OSCE Exam revision 2022 – Collaborative work of Class 190 KA

V6

1-Lipoma :
a- Types: Sub cutaneous, sub mucous,
subserous, sub fascial, intermuscular , intra
muscular , sub periosteal , extradural ,
retroperitoneal , sub-synovial , intraglandular

b- Complications: Cosmetic, pressure on

surrounding, calcifications, Myxoid
degeneration, Malignant transformation , Pressure on spinal cord,
extradural: paraplegia, submucous lipoma cause IO and stridor

c- Special sign: Pseudo-fluctuant-Slippery edge

d- Type that might turn malignant: Retroperitoneal 99% will turn malignant (Liposarcoma)
& deep types affecting the limbs
e- Two lines of ttt: excision by enucleation and conservative

2-Hydrocele :
Types:
-Hydrocele of tunica vaginalis :
Congenital/Infantile/vaginal(1ry or 2ry)
- Hydrocele of spermatic cord: Encysted hydrocele
- Hydrocele of hernia sac

Mention one test & interpretation:

- Test: transillumination test
- Interpretation: translucent

Identify clinically: translucent, cystic swelling at the

neck of the scrotum: Inspection: Swelling in one scrotal compartment, Palpation: non
tender cystic translucent purely scrotal swelling

Confirm test that is purely scrotal: By grasping the neck of the scrotum by two fingers
thumb in front and index finger behind the neck, If the swelling is completely below the
fingers: purely Scrotal

Mention test to confirm consistency: bipolar test

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Investigation of choice: Scrotal duplex (scrotal US)

Complications: Infection / Hge / Rupture / Huge expansion of scrotum leading to
indrawing of penis and may interfere with micturition and intercourse

ttt: For congenital Hydrocele: trans-fixation of the sac at the level of internal ring by
inguinal approach.

Ttt of vaginal hydrocele || Names of operations: Eversion of tunica / Excision of tunica

vaginalis for large or thick walled / Lord Operation - Aspiration is not recommended
2 surgical techniques in ttt of vaginal hydrocele: Lord operation (Plication) or excision
of tunica vaginalis for hydrocele

3- Thyroglossal Fistula:
a- Special sign: Fistula: The opening is crescent in shape and the
Tract can be palpated
If cyst : Swelling Moves up and down with deglutition and
with protrusion of tongue

b- Investigations: Neck US , If infected : CBC , CRP ESR , Culture

and sensitivity of discharge

c- Cause: It is an Acquired fistula Caused by Infection of cyst

leading to rupture or Inadequate removal of cyst.
Thyroglossal cyst: Is a Tubulo dermoid cyst due to persistence of
thyroglossal Duct leading to cyst formation

d- ttt : Antibiotics and Analgesics, once the infection subsides:

Sistrunk operation: Remove the fistula, Central part of hyoid bone,
part of the base of the tongue (foramen cecum), pyramidal lobe of
thyroid.

3.1- Thyroglossal cyst:

Congenital etiology: Is a Tubulo dermoid cyst due to persistence of thyroglossal
Duct remnant leading to cyst formation
Special clinical sign: Swelling Moves up and down with deglutition and with
protrusion of tongue

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Definitive treatment: Sistrunk operation

2 complications:
Infection- thyroglossal fistula

4-Breast cancer:
a- Triple assessment : Comparing the results of 1-Clinical examination: History
and Examination , 2-Soft tissue mammography and US , 3- True cut biopsy If
the 3 parameters are concordant the surgeon can rely on diagnosis , If 3
parameters not concordant then further inv eg. Excisional biopsy is needed
b- Skin lesions in Malignancy: 1-Nipple Retraction 2-Areola : Eroded in pagets 3-
Skin proper: Dimpling/Tethering/puckering/Cancer en cuirasse/skin ulcers/Peu
d’orange 4-others: Sister joseph nodule , Brawny edema (Lymphedema of UL)
c- 2 lymphatic groups affected: 1-Axillary LNS (75%): Ant , Post , Lateral , Medial(Central)
Apical group 2-Internal Mammary LNS 3-Post intercostal 4-Ocassional LNs:
Interpectoral LN Of Rottor , Supra clav LNs
d- 2 immunobiological markers: ER , PR , HER2/neu
e- 2 types of breast cancer: ductal carcinoma in situ – invasive duct carcinoma –
medullary carcinoma
f- What is meant by sentinel lymph node: 1st LN in axilla to be affected by
metastases
g- Value of sentinel lymph node: avoid axillary dissection in node negative
patients → ↓ lymphedema
h- What is meant by T2 N1 M0:
- T2: 2-5 cm diameter of the tumor
- N1: Mobile palpable homolateral axillary lymph nodes
- M0: no distant metastasis

5-Varicocele :
a- Types : Primary and Secondary
b- Causes: 1ry:Etiology in unknown but in young adults 15-30 years
more in pt with congenital mesenchymal weakness /
2ry:Obstruction of venous flow in spermatic vein by an abdominal
tumor usually RCC or Due to retroperitoneal tumors or
retroperitoneal Fibrosis
c- Which side more common and Why? Left side , Bec : 1-Rt angle
termination of left spermatic vein in left renal vein 2-Lower
position of left testis 3-Compression of Lt spermatic vein by heavy
loaded pelvic colon 4-Left suprarenal vein secretes adrenaline near
the mouth of Lt suprarenal vein

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d- 3 Approachs in open surgery:

⁃ Retroperitoneal (Palomo’s Operation): Ligation and division of
testicular vein Retroperitoneal
⁃ Inguinal: Ligation of pampiniform plexus in the inguinal canal +
Excision of the vein to avoid recanalization
⁃ Scrotal (not done anymore dt injury of sympathetic fibers around the
pampiniform plexus —> testicular atrophy): Ligation of pampiniform
plexus high in the scrotum
e- Indications of surgery:
⁃ if sub-fertility after exclusion of all causes of infertility
⁃ Large and Painful varicocele

6- 2ry intention
A-Causes of non healing:
General factors:
• Poor nutritional status
• Old age
• Debilitating disease: DM/ malignancy
• Drug intake: steroids, chemotherapy
Local factors:
• Wound infection
• Ischemic edges
• Irradiation
• Sutures under tension
• Presence of Foreign bodies
B-Complications:
• Wound failure
• Surgical site infection
• Stretching of the scar
• Hypertrophic scar
• Keloid formation
• Wound contracture

7- tracheostomy
A-indications:
• upper airway obstruction
• Laryngomalacia
• Meningitis/encephalitis
• Neuro:GB$

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• Sub glottic stenosis

• Head injury

B- complications:
•bleeding
•pneumothorax
•stomal infection
•displacement
•tracheal stenosis

8- Ape hand deformity:

A- Nerve affected: Median nerve

B-sensory area affected:

lateral 2/3 of the palm, lateral 3 and half fingers.
C-mechanism:
inability to abduct or oppose the thumb + thenar wasting due to
Paralysis of abductor pollicis + 2 lateral lumbricals +thenar muscles

D-special test:
• Tinel - phalen test-loss of opposition

9- olecranon bursitis
A-Other sites:
•prepatellar
•infrapatellar
•semimembranosua bursa

B-complication:
Infection
Rupture
Increase in size

C-special sign:
Cystic swelling
Pagets test
Trans illumination

10- incisional hernia:

A- causes:

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Preop:
• Weak muscles
• Obesity
• Chronic cough
• Debilitating disease
Operative:
• Muscle cutting incisions
• Rough surgical technique
• Use of absorbable sutures
• FB or drainage tube through wound
Post operative:
• SSI
• Wound hematoma
• Persistent ppf

B-ttt:
• ttt of ppf
• Herniorrhaphy
• Mesh hernioplasty

11-Ingrowing toe nail:

Conservative ttt:
• Gauze soaked in anti-septic to separate nail from nail bed
• Correct trimming (square trimming)
• Avoid tight shoes
• Keep foot clean & dry
Surgical ttt:
• Definitive TTT: WEDGE EXCISION (if failed conservative TTT/ if suppurated)
• Excision of germinal matrix
• If heavily infected: left to heal by 2ry intention
Essential operative step to prevent recurrence: Wedge (segmental) excision of the
germinal matrix
Cause of the condition:
• Faulty nail trimming: Oblique trimming of the nail sides may leave behind a sharp spike
that starts the condition.
• Wearing tight shoes

12 - varicose veins
Types: 1ry varicose veins (85%) + Secondary varicose veins (15%)

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2 tests: SCHWARTZ test, CHERVIER test, Morrissey's test

Trendelenburg test, Multiple tourniquets, Perth’s test, Modified
Perth’s test
Why more on left side:
- due to crossing of right common iliac artery to left common
iliac vein).

Its surgical ttt: Trendelenburg operation or stripping

- If sapheno-femoral junction: Trendelenburg operation
- If above knee: Triple ligation of perforators
- If all perforators: subcutaneous stripping
When to do surgery:
• Large primary V.V
• Complicated cases
• Pain as main complaint
2 complications:
- Superficial thrombophlebitis
- Venous ulcer
-Non invasive standard investigation: Duplex ultrasound
Predisposing factors:
1ry:
- Congenital mesenchymal weakness
- Congenital valvular incompetence
- Aggrevating factors: female, high parity, marked obesity, prolonged standing, OCP, +ve
FH
2ry:
- DVT: M/C cause
- AV fistula
- Aneurysm
- Buerger disease
- Pelvic tumors, pregnancy
Clinical signs:
- Multiple dilated tortuous vein along
- long short saphenous veins
- Blow out at site of perforator
- Saphena varix
- Thrill on cough at incompetent sapheno-femoral junction
- Dilated, elongated, tortuous, soft, compressible tubules

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13- Parotid swelling: Hx; painless lobulated slowly growing swelling over 2
months.
Why: Solitary swelling in the anatomical site of the parotid gland
and it’s raising the ear lobule
DD: parotid gland swelling and pre auricular LN swelling. Other
causes : sebaceous cyst/ abscess/hematoma/ lipoma/
neurofibroma/ lymphoma/ metastatic carcinoma/ masseter muscle
hypertrophy.

Most probable diagnosis: Parotid tumor; pleomorphic adenoma

Most common salivary tumor: pleomorphic adenoma,
Most common malignant salivary tumor: Mucoepidermoid
carcinoma
Benign tumors: pleomorphic adenoma, Adenolymphoma
Malignant tumors: Mucoepidermoid carcinoma, Adenoid cystic carcinoma

Investigations: CBC/ US/ X-ray/ sialogram

Most common cause: viral infection like mumps then bacterial infections causing sialadenitis
(S.aureus)

Surface anatomy:
• Gland: 4 points: center of masseter, tragus, mastoid process,2 cm below and behind
angle of mandible
• Duct: middle third of line from tragus to point to ala of the nose and angle of the mouth
Name of duct: Stensen's duct
Site of duct opening: opposite upper 2nd molar
Facial nerve branches: nervus intermedius/ greater superficial petrosal/ chorda tympani + the
terminal branches : temporal, zygomatic, buccal, marginal mandibular, and cervical.

Clinical evidence of diagnosis:

-Clinical evidence of diagnosis if it's a malignant tumor : the tumor infiltrates facial nerve which
causes weakness and paralysis in facial muscles/ the swelling is warm and mildly tender and
hard or firm.
-Clinical evidence of diagnosis in case of stones : painful gland swelling while eating
-Clinical evidence of diagnosis in case of acute sialadenitis : diffusely enlarge gland with red
skin, firm and markedly tender. Pain increases on talking.

How to examine deep part: through the mouth, it may displace the tonsil on the same side.
Superficial part examination: ask the patient to clench the teeth so that the masseter muscle is
palpable and examine behind the masseter and in front of the ear.
Nerve that divides the gland: facial nerve
Treatment: superficial parotidectomy

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14-Graves disease:
Pathological types:
a. Simple diffuse goitre:
1- Parenchymatous:
- Physiological goitre. - Endemic goitre. - Sporadic.
II- Colloid goitre:
b. Nodular goitre: simple multinodular goitre

OR Diffuse toxic – Toxic nodular goiter – Toxic nodule

TTT: mainly medical:
1. Neomercazole
2. B-Blockers (for 2 weeks)
3. Diazepam (for CNS symptoms)
4. Lugols iodine (pre-op)
If medical TTT failed:
<20-25 years & large: surgery
>20-25 years: I131

15- Paget disease of the breast

How to diagnose: Biopsy & histopathology to see malignant
(paget) cells
CI of conservative / surgical management:
- Pregnancy as radiotherapy is contraindicated.
- Extensive microcalcification.
- Multicenteric
- Central mass
- Collagen disease: eg: SLE

TTT:
Simple mastectomy has been the historic standard treatment,
Now: breast-conserving treatment (BCT)

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16- Submandibular gland stone – Acute sialadenitis

Stone is common due to:
1- viscid secretion: high calcium concentration
2-Duct ascends upward: inadequate drainage
3-Orifice in floor of the mouth: easy blockage
How does this stone appear in plain occlusal
radiograph?
Radio opaque stone
Two other radiologgical investigations (besides the occlusal view xray):
Ultrasound –– Sialography – panorama xray view – CT – Magnatic resonance sialography
Name of the duct and opening site:
Warton’s duct: opens in the floor of the mouth on either sides of the frenulum of the tongue
Complications and treatment of this condition:
Sialadenitis (infection)
Antibiotics (clindamycin) and if abscess (incision and drainage)
Final treatment after resolution of the acute stage→ submandibular sialoadenectomy

17- Venous ulcer, Hx: previous DVT

a. Types of leg ulcers: Venous Ulcer (mc), ischemic
ulcer, neuropathic ulcer, T.B. Ulcer, syphilitic ulcer,
squamous cell carcinoma, melanoma, traumatic
b. Causes of venous ulcer: Post-phlebitic,after DVT,
AVF, complication of 1ry varicose veins
c. Describe it (clinical signs):
Site: gaiter area above the medial malleolus
Edge: slopping, irregular, later on punched out
Surrounding skin: pigmentation, eczema, scratch
marks, induration. Takes a long time to heal and frequently recurrent.
Base: indurated
LN: enlarged

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d. Investigations, Duplex (of choice), Doppler, biopsy (if suspecting malignancy)

e. 2 other complications of DVT: Pulmonary embolism - postphlebitic syndrome- varicose veins
– recurrent DVT – death
e. Treatment:
- Conservative: rest – limb elevation – elastic stockings – Dressing with saline
- Surgical (if resistant recurrent): Cockett & Dodd operation or Excise & cover by flap

19- 5 Femoral triangle swellings DD:

Reducible→ Reducible femoral Hernia, Saphena varix, femoral artery
aneurysm, psoas abscess

Irreducible → Irreducible femoral Hernia, lipoma, inguinal

lymphadenitis, ectopic testis
Differentiate between inguinal and femoral hernias:

Inguinal hernia Femoral hernia

Relation to pubic tubercle Above and medial Below and lateral
3 finger test Impulse on index or middle Impulse on ring finger
Common in Male Female
Strangulation Less common More common
Name of defect Deep (internal) ring formed Sac protrudes through
of transversalis fascia femoral ring, femoral canal,
saphenous opening

Complications: Irreducibility – obstruction – strangulation – inflammation

20- Hypospadias
a. Types: Glanular, coronal, penile, penoscrotal, perineal
b. Why Ultrasound?: done to detect upper urinary tract problems
c. 2 clinical signs supporting the diagnosis: dorsal hooded prepuce-
chordee
d- What to adivse the parents against: Avoid circumscision
e. 2 Surgical principles: release chordee & use prepacue to refashion urethra

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21-Basal cell carcinoma:

Inspection: nodule in face (90%): inner@outer canthi of eye, nasolabial
folds, white with dilated capillaries over it, covered with thin
epidermis; ulcerates with serous discharge@bleeding.
Edge: Rolled in and beaded
Floor: necrotic, red, granular, often covered with dry crust/scab
PDF:
1-premalignant lesions:
-xeroderma pigmentosa -keratoacanthoma -Actinic keratosis -Bowen's
disease -leukoplakia
2- UV rays exposure
3- Radiation, immunocompromised
Spread: Direct spread to the surrounding & underlying structures
Ttt:
Radiotherapy (of choice)
Surgical: with safety margin 0.5 cm, elliptical incision
Indications: small, infiltration of cartilage and bone, radioresistant, recurrent
Other: cryotherapy, 5FU
NB: You can write the diagnosis Basal cell carcinoma or squamous cell carcinoma as you like but you
must adhere to your diagnosis for the rest of the questions. Both diagnosis’ will be correct but continue
answering as you choose.

25-Melanoma
-2 Pathological types:
- Superficial spreading type
- Nodular
Signs suspect malignancy:

• Asymmetric
• Irregular borders
• Hard consistency
• Dark colour

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• Itching, tingling, bleeding ulcer

• Diameter>6mm with satellite nodules
Ttt of 3mm and regional LN affection with no distant metastasis:
surgical excision "not included deep fascia", with 2cm safety margin
and LN radical dissection
Safety margin:

• 1mm = 1cm
• 1-4mm=2cm
• >4 mm=3cm
Treatment:
Excision with safety margin and radical LNs dissection if +ve LNs
D.D:

• Dysplastic nevus
• Squamous cell carcinoma
• Metastatic tumors to the skin
• Blue nevus
• Epithelioid (Spitz) tumor
• Pigmented spindle cell tumor
• Halo nevus
• Atypical fibroxanthoma
• Pigmented actinic keratosis
• Sebaceous carcinoma
• Histiocytoid hemangioma
-2 Modes of spread: Direct, lymphatic
2 Prognostic factor:
- Depth (Clark’s) and Thickness (Breslow)
- LNs spread
- Pathological types
3 precipitation factors:

• Prolonged exposure to sunlight

• Increased incidence in Albinism
• On top of benign lesions

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26-Keloid
Description: overactivity of the healing process leading to
excessive scar tissue
Characteristics/pathology: raised above the surface, and extends
beyond the confines of the original wound. It can follow burns,
traumatic or surgical wounds, inflammation, ear holing and
vaccination.
Persons with dark skin are more prone to keloid formation and
there is a familial predisposition.
Common sites:
Certain areas as the ear lobules, shoulder and presternal areas are more liable to
keloid formation.
DD: hypertrophic scar – burn – Stretching scar
Difference between hypertrophic scar & keloid:
- Hypertrophic scar: raised above the surface but limited to the scar
- Keloid: raised above the surface but extends beyond the scar
PDF: familial – black races – burns
3 methods of ttt:
o Continuous pressure by silicone gel sheets.
o intralesional corticosteroids. Triamcinolone is injected in the dermal region of the scar.
o Surgical excision. Recurrence rate after simple excision may reach 80%.
o To minimize recurrence intramarginal excision of the scar is recommended together with
intraoperative injection of steroids.

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27-Generalized neurofibromatosis
Types:
1)Types of generalized neurofibromatosis (type 1):
- cutaneous neurofibromatosis
- plexiform
- elephantiasis
Due to defect in chromosome 17, autosomal dominant.

2)Type 2 acoustic neuroma :

- Age : around 20s
- Positive family history
- Genetic defect on chromosome 22
3)Schwannomatosis

2 associations to this pathology:

− Pheochromocytoma
− Glioma

2 clinical findings:

− Cafe au lait patches

− Skin nodules

Long term complication increased frequency of benign and malignant

tumors - Hypertension

5) 2 indications of surgery

− Large tumors
− Painful tumors
− Tumors producing pressure symptoms.

Ttt:
(Complete resection) Excision of all tumors if:
- Large tumors

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- Painful tumors
- Tumors producing pressure symptoms.

28. Sebaceous cyst:

-Why? Due to blockage of sebaceous gland ducts (commonly in face,
scalp, neck and scrotum) forming a retention cyst.
Never in: palm and soles

DD: Lipoma – Hemangioma – Fibroma

-2 Special characters(signs): 1)It’s attached to the skin at 2) one point called the punctum.
3)cystic swelling: +ve paget 4) if Infected: Signs of inflammation: Redness, Swelling, Edema
overlying the lesion
2 complications: Abscess formation, Sinus Formation, Ulceration, Sebaceous horn, Localized
alopecia
-Treatment:

• Complete excision of the cyst

with an ellipse of overlying skin
containing the punctum.
• If inflamed: antibiotics
• If it forms an abscess: Incision
and drainage

29.Hernia at midline with no scar:

-DD?
* Hernias:
= Fatty hernia of linea alba
= Epigastric hernia
= Paraumbilical hernia (if it’s near the umbilicus)
*Skin:
= Abscess

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= Sebaceous cyst
= Hematomas, haemangioma
*Subcutaneous:
= Sequestration dermoid cyst
= Lipoma
= Neurofibroma, neurofibrosarcoma
*Visceral:
= Stomach: Carcinoma, gastric outlet obstruction
= Pancreatic pseudocyst
= Aortic aneurysm
= Transverse colon: Carcinoma, bilharzial colitis, diverticulitis
Possible hernia: Epigastric hernia
- Treatment? Abdominal Belt is satisfactory in most cases
-How to elicit divarication?
By asking the patient to rise up of his semi setting position with no support, if it’s positive then
there’s separation of the two recti forming a gap through which the finger tip is admitted easily
-Complications?

• Irreducibility
• Obstruction
• Inflammation
• Strangulation
• Sliding Hernia
• Specific for Epigastric hernia: Dyspepsia

31.Breast Abscess:
-2 Clinical signs confirming the diagnosis:

• Throbbing pain
• Hectic fever
• Signs of inflammation are localized
• Overlying skin shows pitting edema

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• Persistence of local signs of inflammation for more than 5 days or of

severe systemic upset for more than 2 days after full antibiotic
treatment
• Fluctuation (but we never wait for this sign in breast abscess)
- 2 Predisposing factors:

• Lactation: S.aureus through mouth of suckling infant

• Milk engorgement
• Nipple abrasion
• Trauma
• Mammary duct ectasia
• Piercing of nipple – Shaving - picking acne lesions-local skin infection
- Organism: Staphylococcus aureus
- Anti-microbial agent: Augmentin (amoxicillin clavulanic acid)
-Treatment? Incision & drainage

• General anaesthesia
• Circumferential incision over the most tender area
• Pus is sampled for culture and sensitivity
• Destroy the loculi by finger to form a single cavity
• Drainage at the most dependent part
• Antibiotics for few days and dressings
• Remove drain when drainage stops

32.Thyrotoxicosis:
Sign in face: true exophthalmos
-Sign of leg?
* Pretibial myxoedema (with Grave’s)
-Sign of hand?
* Onycholysis and thyroid acropachy (with Grave’s)
* Moist warm hands
Complications of eye lesion:
Papilledema – cornea ulceration – optic nerve neuropathy –
diplopia

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2 lines of ttt:
- Medical: carbimazole – propylthiouracil – Inderal
- Radioactive iodine
- Surgical: total thyroidectomy
- Treatment of 2ry thyrotoxicosis?
* Thyroidectomy with preoperative preparation (carbimazole and Beta-blockers)
- Difference between true and false exophthalmos?

False True

No rim of sclera below Rim of sclera below

Due to upper lids retraction in Due to deposition of round cell
response to catecholamines infiltrates in the retrobulbar area
No findings with Nafziger’s method or Nafziger’s method: eyeball protrusion
Russel Frazer. beyond the superciliary ridge plane
Russel Frazer: shallow groove
Mobius sign indicating malignant
exophthalmos
Improves by beta-blockers No response to them

34.Inguinal Hernia-Inguinoscrotal hernia:

-Test to differentiate direct and indirect hernia?
* Internal ring test: if positive then it’s indirect
- Types of indirect hernia?
* Congenital
* Infantile
* Adult type:
= Bubonocele
= Funicular hernia
= Complete (scrotal) hernia

Type of content: Intestine or Omentum

⁃ Consistency: Intestine: Soft

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Omentum: Doughy
⁃ Gurgling occurs during reduction of intestine and absent with Omentum
⁃ Reduction: Intestine: Difficult with the first part then easier. Omentum: Easier at
first then difficult

Complications: Irreducibility – obstruction – strangulation – inflammation

Signs of strangulated hernia: tense, tender, irreducible, doesn’t show expansile impulse
on cough

2 manifestation of IO: vomiting, distension, colics, and constipation-

2 clinical findings: expansile impulse on cough , defect can be felt
Causes Strangulation without obstruction: Richters hernia, Ommentum, littre’s hernia,
Amyand: Appendix,

Treatment and 2 approaches of surgery:

- Hernioplasty (Onlay mesh, Inlay, Sublay) – Herniorrhaphy - Herniotomy
- Approaches: open surgery – laparoscopic

36.Acute Ischemia:
-Signs:
* Pallor (white)
* No pulse
* Poikilothermia (coldness)
* Radial pulse is usually irregular
Symptoms:
- Pain – paresthesia – Paralysis
- Investigations (urgent)
* For diagnosis: Duplex, arteriography (pre- or intra-operative)
* For etiology: Echo, ECG
* For complications:
= Muscle necrosis: high (TLC, CPK) and metabolic acidosis
= Hypovolemia: high (haemoglobin, creatinine, BUN)

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2 PDF:
- Embolism : AF – MI
- Thrombosis: Atherosclerosis – intra-arterial drug injections
Treatment:
For Embolic: Urgent embolectomy and fasciotomy to prevent compartment syndrome And
Control the source
For thrombotic:

• Moderate = Thrombolytic therapy then elective revascularization

• for severe Emergency revascularization surgery

37.Oblique Inguinal Hernia:

-Test to differentiate direct and indirect hernia?
* Internal ring test: if positive then it’s indirect
- Differentiate the content?

Intestine Omentum
Palpation Soft Doughy
(consistency)
Auscultation Occurs during reduction None
(gurgling)
Ease of reduction First part reduction is more difficult Last part reduction is more difficult
than the last than the last
Percussion Resonant Dull

- DD?
* With impulse on cough:

• = Oblique inguinal hernia

• = Direct inguinal hernia
• = Femoral hernia
• = Saphina varix
• = Primary varicocele
* No impulse on cough:

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• = Enlarged inguinal LNs

• = Ectopic or incompletely descended testis
• = Femoral artery aneurysm
• = Hydrocele
• = Lipoma of the cord
• = Psoas bursa
- Types of indirect hernia?
* Congenital
* Infantile
* Adult type:
= Bubonocele
= Funicular hernia
= Complete (scrotal) hernia

39) Epigastric hernia :

a)DD

• mass in epigastrium
• Lipoma
• Gastric cancer
• Liver : cyst or tumor
• Pancreas : pseudocyst or tumor
• Transverse colon : intussusception , lymphoma
• AAA
• Para aortic LN
b) confirm : expansile impulse on cough , defect can be felt, on an anatomical site of hernia,
usually causes dyspepsia due to traction of herniated omentum on stomach .
c) ttt:
1) make sure that the cause of pain is not peptic ulcer
2)excision of protruding fat and hernia sac and simple closure to linea alba

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41) Thyrotoxicosis
Prove it’s True exophthalmos: protrude over the superciliary
ridge + moebius sign, Nafziger’s test, ruler test,
ophthalmometer , shallow groove in Russell Frazer's
Differentiate between True and false exophthalmos:

False True

No rim of sclera below Rim of sclera below

Due to upper lids retraction in Due to deposition of round
response to catecholamines cell infiltrates in the
retrobulbar area
No findings with Nafziger’s Nafziger’s method: eyeball
method or Russel Frazer. protrusion beyond the
superciliary ridge plane
Russel Frazer: shallow
groove
Mobius sign indicating
malignant exophthalmos
Improves by beta-blockers No response to them
Sign in Picture B: Pretibial myxedema : deposition of mucin like substances causing orange
yellow thickening of skin over tibia
Sign in Picture C: Thyroid acropathy (clubbing): clubbing and swelling of digits and toes

42) Acute limb ischemia: H/O: sudden onset of pain:

Signs: signs of ischemia" mottling, cyanosis,
sever edema, blacky discoloration , distal gangrene +
Ps (pulselessness , pallor, paresthesia , paralysis ,poikilothermia (coldness)
Investigations: Urgent Duplex, arteriography, ECG and Echo

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43) Paraumbilical hernia:

3 clinical signs to differentiate the content:

Omentocele Enterocele
Dull resonant on percussion

No gurgle Gurgle sensation on reduction

Doughy Soft
Easy to reduce difficult to reduce at first

Difficult to reduce easy to reduce at END

TTT :
Small defect → Anatomical repair OR Mayo's repair
Large defect → Hernioplasty (prolene mesh graft)
Why does it cause dyspepsia?
Due to traction on the greater omentum which is commonly the content of this hernia.
Differentiate between it and epigastric hernia?
In paraumbilical hernia, the defect is above or below the umbilicus so that the umbilicus is
distorted, while in epigastric hernia, there is a bridge of normal abdominal muscles between
the defect and the umbilicus. Besides, epigastric hernia could be multiple

44) AV Fistula:
Clinical Signs: cystic, compressible, smooth swelling along course of an artery,
proximal compression decreases its size, with continuous thrill and continuous
machinery murmur, pulsating VV, Braham’s sign
Ttt if ruptured: excision of the sac and restoration of continuity of both artery and
vein.

45) true and false exophthalmos:

Signs : moebius sign , Dalrymple sign , Joffrey’s sign , Stellwag's sign, von Graefe's sign
Types in each photo

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46. Chronic limb ischemia

Causes of LL pain:

• CHRONIC:
o Sciatica
o Varicose veins
o Flat foot
o Peripheral neuritis
o Spinal stenosis
o Intermittent claudication
o Post phlebitis limb
• ACUTE:
o Fracture/ dislocation
o DVT
o Rupture baker’s cyst
o Rupture plantaris tendon
o Cellulitis
o Acute ischemia

Allen’s test: Describe:

asking the patient to elevate both arms above the head for thirty
seconds in order to exsanguinate the hands. Next, the patient
squeezes their hands into tight fists, and the examiner occludes the
radial artery simultaneously on both hands. The patient then opens
both hands rapidly, and the examiner compares the color of the
palms. The initial pallor should be replaced with the hands' normal
color as the ulnar arteries restore perfusion. The test is then
repeated while occluding the ulnar arteries rather than the radial.

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47. Jaundice, (if weight loss, anorexia, dark urine, Rt hypochondrial

mass: Malignant obstructive jaundice)
Imaging: US, CT, MRCP, ERCP, PTC
2 lab investigation: Bilirubin (total, direct, indirect) – Alkaline phosphatase – CA19-9
2 Surgical causes:
Malignant: Cancer head of pancreas
calcular obstructive cholecystitis
2 Types of gall stones:
- Pure cholesterol stones
- Brown stones
- Black stones
- Mixed stones
DD:

• Hemolytic: congenital or acquired hemolytic anemia

• Hepatocellular: Viral hepatitis, decompensated cirrhosis, drug induced, pyemic abscess
• Obstructive: CBD stone, Biliary atresia, CBD stricture (traumatic, inflammatory,
malignant), cancer in the head of pancreas
What is meant by Courvoisier law?
- Malignant jaundice: distended palpable gall bladder
- Calcular jaundice: impalpable gall bladder

48. Simple ganglion

Special sign: mobility of the swelling is markedly restricted by
stretching or by contraction of related tendon
DD: lipoma, tenosynovitis, giant cell tumor of the tendon sheath

Complication: cause pain, make it difficult to move the affected

part of your body, recurrence

1 test for consistency: paget test

Cause and pathology: synovial membrane herniation

TTT: excision is the only definitive ttt

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49. Undescended testis

DD: ectopic testis, testicular agenesis, retractile testis, atrophy,
hermaphroditism
Investigation: hormonal assay, US, CT, laparoscopy (detects
intrabdominal testis)
Sites: abodmen – inguinal – external rign

Complication: depressed spermatogenesis, increased liability to

testicular cancer, liable to trauma, torsion of the spermatic cord,
psychiatric disturbances
Ttt: orchidopexy before 2 years of age

50. Ape-hand deformity

Nerve affected: Median nerve
Sensory loss: lateral 2/3 of the palm, lateral 3 and half fingers.
Mechanism: inability to abduct or oppose the thumb + thenar wasting due to
Paralysis of abductor pollicis + 2 lateral lumbricals +thenar muscles
Special test: Phalen’s and Tinel’s -loss of opposition

51. Underwater seal

Main indication: pneumothorax. hemothorax
3 indications of thoracotomy:

• Bronchopleural fistula in pneumothorax that requires closure

• Definitive treatment of cardiac tamponade with pericardiotomy
• Fibrothorax
• Clotted or loculated hemothorax.

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52. Bilateral complete Cleft lip with flattening of the nares

Classifications: unilateral, bilateral, complete,
incomplete.
Age to repair this case: 3-6 months
Complications:
1cosmetic appearance,
2abnormal teeth growth.
3-Respiratory tract infections due to aspiration

4-Hearing problems

5-Nasal tone in speaking

6-Difficult speaking

Principles of surgery:

• Paringing of the edges

• Surtuing 3 layers (skin,muscle, mm) in a zigzag way

52.1 Cleft palate

Classifications:

• Cleft soft palate.

• Cleft soft and hard palate (complete).
• Complete cleft palate plus one side of premaxilla (bipartite).
• Complete cleft palate plus both sides of premaxilla (tripartite,
Age to repair: 12-18 months.
Principles of surgery

• Trimming of edges.
• Suturing in 3 layers in the middle line (nasal mucosa, muscle and oral mucosa).
• Lateral relaxation incisions are needed.
• Fracture of the pterygoid hamulus to relax the tensor palati.
Complications:

• Impairment of normal suckling,

• Food reflux into the nose and aspiration pneumonia.
• Hearing loss

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• recurrent otitis media.

• Speech defects secondary to: Inadequate velopharyngeal mechanism and Hearing loss.
• Distortion of facial growth.
• Interference with normal teeth alignment.

53- Colostomy or ileostomy

- Types:
• Loop colostomy
• End Colostomy ( Single barrel
colostomy)
- Complications:
• Prolapse
• Retraction
• Hemorrhage
• Gangrene
• stenosis of the orifice
• Necrosis of the distal end
• Colostomy hernia
• Masceration in ileal stoma ( irritating content
Indications: FBC – Ulcerative colitis

54- Multinodular goiter - Large Thyroid:

- Carotid pulsation: Felt against carotid tubercle on the transverse spine of 6 th cervical
vertebra.
- Two surgical casues of hyperthyroidism:
Secondary toxic goiter – Toxic nodule
- 2 Clinical symptoms of malignancy:
Pain referred to ear - Hoarseness of voice
- 2 clinical signs of retrosternal extension:
• By Inspection : Superficial veins of the upper part of the
chest dilated and cyanosis – edema of the face and the neck
• By palpation: can't get the lower edge of the gland
• By percussion: retrosternal dullness
- Inv:
• Best imaging: neck US in this patient CT chest and neck for
retrosternal goiter and CT lymph node if malignant suspicious.
- Treatment: Total thyroidectomy + post-operative Thyroid therapy replacement.

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55- Amazia
- Associated anomalies: Absence of the sternal portion of
the pectoralis major.
- 3 Arterial supply of the breast:
• Internal mammary artery
• Lateral thoracic artery
• Pectoral branch of the acromiothoracic artery
• The intercostal perforators

57- Submandibular swelling:

- 3 DD:
• Enlarged Submandibular LNs
• Enlarged Submandibular Salivary
Gland :submandibular sialodenitis (
salivary stone)
• submandibular salivary tumor
• Lipoma
- Inv:
• Occlusal X-Ray for salivary stone
• CT – MRI – FNAC for neoplasm
- How to differentiate between 2 main
causes?
• Salivary gland swelling : can't be rolled over the edge of the mandible, felt as
bulging into the floor of the mouth
• LNs : Not felt but can be rolled
• Submandibular salivary gland swelling differentiated from Submandibular
swelling by Bimanual Examination.

59-Dry gangrene | chronic ischemia Hx; smoking, diabetic, old age

Types of gangrene:
- Dry>>> shrunken dry hard black mummified limb (Gradual ischemia)
- Moist septic >>>>swollen red edematous inflammatory reaction with severe
toxemia

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- Moist aseptic>>>>same size and d consistency but discoloration (Acute ischemia) dead
white later purple later greenish
2 signs: (clinical findings)
- shrunken, dry, wrinkled skin
- Line of demarcation
- Loss of pulse
- Loss of sensation
- Loss of heat (coldness)
2 symptoms: claudication – rest pain
2 investigations: Doppler us – CT angiography – MRA – CBC
2 predisposing factors: diabetes mellitus, atherosclerosis, smoking, prolonged application
of tourniquets, hypercoagulable states, drug abuse, malignancy, and renal disease.
2 Critical limb ischemia:
- persistent recurring ischemic rest pain requiring opiate analgesia for at least 2
weeks,
- ulceration or gangrene of the foot or toes,
- ankle systolic pressure less than 50 mm Hg or toe systolic pressure less than 30 mm
Hg.

60-Raynaud’s phenomena
3 Causes:
1ry phenomena no associated cause or
2ry sec to disease e.g SLE or thoracic outlet syndrome, cold exposure ,
atherosclerosis, smoking
Ttt: CBB, PDEI, topical nitrate, avoid cold exposure and smoking and maintain whole
body and digital warmth and sympathectomy in worst cases

61-True exophthalmos
Possible cause: thyrotoxicosis (1ry toxic -Graves’s disease)

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2 other associated symptoms: diarrhea – palpitations – excessive

sweating – loss of weight despite increased appetite, nervousness,
insomnia
One lab, one radiological investigation: Thyroid function tests –
Ultrasound
2 drugs used in ttt: Carbimazole – propylthiouracil, Inderal
2 complications of medical ttt: GIT upset, rashes, arthralgia, reversible bone marrow
depression
3 other systems manifestations:
- CVS: tachycardia,
- CNS: tremors and Insomnia and
- GIT: diarrhea
Ttt : Medical,surgery after proper preoperative preparation ,Radioactive iodine and special
cases and Malignant Exophthalmos

62-Goiter
Inspection finding: swelling in the lower part of neck deep to
sternomastoid move with swallowing
3 Investigations:
Thyroid profile ,scan , ECG and Echo
Two investigations: one laboratory and one radiology:
Thyroid profile – Ultrasound
Sign to prove the origin of the swelling (most important clinical sign): Moves up and down
with deglutition

63-Simple ganglion
Special sign: cystic translucent swelling present on dorsum of hand
on extensor surface high rate of recurrence &translucent
Fixed by contraction movable by relaxation, +ve paget test
Ttt excision
Complication: recurrence and pressure symptoms

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64- Divarication of recti

DD
- Epigastric hernia
- incisional hernia
- lipoma
PF
- Chronic increase of intra abdominal pressure.
- Weak mesenchyme
- repeated pregnancies
- patients have ascites
- splenomegaly.
Test: : Ask patient to elevate his body from recombinant position, on raising the shoulders, the
linea alba bulges as a longitudinal ridge and the fingers can be dipped into the abdomen
between the two recti.
TTT
abdominal belt is satisfactory in most cases.

67- Gastrostomy:
Indications:
- Neurological diseases (Cerebral palsy)
- Intensive care patients
- Prolonged coma
- Esophageal cancer
- Burns
- Esophageal atresia
- Cystic fibrosis
- Short bowel syndromes (such as
Crohn’s disease)

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- Poly-trauma
Complications
- Gastric outlet obstruction
- Peritonitis
- Aspiration pneumonia
- Hemorrhage
- Perforation of bowel
- Necrotizing fasciitis

68-Ulnar nerve injury – Partial claw hand

Specific test:
- Card board test
- Froments test
- Egawa test
Injury at wrist:
- Hypothenar muscles wasting
- Interossei=guttering + no fanning or adduction
- Medial 2 lumbricals= partial claw hand
- Adductor polices: froment test

69-Hernia after appendectomy

Cause: ilioinguinal nerve injury

70-Lymphedema
2 causes:
- Post traumatic (circumferential scars of limbs )
-Post inflammatory(recurrent non specific lymphangitis)
2 complications:

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- Skin infections: cellulitis – erysipelas – lymphangitis

- Reduced quality of life: functional, physical
- Swelling – edema – thickening & hyperkeratosis of skin
2 embryological types:
lymphedema congenita – lymphedema praecox – lymphedema tarda
2 DD:
- Postphlebitic limb
- Elephantiasis
- Neuro-fibromatosis
- Congenital AV fistula
- Lipedema
2 investigations: Lymphoscintigraphy- Magnetic resonance lymphangiography- ultrasound
2 lines of treatment:
-Conservative (limb hygiene ,elevation ,compression , elastic stockings)
-Surgery (in severe cases)

71-4 Types of thyroid swelling

Goiter -lipoma -lymphadenopathy -thyroglossal cyst

72-Capillary hemangioma
Phases:
-Stage of proliferation: shortly after birth
-Stage of Involution At the end of 1 year of age and till 10 years old
-Involuted phase
Complications:
Serious bleeding with rupture liver hemangioma -congestive cardiac failure with large
cutaneous/visceral hemangioma/ septicemia/ Kasabach-Merritt syndrome
Ttt:
- Reassurance
-laser photocoagulation

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- surgical excision
- Injection of Sclerosing Solutions as 20% sodium chloride
-Compression therapy for venous malformations may relieve pain and edema.

73-Cystic hygroma
TTT: sclerotherapy or excision
Transillumination results: Translucent to
light
Findings on palpation: On palpation soft,
partially compressible
Other sites: Neck – Axilla – Groin –
Mediastinum

74-Squamous cell carcinoma

2 signs of inspection:
Ulcerated mass (Malignant Ulcer)
Edge: raised and everted
Floor: Rough necrotic, fungating tissue
Size: Large
Secondary infected: Blood stained discharge

2 lines of treatment:
- Surgery: Excision with a safety margin of 1 cm (as it’s in the face) , rest of
body is 2 cm
If it was anywhere else in the body: Safety Margine: 2cm
- Radiation: Especially in tumors of the head an neck

NB: You can write the diagnosis Basal cell carcinoma or squamous cell carcinoma as you like but you
must adhere to your diagnosis for the rest of the questions. Both diagnosis’ will be correct but continue
answering as you choose.

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75- Duct papilloma-bleeding per nipple from single duct with underlying
cystic mass
- Nature of the cyst: Retention cyst
- Differential diagnosis: Invasive duct carcinoma
- One radiological and one pathological investigation:
- Cytology of the nipple discharge
- Ultrasound and mammography
- Treatment: Microdochectomy

76- Sequestration Dermoid cyst:

Embryological cause (mechanism): subcutaneous inclusion of portions of
surface epithelium along the lines of fusion of cutaneous dermatomes during
fetal life.

2 clinical tests: Paget test, fluctuation test, transillumination

Sites:

• Ext and internal angular

• pre and post auricular
• Sublingual and submental
• Midline of the body
2 radiological investigations and why:
- Ultrasound: differentiate between cystic and solid swellings
- Fine needle aspiration cytology: cytology
- CT: shows well defined unilocular cystic swelling, bone may be hollowed out
- MRI: relation of the cystic mass and the muscles, connection to dura matter
Treatment: Surgical excision

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77- Branchial fistula:

Embryological cause:2nd branchial arch doesn't completely
fuse with the neck
Where 2 ends of duct open: skin of anterior border of lower
third of sternomastoid muscle
One important relation:
- Between bifurcation of common carotid artery,
- Deep to posterior belly of digastric muscle,
- Superficial to hypoglossal nerve
Ttt: Excision of the whole tract

78- Peutz Jeghers syndrome

Picture of patient with dark pigmentations in his face and
mouth with history of bleeding per rectum
1) What is the syndrome: Peutz Jeghers syndrome
2) 2 components of the syndrome:

− Hamartomatous intestinal polyps

− Oral and mucosal pigmentation
3) Cause of bleeding: Polyps
4) Complications:

− Intestinal obstruction
− Bleeding
5) Long term risk: malignant transformation of polyps and repeated resections of bowel

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79-MEN 2 A syndrome
History of Thyroid & Hand swelling with High: Ca² & Calcitonin with normal TSH

Name of this syndrome: MEN 2 A

Name of Hand lesion: Brown tumor (osteitis fibrosa cystica)

2 Associations: Pheochromocytoma- Medullary thyroid Carcinoma

Type & Origin of this tumor: Medullary Carcinoma from C cells

Treatment: Total thyroidectomy and block neck dissection

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