fistula, done at a higher level in the skin in order to gain easy access to the track of the fistula between the carotids, and it's not needed for acquired branchial fistula as it's already at the same level of the track

3. How to differentiate clinically between congenital and acquired branchial fistulae?

|Acquired |Congenital |

|Age of onset: adulthood on top of pre-existing cyst |Since birth |

|Site: high in the neck at the cyst level |In lower third of the neck |

|Treatment: surgical excision |Surgical excision + step-ladder incision |

4. What is the only translucent neck swelling?

✓ Cystic hygroma

5. What is adson's test?

The patient is asked to extend his head to the opposite side and take a deep breath , the examiner then palpates the radial pulse if the test is positive the pulse will be weaker ( used in thoracic outlet syndrome and is not very accurate test )

6. What's meant by " rule of 10" ?

It means that in management of an infant with cleft lip you have to wait till the infant becomes of suitable weight (10 pounds at least) and the Hb level should be at least 10 gm%

7. In management of cleft palate, why tonsillectomy and adenoidectomy are better avoided?

As tonsils (not inflamed) and adenoid tissue narrow the nasopharyngeal isthmus ( better results for cleft palate repair ( less regurgitation of food and secretions) and may give you a chance not to perform pharyngeoplasty

8. A patient presenting with bleeding tongue, how to manage such a case?!

اخليه يطلع لسانه لبرا و اتنيه على اسنانه اللى تحت

و اضغط بشاش و اوقف النزيف

9. What is meant by operable and in operable malignancies?

✓ Operable: curable; we do surgery aiming for cure

✓ Inoperable: non curable; the patient will die from malignancy but we may do palliative surgery

N.B. Neoadjuvent therapy:

A patient with extensive 1ry malignancy but without metastasis. It is used in advanced malignancy to under stage the case, and do surgery e.g. Breast, wilm’s tumor,…

[pic]

يعنى لو دخلت على الحالة دى

مهم انك تسأل ام العيان

history

- consanguinity انت و جوزك قرايب؟

- Prenatal history اخدتى ادوية او حاجه اثناء الحمل؟

- Similar conditions in the family حد فى العيلة او فى اخواته عنده الحكاية دى؟!

General examination و عليك بس فى ال

انك تشوف اذا كان فيه اى

associated anomaly specially CARDIAC

local examination اما فى ال

عليك انك تعرف ال

type

بس

يعنى حسب الرسمة

- unilateral or bilateral

- complete or incomplete

- simple or complicated

[pic]

• In clinical, ask in salivary sheet about associated

- dry mouth

- dry eye

( To exclude Mikulicz’ and sJogren's disease

يفرح بيك اوى لو قولتله الحته دى

• Why is submandibular gland felt in oral cavity?

As deep part of the gland is above myelohyoid

• how to differentiate between submandibular LNs and submandibular gland?

|Lymph nodes |Gland |

|Multiple |Single |

|Can be rolled on the edge of the mandible |Can't be rolled |

|Can be felt only in neck |Felt in neck and oral cavity |

• sites of stones in the body:

1- Urinary tract ( 90% radio-opaque )

2- Biliary tract ( 10% radio-opaque)

3- Salivary (100% radio-opaque)

4- Pancreas

5- Prostate

6- Umbilicus ( dirts)

7- Intestine ( gallstone ileus)

[pic]

1. Sebaceous cysts may occur any where except in …..?!

In palms and soles (devoid of sebaceous glands)

2. What are the types of dermoid cyst?

a) Sequestration dermoid

b) Tubulodermoid

c) Inclusion dermoid

d) Teratomatous dermoid

e) Implantation dermoid

3. In case of hemangioma , if you diagnosed a port wine lesion in the face , what investigation would u like to proceed with?

CT scan as this lesion is usually associated with similar lesion in the meninges (sturge-weber syndrome)

4. can lipoma cause death in a patient?

Yes, in case of submucous lipomata if present in

• Larynx( suffocation

• Intestine ( intussusceptions ( intestinal obstruction

5. When do we find LNS enlarged with basal cell carcinoma?

- associated infection (any chronic non-specific infection)

- baso-squamous cell carcinoma

6. Is spontaneous cure possible in malignancy in skin?

Yes, in case of '' lentigo'' which is the least aggressive type of melanomas

7. What is the meaning of sentinel LNs?!

Sentinel lymph node: 1st LN to be affected by metastasis.

Detected by injection of a dye around the tumour during the operation, it is the1st LN to be colored

• Classification of lipoma is very important for oral exam (refer to your book)

[pic]

1. When will the patient have strangulation without intestinal obstruction?

o Richter's hernia

o Littre's hernia

o If the content is omentum

2. What are complications of the truss?

• Inflammation of the hernial sac

• Adhesions within the sac

• Increased risk of the strangulations

• Improper fitting to truss

3. Is irreducibility an emergency?

No, but needs surgery

4. How do we suspect congenital hernia?

-Common in child

-Reaches bottom of scrotum rapidly

- Strangulation common at the moment of presentation

-Testis is separate from the sac

5. What is the hernia of nuck?

It is oblique inguinal hernia in females

6. Is skin the covering of all hernias?

No, exomphlus is covered by peritoneum only that's why it is an emergency

7. When does true umbilical hernia occur in adults?

-In ascitic patients

8.What is the significance of divarication of the two recti?

-Weak abdominal ms

-Increased intra-abdominal pressure

8. What are the commonest organs in sliding hernia?

-Urinary bladder

-Ceocum

-Sigmoid colon

9. How to suspect sliding hernia?

If:

-huge

-Long standing

-Incompletely reducible

-Desire of micturition

-Double of micturition

10. Difference between seminoma and teratoma microscopically?

|Seminoma |teratoma |

|No hemorrhage and necrosis |there is Hemorrhage and necrosis |

|fibrous septa |No fibrous septa |

11.Why do you examine the inguinal lymph nodes in inguino-scrotal sheet???

Because the skin of the scrotum drains to medial half of the transverse limb of superficial inguinal LNs

But where the testis itself drained?

To the para-aortic L.Ns at L2 because of origin of testicular artery

Why?

أين ترعرعت مولاتي

So when it is drained to inguinal lymph nodes?

If there is:

• Scrotal skin infiltration

• After testicular biopsy

• After previous orchiopexy

12. Functions of testis?

• Hormone production

• Spermatogenesis: Needs 35'C……..dartos ms is the thermostat for spermatogenesis

13. Why normally left testis is lower than the right?

Embryologically Lt Testis descends first……..so the Rt undescended testis more common And so the Rt inguinal hernia is more common

14. When we do semen analysis after the operation?

At least 3 months(spermatogenesis cycle takes about 3 months

15. Why the unilateral varicocele causes infertility?

Due to vascular communications between the 2 testis which transmit hotness and toxins of the congested testis to the other one

-----------------------

Arterial disorders

Venous system

Lymphatic disorders

NERVE INJURIES

Thyroid diseases

Breast

Face and neck

❖ Differential diagnosis of masses in the neck according to site is VERY IMPORTANT (refer to your book )

Salivary gland

Non neoplastic salivary gland diseases (review titles for oral questions)

Skin

Hernia and scrotum

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