Q. Why this is a lipoma?
A. Because it is a very slowly growing swelling
which is soft, pseudofluctuant with a slippery edge.
Q. Why the edge of the lipoma is slippery
?
A. Because it is present within a very loose
capsule so that pressure on one edge moves the swelling within the capsule.
Q. Why the lipoma is pseudofluctuant ?
A. Because the fat globules constituting
the lipoma are very soft in consistency.
Q. How do you elicit fluctuation in a very
small swelling ?
A. By Paget's test; the swelling is fixed
by the index and thumb of the left hand and pressure is applied on the
center of the swelling by the index of the right hand. If there is yeilding
in the center of the swelling, it is considered fluctuant.
Q. Why this is a subcutaneous and not a
subfascial lipoma ?
A. Because it is attached to the skin at
multiple sites while in subfascial lipoma the skin is not attached to the
swelling at all. Also, making the fascia tense does not make the swelling
smaller.
Q. How did you detect the skin attachment
?
A. There are two methods to detect skin attachment;
either by pinching or by gliding
Q. Mention the different sites of lipoma
?
A. 1. Subcutaneous lipoma
2. Subfascial lipoma,
3. Intermuscular lipoma
4. Intramuscular lipoma
5. Subperiosteal,
6. Subserous lipoma,
7. Extradural lipoma
8. Retroperitoneal lipoma
9. Subsynovial
10. Intraglandular
Q. Which site is famous for being precancerous
?
A. Retroperitoneal lipoma.
Q. What are the multiple skin swellings
?
A. 1. Multiple Lipomata
2. Multiple Sebaceous
Cysts
3. Multiple Naevi
4. Multiple Haemangiomata
5. Multiple Lymphangiomata
6. Multiple Neurofibromata
7. Multiple Papillomata
8. Multiple Warts
9. Multiple Keloids
10. Multiple Boils
11. Multiple Skin Metastases
Q. What is the commonest multiple skin
swelling ?
A. Multiple naevi.
Q. How do you treat this patient ?
A. The treatment of lipoma is usually conservative.
Excision is indicated if 1) cosmetically annoying the patient , 2) complicated,
3) painful, or 4) causing pressure on a surrounding structure.
Q. What are the complications of a lipoma
?
A. Pressure on a surrounding structure e.g.
a retroperitoneal lipoma compressing the ureters, hindering the movement
of a nearby joint, calcification, myxomatous degeneration, and very rarely
malignant transformation (liposarcoma).
Q. What is Dercum's disease ?
A. It is a painful lipoma, also called "adiposa
dolorosa".
Q. Why this is a haemangioma ?
A. Because it is a skin swelling dating since
birth (may be shortly after), it is pink in color and compressible.
Q. Why the haemangioma is compressible
?
A. Haemangioma consists of multiple blood-filled
vascular spaces. These spaces communicate with the surrounding veins. Haemangioma
is compressible because its contained blood empties into the veins communicating
with the haemangioma.
Q. What are the compressible swellings
you know ?
A. Haemangiomas, lymphangiomas, aneurysms,
pharyngeal pouch, saphena varix, varicocoele, pneumatocoele, laryngeocoele,
tracheocoele and hernias.
Q. What is the commonest site of a haemangioma
?
A. The head and neck region.
Q. Does it affect internal organs ?
A. Yes, for example the liver and spleen.
Q. What are the different types of haemangioma
you know ?
A. The different types of haemangioma are
:
1. Capillary Haemangioma :
Port wine stain, Strawberry angioma, Salmon patch, Spider naevi
2. Venous Haemangioma (Cavernous haemangioma)
3. Arterial Haemangioma (Circoid aneurysm)
Q. What is the commonest complication of
a haemangioma ?
A. Haemorrhage.
Q. What is the treatment of a cavernous
haemangioma ?
A. The different lines of treatment are :
1. Injection of a sclerosant material
2. Embolization injection
3. Surgical excision
4. Laser radiation
Q. As regards injection sclerotherapy,
what is the commonest material to be used ?
A. Ethanolamine oleate.
Q. What do you mean by embolization injection
?
A. That is the injection of some material
into the feeding artery of the haemangioma through angiography to produce
occlusion of this artery and so necrosis of the haemangioma.
Q. What are the famous materials to be
used in this regard ?
A. Gelfoam, alcohol foam and silicon particles.
Q. What is a hamartoma ?
A. A hamartoma is "a developmental tumour-like
malformation characterized by being formed of the same tissues particular
to the part of their origin and these tissues are arranged in a haphazard
fashion. It is also characterized by a rate of growth similar to the surrounding
structures".
Q. Mention the different types of hamartomas
you know ?
A.
1. Haemangiomas
2. Lymphangiomas
3. Neurofibromas
4. Benign naevi.
Q. What are the types of lymphangioma ?
A. There are two types :
1. Capillary lymphangioma (lymphangioma circumscriptum)
2. Cavernous lymphangioma (cystic hygroma)
Q. What is the commonest site of a cystic
hygroma ?
A. The neck.
Q. Is lymphangioma compressible or not
?
A. Lymphangioma is partially compressible.
Q. A cavernous lymphangioma in the neck
has a character that differentiates it from other neck cysts, what is this
character ?
A. It is the only translucent neck cyst.
Q. When does it become opaque ?
A. When it becomes infected
Q. What are the types of neurofibroma ?
A.1. Solitary neurofibroma
2. Generalized neurofibromatosis (von
Recklinghausen's disease of nerves)
3. Molluscum fibrosum
4. Plexiform neurofibroma (pachydermatocoele)
5. Elephantiasis neuromatosa
Q. Mention the types of benign pigmented
naevi (moles) ?
A. Benign pigmented naevi include the following
types :
1. Intradermal naevus
2. Junctional naevus
3. Compound naevus
4. Blue naevus
5. Juvenile naevus
6. Congenital giant naevus
7. Halo naevus
8. Spindle cell naevus
9. Naevus of Ota
10. Naevus of Spilus
11. Lentigo
Q. At what age do benign pigmented naevi
start to appear ?
A. They present in childhood and adolescence,
rarely they present at birth.
Q. What are the characteristic features
of congenital giant naevus ?
A. It is present since birth, may occupy
very large areas of the body, usually hairy, and what is more important
is that it is precancerous in about 15% of the cases.
Q. Why this is a hernia ?
A. Because 1) It is a swelling, 2) At the
anatomical site of a hernia, 3) Gives an impulse on cough, and
4) It is (or was) reducible on lying down and by the patient fingers.
Q. Why inguinal and not a femoral hernia
?
A. Because 1) the hernia is above the inguinal
ligament and not below it, and 2) the neck of the hernia is above and medial
to the pubic tubercle and because the hernia descends into the scrotum.
Q. Why oblique and not direct ?
A. Because 1) it descends into the scrotum,
2) On doing the internal ring test, there was no swelling to appear on
coughing, and 3) the patient is a young male.
Q. Describe how did you do the internal
ring test ?
A. After reduction of the hernia, the patient
is asked to stand while occluding the internal ring (by pressing the finger
1/2 an inch above the mid inguinal point), the patient is then asked to
cough, observing the appearance of any inguinal swelling.
Q. Why you did not do the external ring
test ?
A. Because it is painful.
Q. Can a direct hernia descend into the
scrotum ?
A. A direct hernia can reach the scrotum
very rarely.
Q. Where is the defect in oblique inguinal
hernia ?
A. In the internal ring.
Q. Where is the defect in direct inguinal
hernia ?
A. The posterior wall of the inguinal canal
(Hasselbach's triangle).
Q. What are the boundaries of Hasselbach's
triangle ?
A. Lateral border of the rectus abdominis
muscle medially, the inferior epigastric artery laterally and the inguinal
ligament inferiorly.
Q. What are the subdivisions of the Hasselbach's
triangle ?
A. Hasselbach's triangle is subdivided into
medial and lateral parts by means of the medial umbilical ligament.
Q. What are the common contents of a hernia
in general ?
A. Intestine, omentum and fluid.
Q. Mention the clinical types of oblique
inguinal hernias ?
A. 1) Bubonocoele, 2) Funicular type and
3) Scrotal (complete) type
Q. What are the causes of residual swelling
after reducing the hernia ?
A. 1) Sliding hernia , 2) incomplete reducibility
due to adhesions between the contents and the sac , 3) hydrocoele
of the hernial sac and 4) associated lipoma of the cord
Q. How would you clinically differentiate
between obstructed and strangulated hernias ?
A.
Q. What are the conditions that you may
find strangulation without obstruction ?
A. If the content of the hernia is one of
the following :
1. Omentum
2. Part of the circumference
of the intestinal lumen (Richter's hernia)
3. Michael's diverticulum
(Littre's hernia)
4. Fallopian tube &
ovary
5. Intestine, but there
is an associated mesenteric vascular occlusion
Q. What is the treatment of this case of
oblique inguinal hernia ?
A.
Q. What is the principle of operation for
O.I.H. in adults?
A. Excision of the sac + repair of the defect
Q. What are the principles of such repair
?
A. Repair of the defect is done either by
the local tissues (herniorrhaphy) or by adding a graft of tissue (hernioplasty).
The principles in both herniorrhaphy and
hernioplasty, in general, are the following ;
1. Narrowing the internal
ring,
2. Repair of the fascia
transversalis, and;
3. Reinforcement of the
posterior wall of the inguinal canal.
Q. What is the most popular type of repair
?
A. Bassini repair.
Q. What is its principle ?
A. Suturing the conjoined muscle to the inguinal
ligament.
Q. What are the causes of recurrence of
a hernia ?
A.
Q. What are the types of umbilical hernias
you know ?
A.
1. True umbilical hernias :
i) Congenital umbilical
hernia (exomphalos major and minor)
ii) Infantile umbilical
hernia (from weak umbilical cicatrix)
iii) Adult umbilical
hernia (from increased intrabdominal pressure)
2. Paraumilical hernias : due
to defect in linea alba close to umbilicus:
1) Supraumbilical
2) Infraumbilical
Q. Is it common for patients with PUH
to complain of dyspepsia ?
A. Yes.
Q. Why ?
A. Due to traction on the greater omentum
which is commonly the content of such a hernia.
Q. What is the commonest complication of
paraumbilical hernia ?
A. Irreducibility, due to marked adhesions
between the contents.
Q. What is the danger of such irreducibility
?
A. It predisposes to obstruction and strangulation.
Q. What is the treatment of this case ?
A. Herniorrhaphy.
Q. What type of repair do you do ?
A. It varies according to the size of the
defect as follows :
Q. What are the causes of incisional hernia
A. There are;
Q. Why this is varicocoele ?
A. Because there is an inguinoscrotal swelling
characterized by ;
* By inspection : Varicose veins are
seen just beneath the skin of the scrotum (bag of worm appearance)
* By palpation : There are multiple
soft, compressible swellings with impulse and thrill on cough. They decrease
in size on lying down and disappear on elevation of the scrotum.
Q. What is the definition of varicocoele
?
A. It is dilatation, elongation, and tortuosity
of the pampiniform plexus of veins.
Q. What are the types of varicocoele ?
A. Primary and secondary varicocoele.
Q. How does hypernephroma produce secondary
varicocoele ?
A. By extension of tumour thrombus into the
renal vein leading to obstruction of the testicular vein.
Q. On which side is 2ry varicocoele more
common and why ?
A. On the left side, because the left testicular
vein drains into the renal vein, while the right testicular vein drains
into the inferior vena cava. So, 2ry varicocoele on the left side occurs
when there is tumour thrombosis of the left renal vein, whereas on the
right side, thrombosis should extend to the IVC to occlude the right testicular
vein.
Q. Why 1ry varicocoele is more common on
the left side ?
A. Because of the following reasons :
Q. What are the different lines of treatment
of 1ry varicocoele ?
A. 1. Conservative treatment
for all cases.
2. Operative
treatment for some cases.
Q. What are the indications for surgery
in 1ry varicocoele ?
A. 1. Serious depression
of spermatic count (oligospermia).
2. Big painful
varicocoele.
3. Employment
and acceptance in military & police academies.
Q. Do you know the different approaches
for varicocoele ?
A. Yes, there are 4 approaches :
1. Scrotal
2. Inguinal
3. Pelvic (Palomo op.) 4. Laparoscopic
Q. What are the types of hydrocoele ?
A. 1. Congenital hydrocoele
2. Infantile hydrocoele
3. Vaginal hydrocoele
4. Encysted hydrocoele of the cord
5. Hydrocoele of the canal of Nuck
6. Hydrocoele of hernial sac
N.B. The so called diffuse hydrocoele
of the cord is one of the forms of chronic filarial funiculitis. It is
not a true hydrocoele but it is just a lymphoedema of the cord making it
soft gelatinous in consistency.
Q. What is vaginal hydrocoele ?
A. It is accumulation of serous fluid between
the two layers of the tunica vaginalis.
Q. What are its types ?
A. It is of two types :
Q. How did you know that it is a cystic
swelling ?
A. By doing the bipolar fluctuation test
; One hand's fingers are placed around the neck of the scrotum, and the
other hand's fingers hold the bottom of the swelling. The latter squeezes
the swelling where an impulse is perceived by the other hand's fingers
at the top of the swelling.
Q. What are the values of transillumination
in hydrocoele ?
A. It differentiates between hydrocoele which
is translucent and other opaque cysts. It also localizes the testis in
case of vaginal hydrocoele.
Q. What is the value of localizing the
site of the testis in hydrocoele ?
A. To avoid its injury if aspiration is done.
The shape and size of the testis also could be assessed
Q. How can you detect secondary vaginal
hydrocoele ?
A. By pinching the tunica vaginalis.
Q. What are the other intrascrotal cysts
you know ?
A. Spermatocoele, Pyocoele, Acute heamatocoele,
Encysted hydrocoele of the cord, Cystic teratoma, Breaking down gumma,
Cysts of embryonic remnants of the epidedymis.
Q. What is spermatocoele ?
A. It is a retention cyst situated in the
head of the epidedymis due to obstruction of the vasa efferentia.
Q. What do you mean by transillumination
is opalescent in spermatocoele ?
A. This word means that the cyst is a midway
between translucent and opaque.
Q. How can you explain this type of transillumination
in spermatocoele ?
A. It is due to its content of sperms.
Q. What are the complications of hydrocoele
?
A. complications of hydrocoele include :
Q. What are the operations you know for
1ry vaginal hydrocoele ?
A. 1. Excision of the tunica (if very
large, thickened or calcified)
2. Evertion of the tunica
(if not large, thickened or calcified)
3. Lord's operation (if
not large, thickened or calcified)
Q. What are the complications of aspiration
?
A. 1. Recurrence (100%).
2. Infection.
3. Haemorrhage.
4. Puncture of the testis.
Q. What is your diagnosis ?
A. Simple nodular goitre.
Q. Why this is a goitre ?
A. Because there is a swelling in the lower
part of the front of the neck which is the anatomical site of the
thyroid gland, having the shape of the thyroid gland (butterfly) and this
swelling moves up and down with deglutition.
Q Why does a goitre move up and down with
deglutition ?
A. Because the thyroid gland is enclosed
within the pretracheal fascia which is attached to the thyroid cartilage
and hyoid bones.
Q. Mention other swellings that move up
and down with deglutition.
A. Subhyoid bursitis, prelaryngeal L.Ns.,
thyroglossal cyst, ectopic thyroid gland, pretracheal L.N., cold abscess
of the larynx, parathyroid gland tumours, laryngocoele and tracheocoele.
Q. When doesn't the goitre move up and
down with deglutition ?
A. In 1) Huge goitre, 2) Malignant goitre
and 3) Retrosternal goitre.
Q Why this is a simple goitre ?
A. Because there are no manifestations suggestive
of thyrotoxicosis, no manifestations suggestive of malignancy and no manifestations
suggestive of inflammation.
Q. What are the manifestations suspicious
of malignancy in a goitre ?
A.
Q. How do you elicit fixity to the sternomastoid
?
A. By asking the patient to swallow while
pinching the relaxed sternomastoid, normally I do not feel something pulling
on the sternomastoid between my fingers.
Q. Can the cervical L.Ns. develop secondaries
from a thyroid carcinoma while the 1ry is not felt clinically ?
A. Yes, in occult papillary carcinoma of
the thyroid gland. This was thought in the past as some form of ectopic
thyroid gland and was called "lateral aberrant thyroid".
Q. What are the manifestations suspicious
of an inflammatory goitre ?
A.
Q. What are the causes of iodine deficiency
?
A.
Q. What is Pendred's syndrome ?
A. This is a cretinoid goitre associated
with deafness.
Q. What is the cause of this goitre ?
A. Congenital deficiency of peroxidase enzyme.
Q. What are the types of simple goitre
?
A. 1. Simple diffuse goitre (Physiological
goitre)
2. Simple nodular goitre (S.N.G.).
Q. Which of them is reversible ?
A. Physiological goitre can be reversible
if the cause of iodine defeciency is eliminated.
Q. What are the complications of simple
nodular goitre ?
A. 1) Pressure on surrounding structures
(dyspnoea and dysphagia), 2) Disfigurement, 3) 2ry toxic goitre (30%),
4) Haemorrhage in a cyst, and 5) Malignant transformation (1/2%), {Follicular
Type}.
Q. How does a patient with a haemorrhage
in a cyst present ?
A. Sudden onset of dyspnoea.
Q. What is the cause of dyspnoea in such
cases ?
A. Sudden enlargement of the gland and more
important is the reflex spasm of the pretracheal muscles.
Q. How do you manage such a patient ?
A. Emergency needle aspiration.
Q. What investigations do you want to do
for this patient with a goitre ?
A. In addition to the routine laboratory
investigations, we do thyroid function tests.
Q. What are the complications of subtotal
thyroidectomy for S.N.G.?
A. Complication of subtotal thyroidectomy
for S.N.G. include :
Q. How do you treat it ?
A. First, urgently, while the patient is
in bed, the sutures are cut to relieve the tension and the patient is taken
to the theatre to deal with the bleeder.
Q. What are the causes of dyspnoea after
thyroidectomy ?
A. 1) Tension haematoma, 2) Laryngeal oedema
due to rough manipulations during the operation, 3) Bilateral recurrent
laryngeal nerve injury, and 4) Tracheomalacia (very rare).
Q. What are the effects of RLN injury ?
A.
&Unilateral RLN injury ------------->
hoarseness of voice which is improved by time due to compensatory crossing
of the contralateral cord to the other side.
&Bilateral RLN injury ------------->
Suffocation which should be treated at once by emergency tracheostomy.
Q. What is the effect of external laryngeal
nerve injury ?
A. Loss of high pitched voice due to paralysis
of cricothyroid muscle..
Q. Why this is a goitre ?
A. Because there is a swelling in the lower
part of the front of the neck which is the anatomical site of the thyroid
gland, having the shape of the thyroid gland (butterfly) and this swelling
moves up and down with deglutition.
Q. Why it is toxic ?
A. Because the patient has manifestations
of thyrotoxicosis in the form of:
Q. What is the pathogenesis of each of
these eye signs ?
A.
# Infrequent blinking, apparent rim of sclera
above the cornea, lid lag and apparent exophthalmos are all due to upper
eyelid retraction which is caused by spasm of MullerÕs muscle (thyroxine
makes this muscle oversenstised to the effect of circulating catecholamines).
# Absence of forehead corrugation is caused
by true exophthalmos.
# Absence of convergence on looking to a
near object is due to paresis of the medial recti.
# True exophthalmos is due to exophthalmos
producing substance which causes deposition of oedema fluid and round cell
infiltration in the retro-orbital space.
Q. How to differentiate between true &
apparent exophthalmos ?
A. By 1) Naffziger's test; 2) Frazer's test;
3) Ruler test
(See clinical notes for details of these tests)
Q. Define hyperthyroidism and thyrotoxicosis.
A. Hyperthyroidism is the term referred to
the manifestations caused by the increased level of circulating thyroid
hormones. Thyrotoxicosis is a syndrome consisting of
manifestations caused by the increased level of circulating thyroid hormones
as well as others that are not due to increased level of circulating thyroid
hormones (Exophthalmos and Pretibial myxoedema).
Q. What are the types of toxic goitre ?
A. There are three types
1) Toxic diffuse goitre (1ry toxic
goitre) (Grave's disease)
2) Toxic nodular goitre (2ry toxic
goitre) (Plummer's disease)
3) Toxic nodule.
Q. Are there other causes of thyrotoxicosis
?
A. Yes. the following are rare causes of
thyrotoxicosis :
1. Thyrotoxicosis factitia : Due to
intake of thyroxine (e.g. for weight reduction)
2. Infantile thyrotoxicosis : A baby
born to a thyrotoxic mother
3. Jod Basedow disease : Due to high
intake of iodides in a colloid goitre
4. De Quervain thyroiditis (in some
cases)
5. Hashimoto thyroiditis (in early
cases)
6. Some tumours secrete thyroxine
e.g. struma ovarii.
Q. How do you treat a case of toxic nodular
goitre (2ry toxic goitre) ?
A. Subtotal thyroidectomy.
Q. How would you prepare a case of toxic
goitre for operation ?
A. 1. Antithyroid drugs e.g.
Neomercazole until the patient is euthyroid,
2. Propranolol (Inderal)
for regulation of heart rate,
3. Lugol's Iodine
Q. When do you contraindicate antithyroid
drugs in preop. preparation ?
A. In retrosternal goitre.
Q. Why ?
A. Because antithyroid drugs cause enlargement
of the thyroid gland which may lead to mediastinal syndrome.
Q. What is Lugol's iodine ?
A. It is 5% iodine and 10% KI in water.
Q. What is its mechanism of its action
?
A. 1) Inhibition of protease enzyme which
releases thyroid hormones from thyroglobulin,
2) Inhibition of organic iodine formation,
3) Prevention of the stimulant effect of
TSH on adenyl cyclase enzyme.
Q. What is the principle of subtotal thyroidectomy
in toxic goitre ?
A. Subtotal Thyroidectomy = Removal of both
lobes + Isthmus, Leaving postero-medial part of the lobes on each side
to protect the recurrent laryngeal nerve and parathyroid glands.
Q. What are the complications of subtotal
thyroidectomy for toxic goitre ?
A. 1. Tension haematoma (due to slipped ligature
from the superior thyroid artery).
2. Dyspnoea.
3. Injury to the related nerves : i) recurrent
laryngeal nerve, and ii) external laryngeal nerve .
4. Thyrotoxic crisis.
5. Hypoparathyroidism (due to accidental
removal of the parathyroid glands).
6. Hypothyroidism in 20-30% (if the gland
was removed near totally).
7. Recurrent thyrotoxicosis in 5-10% (If
no adequate excision is done).
Q. What is thyrotoxic crisis ?
A. It is an acute exacerbation of hyperthyroidism.
It occurs if the patient is not adequately prepared for thyroidectomy.
Q. What are the manifestations of thyrotoxic
crisis ?
A. Hyperpyrexia, restlessness, severe tachycardia,
and dehydration.
Q. Is it a dangerous condition ?
A. Yes it is. Severe tachycardia may lead
to heart failure and hyperpyrexia may lead to brain damage.
Q.What are the indications of antithyroid
drugs in toxic nodular goitre ?
A.
Q. How do you treat a case of toxic nodule
?
A. Surgery (hemithyroidectomy) is the main
line of treatment. Medical treatment is indicated in preoperative preparation,
in young patients and in patients refusing surgery or unfit for surgery.
Radio-iodine can be given to patients over 45 years as an alternative to
surgery.
Q. What is the mechanism of action of radioactive
iodine in the treatment of toxic goitre ?
A. Radioactive iodine emits beta rays which
destroys the thyroid cells without affecting much the surrounding tissue
due to their low penetrability.
Q. What type of radioactive iodine is given
in the treatment of toxic goitre ?
A. I 131.
Q. Why I131 and not I123 ?
A. Because I131 can emit beta rays while
I123 can emit only gamma rays which are ineffective.
Q. What is the dose of radioactive iodine
in treatment of toxic goitre ?
A. 10 uCi (10 micro Curi).
Q. What are the disadvantages of radioactive
iodine ?
A. 1. Isotope facilities must be present.
2. Indefinite follow up is essential.
3. Thyroid insufficiency in 80% after 10
years.
4. Recurrence of toxicity if low dose is
given.
5. Risk of inducing carcinoma in adults if
given in childhood or adolescence (that is why it is not given for patients
below 45 years).
6. Risk of hypothyroidism and foetal anomalies
if given in pregnancy.
Q. What are the contraindications to radio-iodine
?
A. 1. During pregnancy (risk of foetal anomalies
and foetal hypothyroidsm).
2. During lactation (risk of hypothyroidsm
to the baby).
3. Young age (risk of inducing thyroid
carcinoma).
4. Toxic nodular goitre (ineffective).
5. Iodine allergy.
Q. What is the advantage of radio-iodine
in a case of toxic nodule ?
A. No, because the thyroid tissue surrounding
the toxic nodule is suppressed and so will not uptake iodine.
Q. Why did you diagnose it non specific
ulcer ?
A. Because it has the following characters
(in addition to a history of severe trauma) :
Q. What is the aetiology of this type of
ulcers ?
A. It is caused by wounds, burns, corrosives,
radiation or traumatic gangrene including bedsore (decubitus ulcer), plaster
sores and direct crushes.
Q. Why this type of ulcer has the tendency
to become chronic ?
A. It becomes chronic being maintained by
repeated trauma, pyogenic infection and poor blood supply from congestion
caused by long sitting or standing.
Q. What is indolent ulcer ?
A. In very chronic ulcers with excess fibrosis
base and edge become hard (callous) and such an ulcer resists healing and
is called indolent ulcer.
Q. What are the investigations required
in this case ?
A. Plain X ray tibia to show any bony involvement,
culture and sensitivity to give the specific antibiotic, Biopsy from the
edge to confirm the diagnosis. This is in addition to the routine investigations.
Q. What is the treatment of this case
?
A.
1. Conservative treatment : This is indicated
in small ulcers, provided that they are not indolent. (i.e. not callous).
Conservative treatment includes : rest, elevation of foot, avoid long sitting
or standing, frequent dressings, pressure bandage, and antibiotics if indicated
(according to culture and sensetivity).
2. Surgery : It is indicated in 1) large
ulcers, 2) indolent ulcers. Surgery includes excision of the ulcer
and covering the defect by a skin flap.
Q. Why do you prefer a skin flap as the
method of coverage ?
A. Because skin grafts in the leg have the
tendency to re-ulcerate (venous congestion, poor blood supply, frequent
traumata,...)
Q. What are the characters of venous ulcer
?
A. Over the medial malleolus; surrounded
by pigmentation, dermatitis, scaly skin and leg oedema; sloping edge; floor
shows healthy or unhealthy granulations which may be raised, flat or below
surface; indurated base, and serous or pus discharge.
Q. What is the aetiology of this type of
ulcers ?
A. It is caused by 1ry or 2ry varicose veins
but more commonly with 2ry V.V (in postphlebitic limbs following D.V.T.).
Q. What are the trophic ulcers ?
A. These are ulcers due to impaired nutrition
of the skin. They include both ischaemic ulcers and neurotrophic ulcers.
Q. What is chronic osteomyelitis ulcer
?
A. It Develops at outer opening of osteomyelitis
sinuses. There are multiple sinuses discharging sequestra.
Q. What are the malignant ulcers that can
develop in the leg ?
A. Malignant leg ulcers include :
Q. What is your diagnosis ?
A. Unilateral incomplete simple cleft lip
not associated with cleft palate.
Q. What do you mean by incomplete ?
A. The cleft is not reaching the nostril
floor.
Q. What do you mean by simple ?
A. There is no associated cleft of the alveolar
margin.
Q. Did you hear about cleft lower lip ?
A. It is an extremely rare anomaly it is
characterized by being median in position.
Q. What are the types of cleft palate you
know ?
A. Cleft uvula, cleft soft palate, incomplete
cleft palate (Cleft soft and hard palate not reaching the alveolar margin),
Complete cleft palate. Incomplete and complete cleft palate could be unilateral
or bilateral.
Q. What do you mean by uni or bilateral
cleft palate ?
A. It depends on whether the mouth cavity
is communicating with one or the two nasal cavities.
Q. When do you repair cleft lip ?
A. At about the age of 3 months.
Q. Why this age specifically ?
A. It is preferred not to do the operation
before this age because at that age the Hb% is almost 10 gm% and the weight
of the child is almost 10 bounds and this is optimum and safe for anasthesia
(in other words, the operation before this age is rather risky).
On the other hand, the operation is preferred
not to be delayed after that age for the following reasons : 1) for the
proper development of teeth, 2) for psychological relief of the parents'
worry about their child and 3) for proper suckling (although the role played
by the lip in suckling is not that considerable if compared with that of
the palate).
Q. What is the principle of any operation
described for the repair of cleft lip ?
A. The principles for any repair of cleft
lip are :
1. To bypass the defect : by suturing
the muscles, skin and mucous membrane (3 layer closure)
2. To lengthen the lip : by interpositioning
of flaps from both sides adjusting all esthetic points.
Q. What is the commonest operation for
the repair cleft lip ?
A. Millard repair.
Q. Why not to do freshening and direct
suture without the need to do rotation and advancement flaps ?
A. This direct suture would produce what
is called "a lip notch" because of the shortening of the lip at the edges
of the cleft.
Q. What are the complications of cleft
palate ?
A. 1) Malnutrition due to improper suckling.
2) Repeated chest infection due to aspiration
from regurgitated food and water
3) Speech abnormalities
4) Otitis media due to Eustachean tube obstruction
by oedema around its mouth.
Q. What is the cause of improper suckling
in cleft palate ?
A. Failure to create an intraoral negative
pressure.
Q. What are the speech abnormalities encountered
in cleft palate ?
A. 1) Nasal tone of speech (Rhinolalia) and
2) Inability to pronounce some syllables like K, L, Q.
Q. At what age do you prefer to repair
cleft palate ?
A. The repair of the most anterior palate
can be done during the same operation of repair of the cleft lip, while
the remaining posterior palate is repaired at about the age of 11/2 to
2 years.
Q. Is it preferred to postpone the operation
after the age of 2 years ?
A. No, because the speech abnormalities of
the cleft palate become irreversible (Imprinted in the brain).
Q. So, you mean if the patient presents
to you at a later age, you do not recommend to do the operation ?
A. No, the operation is still recommended
as it would prevent nasal regurgitation and might improve the nasal tone
of speech.
Q. What is your diagnosis ?
A. Distal shaft hypospadias.
Q. What other types of hypospadias do you
know ?
A. Glandular, coronal, midpenile, posterior
penile, penoscrotal, scrotal and perineal hypospadias.
Q. What are other deformities that can
be seen in the penis ?
A. 1) The prepuce is incomplete on the ventral
aspect, being represented as a dorsal hood,
2) Chordee may be present especially
in the posterior types.
3) There may be meatal stenosis.
4) The penis may be smaller in size
(microphalus)
5) May be deviation of the median raphe.
Q. What are the associated anomalies that
can be seen in the testis and scrotum ?
A. 1) Incompletely descended
testis.
2) Split scrotum.
Q. What is chordee ?
A. It is the ventral curvature of the penis
on erection.
Q. What is the principle of treatment of
hypospadias ?
A. Two things : 1) To correct (to release)
the chordee (if present) by excision of the fibrous tissue causing this
chordee. 2) To replace the missing urethra (urethroplasty)
Q. When do you prefer to repair hypospadias
?
A. Before school age, between 4 to 5 years.
Q. Why this age in particular ?
A. The repair is better not to be delayed
after the age of school because the child develops psychological disturbances
if he was admitted to school while he has hypospadias. On the other hand,
before this time, the penis is not that developed to allow the operation
to be done easily.
Q. How do you explain the psychological
disturbances in hypospadias in school age children ?
A. Due to the abnormal direction of the stream
of urine, the child sprays urine on his clothes which makes him feels guilty
and shy.
Dear Student,
Now it is your turn to ask me about what
is wondering you !!! and I am going to answer. The following are questions
frequently asked by the students and provided are their proper answers.
Q. How should I appear in the oral exams
?
A. You should appear gentle, polite, properly
dressed, confident.
Q. How should I talk ?
A. You should talk clearly, slowly and concisely.
DO NOT RUSH TO THE ANSWER, think for a while (few seconds) before you begin
to answer the question. Also, do not move your hands describing what you
are saying.
Q. How should I listen to the professor's
question ?
A. You should be listening carefully,
looking interested in what he is saying and NEVER INTERRUPT HIM/HER.
Q. How should I behave to the examiner
?
A. You should be stable, polite, do not smile
too much, do not look miserable, do not be too friendly with the examiner,
and NEVER SAY JOKES.
Q. What to do if I cannot understand the
question mentioned by the examiner ?
A. Say "Sorry Sir, I could not understand
this question ".
Q. What to do if I have not the answer
in mind ?
A. Say "Sorry Sir, I do not know the answer
of this question". NEVER EVER SUGGEST AN ANSWER, otherwise you may be trapped
!!!!!
Q. What to do if I said an answer and the
professor considered it incorrect although I can see it correct ?
A. This situation is very rare. Examiners
ask you simple direct questions with basic standard answers. Examiners
know better than you. So, NEVER ARGUE WITH THE EXAMINER.
Q. What are the statements that the examiners
do not like to hear ?
A. Examiners hate to hear excuses of your
lack of the answers, your repetition of the questions before you answer,
saying irrelevant answers and saying jokes.
Q. Are there some attitudes that examiners
do not like ?
A. Yes, the examiner might get mad at you
if you try to deceive him (like saying an irrelevant answer), if you lie
(like saying something that is clearly not present in the patient), if
you try to look overconfident (like showing that you know better than the
examiner) and if you try to make jokes.
Q. What are the materials and instruments
that I should have with me in the clinical exam. ?
A. These include :
1. STETHOSCOPE
2. SPHYGMOMANOMETER
2. THERMOMETER
4. MEASURING TAPE
5. METAL RULER
6. WOODEN TONGUE DEPRESSOR
7. GLOVES
8. SKIN MARKER
9. POCKET TORCH
10. MAGNIFYING LENS
11. TENDON HAMMER
12. PINS
13. TOURNIQUET OR GAUZE
BANDAGE
Q. What is the time allowed for me in the
clinical exam to make the clinical sheet ?
A. You are going to have 20-30 minutes in
the long case exam and 10-15 minutes in the short case exam.
Q. Isn't that a short time ?
A. Absolutely not, you will find it more
than enough. Do not be afraid of this time factor.
Q. Do you have some advises for me in making
the sheet ?
A. Sit or stand on the right side of the
patient. Do not sit on the patient's bed !!!!!. Do not take much time in
the history taking, concentrate on the examination. Do not write down every
word the patient says. You can keep some information in mind to write them
later after finishing the sheet. You will have a time lapse between taking
the sheet and getting examined,. So, do not waste your time writing every
bit besides the patient. Lastly, Your sheet should be well organized.
Q. What is the usual first question said
by the examiner ?
A. The examiner either asks you to read the
sheet or goes directly to "what is your diagnosis ?".
Q. Do many examiners ask the students to
show how they did examined the patient ?
A. Yes, and you should be ready for that.
Q. What do I do if the examiner got mad
at me due to any mistake done by me ?
A. DO NOT PANIC. Be confident and calm. Some
examiners may do this to test your self confidence.
Q. My exam is going to be after few months,
what do you advise me to do nowadays ?
A. SHEETS......SHEETS....SHEETS. Go and do
some sheets to get trained. Every day after finishing your classes, go
to the wards and select some patient and make an elaborate written sheet.
Then, discuss the sheet with the resident or any of the staff members at
that section. You will find all of them helpful. If you do not find one
having time to help you, come to me and you are always welcome.