ࡱ> ~[0bjbj |ΐΐZ~ ~ 8\EA!!!!!333\31 333!!@;;;3V!!;3;;{!a1ay6!uV0 G9 33;33333;3333333333333333~ : 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  SHAPE \* MERGEFORMAT   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 1st line in management of embolic acute ischemia? Immediate heparinization 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! If arterial injury is associated with fracture, correct fracture 1st, usually ischemia is corrected afterwards. If not ( open Which is better, partial or complete division of an artery? Partial division is better. (distal tissues remain viable and pulse maybe palpable) On injection of short acting barbiturates for induction of anesthesia, if arterial spasm occurs, what will you do? Dont remove the canula; its an access to the artery through which you can inject vasodilators or heparin. Most important investigation for abdominal aortic aneurysm? Ultrasonography. 2 types of Buergers 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) Frost bite? Severe cold Freezing of tissues Thrombosis of arterioles. trench (.F/B) foot? Severe cold to foot Spasm (VC) Jobs predisposing to ischemia? Vibrating machine. Patient with Raynauds, 1st thing to do? Exclude raynauds phenomenon (it is 2ry to some occupations and diseases, revise them)  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 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) why profunda femoris artery is not affected by atherosclerosis? As it is deep artery and not subjected to trauma claudication is from the name of the roman empror Claudis, it means to limp pseudocluadication: due to neurospinal compression, exaggerated by lumbar lordosis and relieved by straightening the back. 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 wont complain from claudication and the 1st presentation is rest pain 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 A patient may have both intermittent claudication and rest pain, as they are different manifestations of different etiologies (not related) Disappearing pulse: pulse that disappears with exercise 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 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. Why do you investigate for blood urea and renal functions in chronic ischemia? As renal arteries are commonly affected by atherosclerosis. *-( *(5 9DI 'JG AI 1,D 'D9J'F Beurger s/G '-( '(5 9DI : 1-Gangrene 2- Taenia interdigitalis (fungal infection that has to be properly treated as minor trauma or infection predispose to gangrene) In chronic ischemia, If the doctor asks you, what to do for management of this patient, you reply according to the patients category, so you have to know it well Patient is feasible for surgery = proximal obstruction + patent distal run-off 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 Beurgers 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  SHAPE \* MERGEFORMAT  After surgery, patient suffered unexplained fever and tachycardia, what do you have to exclude? Asymptomatic DVT Difference between thrombophlebitis, and phlebothrombosis: Thrombophlebitis: !!!!local manifestations, !! risk of pulmonary embolism (inflammation!adherent thrombus) Phlebothrombosis: ! local manifestations. !! risk of pulmonary embolism 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 Whats the first thing to do if you diagnose DVT? Immediate heparin No anticoagulants after operations leaving large raw surface. What if bleeding occurs to a patient receiving heparin? ttt by protamine sulphate 1 mg IV for every 100 IU heparin BJ3 9DI ".1 'E(HD, if protamine sulphate is not available, use protamine zinc insulin + glucose 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 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. 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 what are sites of VV? LL Oesophagus Spermatic cord Anal canal ( ano rectal varices) Caput medusae Bronchial varices 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) what question you should ask the pt before injection ttt? We must ask about use of pills Precautions to avoid DVT during injection ttt of VV? Only 1ml is injected No injection is done above knees Walking after injection Tourniquet above knee Not to be done in females taking OCPs or with predisposition to thrombosis Substances injected: 5% ethanolaine oleate and 3% sodium tetradecyl sulphate Why are the elastic stockings below knee, not above? As no complications occur above knee 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 Can complications of VV occur in lateral malleolus? Yes, some people have lateral perforators Why is varicose ulcer a chronic ulcer? %Due to anoxia, liposclerosis, %chronic irritation by hemosiderin, %superadded infection and periosteitis 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 ) 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. Margin is the most important for diagnosis of cause of ulcer; its the part that has the original disease, before sloughing of skin How to know if this is healthy granulation tissue? Healthy granulation tissueUnhealthyRedPaleFinely granular, flat surfaceCoarsely ranular, raised surfaceDoes not bleed easilyBleeds easilyMinimal serous dischargeProfuse pus dischargePainlesspainful TB ulcer shows thin cyanotic margin as TB bacilli produce vasoconstricting substances.  Famous sites for chronic non-specific lymphadenopathy? Inguinal and cervical LNS What to do in case of chronic non specific lymphadenopathy? Dont say give antibiotics, because ttt has to be directed to original focus, nodes are not treated.  Giant cell? It is multinucleated cells. Famous giant cells in surgery? Langerhans giant cell. (TB, with horse shoe nucleus) Reed Sternberg cell. (in lymphoma) Giant cells of osteoclastoma. Giant cells of Granulomas. 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 Management of cold absess is very important, revise from book. Sites of primary T.B.? Lung. Intestine Tonsils Skin.  In Hodgkin;s lymphoma, dont describe LNS as rubbery, better say firm When is staging laparotomy indicated? Stages I and II 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. Why is staging laparotomy not preferred in some centres? Risk of OPSI (overwhelming post splenectomy infection) High accuracy of non-invasive CT and MRI Role of surgery in lymphoma? Staging laparotomy. Gastric or intestinal lymphoma. 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.  Preserved ankle crease in lymphedema? Skin at ankle is adherent to deep fascia and drained by deep lymphatics. In complications of lymphedema ( on top of lymphedema, lymphangiosarcoma may occur (Stewart Trevus Syndrome) Causes of chronic diffuse Limb swelling? %Lymphedema %Pospphlebitic % elephantiasis neurofibromatosis % congenital arteriovenous fistula (local gigantism) How to differentiate between post-phlebitic limb and lymphedema limb? Post phlebitis LymphedemaPainfulPainlessHistory DVTLives in endemic area, not DVT historyAnkle crease not preservedAnkle crease preservedPitting edemaNon-pitting edemaSkin shows uiceration and pigmentationRecurrent attacks of streptococcal inflammation (cellulitis) Sistrunk operation in surgery? Lymphedema. thyroglossal cyst or fistula. Hypospadius Filarial lymphedema is important oral Varicose gland: cystic enlargement of lymph node 2ry to obstruction of lymph flow in LNS (worm remains is cortex of LNS) 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  In axonotemesis, what is the expected time for regeneration? From date of injury, 1 week lag + 1-3 mm/day 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. 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.) 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 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) what less important nerves? Sural and saphenous sural nerve: is a branch of medial popliteal nerve (a branch from sciatic) accompanying short saphenous vein. Saphenous nerve: a branch of femoral nerve, accompanying long saphenous vein. Which is more important, Median or ulnar nerve? Median J9FI './ EF 'Dmedian '5D- 'D ulnar HDJ3 'D9C3 As median supplies opponens pollicis, so it is responsible for opposition of thumb, which is responsible for 50% of movement When to seek orthopedic ttt? In a chronic patient, with failure to get the nerve to recover. 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 (9F'HJF)  All thyroid is very important oral Thyroglossal cyst and fistula: important oral 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) How to know that this is thyroid tissue? Thyroid scan 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. DD of any sinus chronic osteomylitis T.B. All thyroid diseases are more common in females except anaplastic carcinoma (fatal disease) 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 euthyroid= normal T3 and T4 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 %D)'D,E'D AI 'D#3'7J1! Colloid goiter Is a pathological diagnosis not a clinical one A phase between physiological goiter and S.N.G How S.N.G. cause dyspnea?'2'I (J-5D dyspnea(JB5/ '2'I (J/H3 AJ3((G) By pressure on trachea : anteroposterior pressure especially in retrosternal cases lateral kinking of trachea by unilateral goiter compression from both sides in bilateral huge goiter (scabbard trachea .F,1 ) prolonged compression of trachea results in resorption of cartilaginous rings ( tracheomalacia Is knowing if theres tracheomalacia before thyrtoidectomy important? Yes, as after gland removal ( trachea collapse so u must do a tracheostomy 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) 'D#-3F 'FG J9J4 (huge goiter 9F 'FG J9J4 ( tracheostomy If thyrtoidectomy is wrongly done in case of tracheomalacia, what will you do? Tracheostomy is a must Krocher's in surgery Sign to diagnose tracheomalcia forceps reduction of shoulder dislocation 2 incisions, in thyriodectomy & Subcostal incision in cholecystectomy Trendlenberg in surgery Test for VV position ( head down ) valve 2 operation in varicose vein & pulmonary embolism Examination in hip joint Waldeyers in surgery : waldeyers ring in neck waldeyers fascia between rectum and sacrum (delays direct spread of rectal carcinoma to sacrum) consistency of SNG? Firm when is it hard? In calcification, malignancy, reidls thyroiditis and tense cyst when is it cystic? In cystic degeneration, hge or suppuration whats berry s sign? It occurs due to biding of malignancy on carotid ( absent carotid pulse.((J-6FG ) as malignancy cant infiltrate carotid (there will be no signs of cerebral ischemia) complications of SNG: v imp What to be done preoperatively for any thyroidectomy? Routine preoperative investigation & ECG indirect laryngoscopy ( for medico legal purpose to be sure that that the recurrent laryngeal nerve was not already injured before operation ) 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. What are types of calcification in plain x-ray thyroid Linear: around nodules ('D7HD punctate : in papillary carcinoma FB7 patchy : in medullary carcinoma (74 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 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) Why manubruim is normally resonant on percussion? As trachea is behind it What does autoimmune thyroiditis mean? Antibodies acting on thyroid instead of TSH, so response of thyroid will be longer and stronger.  Which term is better thyrotoxicosis or hyperthyroidism? Thyrotoxicosis is better as some manifestation are due to autoimmune mechanism ( exophalmos & pretibial myxedema & thyroid acropathy & What are the complications of 2ry toxic goiter? The same as SNG + heart failure What is hashitoxicosis ? Thyroiditis & destruction of gland ( release of t3 & t4 Cause hyperthyroidism early only but after complete destruction of the gland( fibrosis ( hypothyroidism 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 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) What are the names of antibodies? LATS : long acting thyroid stimulators LATS -P : long acting thyroid stimulators protected What are the grades of toxic goiter according to tachycardia? Milde: 80 90 Moderate: 90- 110 Severa: >110 DONT diagnose toxic goiter if pulse is less than 80/min ECXEPT if under ttt. In metabolic manifestations of toxic goiter, there is recent intolerance to hot weather Where can you see tremors in thyrotoxic pt? %outstretched hands, %lightly closed upper eyelids %protruded unsupported tongue Sleeping pulse? While sleeping, or Sedated pulse, #G/I 'D9J'FG H'BJ3G Can pretibial myxedema be unilateral? No, it is always bilateral, and always associated with true exophthalmos (#5DG' immune) diarrhea with goiter? toxic goiter medullary carcinoma goiter with spleenomegally? toxic goiter lymphoma thyroid thyroid with LNS? thyroiditis lymphoma spread from carcinoma not related Why polyurea in toxic goiter? high metabolic rate glycosuria as thyroid hormone is diabetogenic high blood flow to kidneys Why isthmus should be removed in all thyroid operations? As recurrence will manifest early And when reccurence occurs? GJ(BJ 9F/G (DJG AJ 1B(*G (*7D9 H *F2D E9 'D(D9 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 Complications of thyroidectomy? Thyrotoxic crisis Convulsions give sedatives Fever ice pack Dyspnea oxygen Tachy cardia indral with monitor & ECG & give steroids Why after thyroid operations there may be change of voice Cocussion of nerve Tracheitis Laryngitis Vessels supplying parathyroid: inferior thyroid artery what will you do if you accidentally removed all parathyroid tissue ? Autotransplantaion in forearm muscles (it will take blood supply from the surrounding) what is the 1st symptom of hypothyroidism ? Personality changes keloid on thyrtoidectomy scar :- Why on sternum? A common place for development of keloid Why did the incision become on sternum? as patients 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? 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. Why? There are some explanations saying that hypothyroidism (after surgery) stimulates piutuitary. And Exophthalmos Producing Substance (EPS) is produced from anterior pituitary. What is malignant exophthalmos? It means it is progressive despite all lines of ttt. Eye signs other than exophthalmos: very important (dont forget to put your hands to stabilize patients head in all of them ) Difference between 1ry thyrotoxicosis and 2ry thyrotoxicosis? Revise table from book (10 points) Thyroid function tests: oral, specially radioactive iodine studies (v imp) 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) 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 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 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. In thyrtoidectomy for ttt of SNG & thyrotoxicosis, how much of the gland should be left in the body? According to the surgeons experience, but usually in SNG, 8 gm on each side, which is equal to distal phalynx of thumb. In toxic goiter, or 1/3 this amount is left Embryology of thyroid? Thyroglossal duct ! follicles, neural crest ! para-follicular cells (that produce calcitonin ! ! serum ca 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. Malignant neoplasms of thyroid are very important oral. 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. Why? Because before malignancy develops, it passes through a phase of hyperplasia of parafollicular cells, which secrete calcitonin. Medullary carcinoma is very imp oral How does medullary carcinoma produce diarrhea? By production of serotonin (5-hydroxytryptamine) or PGs What is the microscopic picture of medullary carcinoma? %Sheets of Neoplastic cells %in a hyaline sroma %hyaline stroma may contain amyloid material What is MEN? It is multiple endocrinal neoplasia syndrome 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 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. What is the 1st LN to be affected in thyroid carcinoma? Recurrent laryngeal node Then? Then pretracheal and prelaryngeal (Delphic), and to lower deep cervical LNS Which are more commonly affected, upper or lower deep cervical LNS? Lower 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) 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) How do we scan for recurrence of thyroid tumour after TOTAL thyroidectomy? Thyroglobulin, as it is only produced from thyroid and tumour cells. What would you like to give the patient post-thyroidectomy? L-thyroxine short of toxicity Why? as Replacement and for suppression of metastasis. What are the hormone dependant tumours? %breast %differentiated thyroid carcinoma Criteria inoperability? Extensive local spread Extensive lymphatic spread Blood spread Unfit patient. Prognosis of differentiated thyroid carcinoma? These factors increase the risk: in this order Age: males above 40 and females above 50 Sex: females have better prognosis T: %size (more than 5 sm) %microscopic picture (vascular or capsular invasion) %type N: presence of LN metastasis M: presence of distal metastasis. Thyroiditis: imp oral 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. Causes of chronic thyroiditis? TB and Syphilis Autoimmune thyroiditis = hashimoto s thyroiditis, investigations? Serum titres of antimicrosomal, antimitochondrial and antithyroglobulin antibodies. Reidles thyroiditis: probably a collagen disease, thyroid is hard (extensive fibrosis), differentiation from anaplastic carcinoma may need an open biopsy Which part will you remove for biopsy? a wedge of isthmus is removed Why? So that in addition to biopsy, trachea is relieved from obstruction. (remember, in all thyroid operations we remove isthmus, check Q 48) Thyrtoidectomy is v imp oral If trachea is injured during thyrtoidectomy, what will you do? Immediate suturing, with prolene 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)  SHAPE \* MERGEFORMAT  1. 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h<,h<,OJQJ_H ʝ˝@OPaoq̞͞؞ٞڞ±xlllll\h3)h\zCJOJQJZaJh\zCJOJQJaJ)h3)h\zB*CJOJQJ_H aJphh3)h\zCJOJQJaJ)h h\zB*CJOJQJ_H aJph h3)h\zCJOJQJ_H aJh\zCJOJQJ_H aJ%h3)h\zB*CJOJQJaJphh\zCJOJQJ_H aJh3)h\zCJOJQJaJٞ͞ڞ=\d\e\f\\]]] ^=^`^^^^g_h__`gd & F6gdxgd#-gd\z & F7gdx8^8gd\z & Fgdxڞ%&'\\?\c\d\ʻ{cSQ>S>S%h2gh\zB*CJOJQJaJphUh\zB*CJOJQJaJph/h5h\z5B*CJOJQJ\_H aJph h2gh\z>*B*OJQJphh2gh\zB*OJQJphh2gh\z5B*\_H phh h\z5B*\_H phh h\zB*OJQJph#h h\z5B*OJQJ\phh\zB*CJOJQJaJph%h h\zB*CJOJQJaJphPressure necrosis in case of rapidly growing benign neoplasm b) Infiltration of malignant neoplasm. 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 What is meant by Radical surgery? = Removal of 1ry tumor with safety margin + draining LN in one block Why Radical Mastectomy of Halsted isnt 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 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 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 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  SHAPE \* MERGEFORMAT  How to differentiate between thyroglossal cyst and subhyoid bursitis? Thyroglossal cyst: Rounded subhyoid bursa: oval with transverse axis 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 How to differentiate clinically between congenital and acquired branchial fistulae? AcquiredCongenitalAge of onset: adulthood on top of pre-existing cystSince birthSite: high in the neck at the cyst levelIn lower third of the neckTreatment: surgical excisionSurgical excision + step-ladder incision What is the only translucent neck swelling? Cystic hygroma 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 ) 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% 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 A patient presenting with bleeding tongue, how to manage such a case?! '.DJG J7D9 D3'FG D(1' H '*FJG 9DI '3F'FG 'DDI *-* H '6:7 (4'4 H 'HBA 'DF2JA 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, wilms tumor,  J9FI DH /.D* 9DI 'D-'D) /I EGE 'FC *3#D 'E 'D9J'F history - consanguinity 'F* H ,H2C B1'J( - Prenatal history './*I '/HJ) 'H -',G '+F'! 'D-ED - Similar conditions in the family -/ AI 'D9JD) 'H AI '.H'*G 9F/G 'D-C'J) /I! General examination H 9DJC (3 AI 'D 'FC *4HA '0' C'F AJG 'I associated anomaly specially CARDIAC local examination 'E' AI 'D 9DJC 'FC *91A 'D type (3 J9FI -3( 'D13E) - unilateral or bilateral - complete or incomplete - simple or complicated    SHAPE \* MERGEFORMAT  In clinical, ask in salivary sheet about associated dry mouth dry eye ( To exclude Mikulicz and sJogren's disease JA1- (JC 'HI DH BHD*DG 'D-*G /I 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 nodesGlandMultipleSingleCan be rolled on the edge of the mandibleCan't be rolledCan be felt only in neckFelt 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)  SHAPE \* MERGEFORMAT  Sebaceous cysts may occur any where except in ..?! In palms and soles (devoid of sebaceous glands) What are the types of dermoid cyst? Sequestration dermoid Tubulodermoid Inclusion dermoid Teratomatous dermoid Implantation dermoid 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) can lipoma cause death in a patient? Yes, in case of submucous lipomata if present in Larynx( suffocation Intestine ( intussusceptions ( intestinal obstruction When do we find LNS enlarged with basal cell carcinoma? - associated infection (any chronic non-specific infection) - baso-squamous cell carcinoma Is spontaneous cure possible in malignancy in skin? Yes, in case of '' lentigo'' which is the least aggressive type of melanomas 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)  SHAPE \* MERGEFORMAT  When will the patient have strangulation without intestinal obstruction? Richter's hernia Littre's hernia If the content is omentum What are complications of the truss? Inflammation of the hernial sac Adhesions within the sac Increased risk of the strangulations Improper fitting to truss 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 What is the hernia of nuck? It is oblique inguinal hernia in females Is skin the covering of all hernias? No, exomphlus is covered by peritoneum only that's why it is an emergency 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? SeminomateratomaNo hemorrhage and necrosisthere is Hemorrhage and necrosisfibrous septaNo 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? 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