This document provides tips and information for revalida exams. It discusses general study tips like pacing oneself and taking breaks. It also covers specific topics that may come up like breast diseases, thyroid surgery, and gallbladder conditions. For breast exams, it outlines diseases and treatments like lumpectomy. For thyroidectomy, it discusses anatomy like the recurrent laryngeal nerve. Gallbladder topics include cholecystectomy, cholelithiasis, and imaging tests for stones. The document emphasizes knowing content well while also resting the brain between study sessions.

1. REVALIDA
TIPS

2. General Tips
Secrets
Surgery Tips

3. 1. Study well
2. No one can ever “be prepared”
3. Pace yourself
4. Take a break
5. Know your panel
6. Pray

4. STUDY
You’ve been doing it for 4-5 years. Don’t stop because it
won’t stop.
Enjoy studying. Imagine how many people you’ll be helping
from just reading a book – or a couple.

5. NEVER PREPARED
No one was and will ever be prepared for interviews, Q&A, or
this
So don’t be. Don’t think about it.
Focus on you’re goal. I wrote down my goal and hung it by
my desk.
Motivation will produce hard work.

6. PACE
People have different paces. Some do it fast. Some need to
read a book more than once.
I read fast. But I read more than once. I scan as 1st read, read
and memorize 2nd, and analyze 3rd. But I schedule my
studying based on my pace.
Set a date for each topic/subject/specialty. If you don’t finish,
move on. Better to read more than one subject than just to
finish one.

7. HAVE A KITKAT
Just like exercising, you need to rest some muscles while
training the others
Rest your brain, watch a movie, swim, eat, go to events, etc.
– it helps more than you know
But everything in moderation
Also there are no cheat days. Once you start cheating, it will
only escalate. Please, don’t

8. KNOW YOUR PANEL
Know more or less how they think
Know how they were in previous revalidas
They are not there to fail you. There are there to test how well
you can handle REAL patients ALONE

9. PRAY
Let your gentle spirit be known to all men. The Lord is near.
Be anxious for nothing, but in everything by prayer and
supplication with thanksgiving let your requests be made
known to God. And the peace of God, which surpasses all
comprehension, will guard your hearts and your minds in
Christ Jesus.
• Philippians 4:5-7

10. SECRETS
Panel
• They can’t ask under their specialty unless you “force/push”
them to.
• If you say something erroneous, they’ll say something about
it. So be conscious
Chairperson
• He/she has the power (sometimes) to change the votes of the
tribe. So know the chair well.

11. On cases
• Your residents help
• In the OPD, we give (or at least try until we almost die) the
cases that are obvious.
• In the wards, we are asked every day to pass a list of cases
that will be included as ward cases. We still give the basic
ones. We also try limiting admissions during revalida season
• Visit the wards and opd before your day. Tell the residents in
the opd/ward of your impending success

12. MANDATOR
Y ICE
CAUTION: THE NEXT FEW SLIDES WERE MADE
AS ADD ON READING. NOT MEANT FOR “I WON’T
READ THE BOOK ANYMORE BECAUSE I HAVE
THIS” SORT OF CRAP.

13. READY?

14. SURGERY
Most common cases given
1. Breast
2. Thyroid
3. Skin lesions (sebaceous cyst, lipoma, etc)
• I wont be discussing skin lesions anymore. Get it from your
opd lecture ppts
4. Gallbladder

15. TO BE PRESENTED AS
1. History
2. PE
3. Assessment
4. Diagnostics
5. Management
• Conservative
• Surgical/Invasive
(This is how you’re really supposed to present anyway)

16. BREAST
15 to 20 lobes  lobules
Cooper’s ligament – fibrous band providing support
Female mature breast from second or third rib to the
inframammary fold 6th to 7th rib
Deep surface lies above pectoralis, serratus anterior, and
external oblique msucle

17. Axillary tail of spence is part of the breast
Upper outer quadrant greatest volume of tissue than other
quadrants
During pregnancy and lactation, breasts become larger and
increase in volume and density, in contrast during sensence

18. Blood supply
• Perforating branches of internal mammary artery
• Lateral branches of posterior intercostal a.
• Branches from the axillary a.
• Highest thoracic, lateral thoracic, pectoral branch of
thoracoacromial a.
• Veins follow arterial course
• BATSON’S vertebral venous plexus extent from skull to
sacrum which may provide route for distant mets to bones
and cns

19. Lymph nodes
• assigned levels according to their anatomic relationship to the
pectoralis minor muscle
• Level I: lateral or lower border of pec minor
• Level II: central and interpectoral groups
• Level III: medial or upper border
Review on effect of estrogen and progesterone on the breast

20. BENIGN BREAST
DISEASES
Cysts
• volume of a typical cyst is 5 to 10 mL, but it may be 75 mL or
more. If the fluid that is aspirated is not bloodstained, then the
cyst is aspirated to dryness. When cystic fluid is bloodstained,
fluid can be sent for cytologic examination.
Abscess
• Usually by staph aureus
• Tender, red, sometimes with fever, with purulent discharge
sometimes
• Treat with incision and drainage and antibiotics

21. Fibroadenoma
• Varies in size, usually less than 3 cm (giant fibroadenoma
size is >3cm)
• Rubbery, smooth, rounded, regular, movable, mostly
nontender, in the young (less than 25), mostly solitary
• Maybe observed, unless the patient wants it to be removed
• If found in older people, core needle, or mammogram may be
indicated to rule out breast cancer
• Treatment: excision

22. Fibrocystic change
• Multiple lesions, variable in size, mostly regular non tender
cystic lesions involving both breasts during or close to
menstruation.
• Enlarges during menstruation, also may become painful
during this time
• Treatment: observe, if with large lesion may excise
• If found in higher ages, may need imaging and biopsy

23. Phyllodes Tumors
• Mostly large in a small amount of time, movable, irregularly
shaped
• Classified as benign, borderline, malignant
• But only less than 5% are truly malignant (spreads to lungs if
it is)
• Leaf like appearance in histopath
• Treat: wide excision, if almost or whole breast, do
mastectomy
• 1cm margin for wide excision

24. REVIEW:
FOR BREAST CANCER
Modified Radical Mastectomy (what do you preserve?)
• Thoracodorsal nerve
• Long thoracic nerve
• Borders
• Lat dorsi laterally
• Clavical superiorly
• Inframmamary area inferiorly
• Sternum medially
• Axillary lymph node dissection up to level I and II unless you
have palpable “diseased” lymph node at level III
For breast conservation therapy
• lumpectomy/wide excision/qudratectomy + sentinel lymph
node/ axillary lymph node dissection + radiation therapy

26. THYROID
Weighs 20g but varies based on body weight and iodine
intake
Adjacent to thyroid cartilage connected by isthmus just
inferior to cricoid cartilage
Strap muscles (sternohyoid, sternothyroid, omohyoid)
located anteriorly
Covered by loose fascia formed from deep cervical fascia
condensed posterior into the berry’s ligament near cricoid
cartilage

27. Blood supply
• Superior thyroid from the external carotid artery
• Divered to anterior and posterior apices of thyroid
• Inferior thyroid from the thyrocervical trunk
• Enter thyroid at midpoint
• Descends with recurrent laryngeal nerve so identify before
ligate
• Thyroidea ima from aorta or inominate
• Enters isthmus

28. Recurrent Laryngeal Nerve
• Left RLN from vagus
• Crosses aortic arch, loops at ligamentum arteriosum, ascends
medially in the tracheoesophageal groove
• Right RLN from vagus
• Crosses right subclavian artery
• passes posterior to the artery
• Innervate all intrinsic muscles except cricothyroid muscle
• injury to one = paralysis of ipsilateral vocal cord = lie
paramedian or abducted position
• Paramedian – weak but normal voice
• Abducted – hoarse voice or ineffective cough
• Injury to two may lead to airway obstruction

29. Superior laryngeal nerves
• From vagus
• Travel along internal carotid artery dividing into two at the
level of hyoid bone
• Internal branch sensory to supraglottic larynx. Injury rare in
thyroid surgery. Injury = aspiration
• External branch descends along with the superior thyroid
vessels. Injury leads to hitting high notes or voice fatigue

30. Review iodine metabolism
• So you understand the effects of thyroid drugs
Review
• Difference in papillary and follicular cancer
• Different in staging of ages of patients with ages <45 (only up
to stage 2)
• Follicular cancer to be dx properly you need to see capsular
and/or vascular invasion
• Medullary Cancer (MEN syndrome)

32. WHAT WAS THE
PREVIOUS SLIDE?
We (SRODs) follow this for SOLITARY thyroid nodules
What we do:
• Request for NECK ultrasound (evaluate not only thyroid but
also cervical LNs) AND thyroid function test
• If low TSH follow algorithm
• If solitary nodule – do FNAB (ideally utz guided for better
results and sure to hit nodule) then follow algorithm based on
results
• If benign – may do lobectomy with isthmusectomy
• If malignant – total thyroidectomy
• If multiple nodules
• Normal thyroid tests – advised total thyroidectomy
• If abnormal thyroid tests – have endocrinologists control
and clear patient prior to surgery

34. GALLBLADDER
7-10cm long
30 to 50cc capacity but can carry up to 300cc
• Liver can produce up to 1L of bile per day
Cystic artery comes from right hepatic artery 90% of the time
• Triangle of calot = location of artery = cystic duct, common
hepatic duct, liver margine
• Good to know: lymph node of calot overlies insertion of cystic
artery into the gallbladder
Wall thickened at 4mm

35. Bile ducts
• Left and right hepatic  common hepatic  common hepatic
+ cystic duct = common bile duct  pass through sphincter of
Oddi through ampulla of Vater together with main pancreatic
duct  second part of duodenum
Bile duct diameter = 5 to 10mm but filipino standards bile
duct is already dilated by >7mm
Ducts of luschka – ducts draining directly from liver to body
of gallbladder
• If not identified might cause bile leak post cholecystectomy

36. Primary bile salts = cholate and chenodeoxycholate
• Conjugated with taurine and glycine
Secondary bile salts = deoxycholate and lithocholate – 20%
of the bile salts not absorbed in the terminal ileum that are
dehydroxylated.
• Absorbed in the colon and recycled.
95% reabsorbed via enterohepatic circulation
5% excreted in stool

37. IMAGING
UTZ
• Initial investigation for patients suspected of biliary tree
diseases
• Dependent on technical skills and experience
• Will show stones within the gallbladder WITH >90%
sensitivity and specificity
• Stones – echoes with posterior acoustic shadowing
• Polyp – may be revealed as echoes but NO acoustic
shadowing

38. UTZ findings of cholecystitis
• Thickened wall
• Pericholecystic fluid
• Sonographic murphy’s sign
• Distended gallbladder

39. UTZ
• Extrahepatic ducts are well visualized by ultrasound except
retroduodenal portion
HIDA scan
• Primary use is to diagnose acute cholecystitis
• NOT STONES
CT scan
• Inferior to utz in diagnosis of stones
• usually to trace course of extrahepatic biliary tree and nearby
organs and to diagnose periampullary tumors

40. MRCP
• 95% sensitivity and 89% specificity in detecting
choledocholithiasis
• Better in diagnosing intrahepatic bile ducts than utz
ERCP (ENDOSCOPIC RETROGRADE PANCREATOGRAPHY)
• Diagnostic and therapeutic
• For stones in the common bile duct, cholangitis, stent
placement for OBD due to perimapullary tumor,
• lithotripsy and extraction
• Complications: pancreatitis (watch out) and bile duct
injuries/strictures

41. Endoscopic UTZ
• For noninvasive imaging of bile ducts and adjacent structures
• Evaluation of tumor and resectability
• Biopsy possible

42. GALLSTONE DISEASE
3% of asymptomatic individuals become symptomatic per
year
• Prophylactic cholecystectomy not indicated unless:
1. Elderly patients with diabetes
2. Isolated from medical care for extended periods of time
3. Populations at increased risk of gallbladder ca
Porcelain gallbladder – absolute indicated for
cholecystectomy

43. CHOLESTEROL
STONES
Pure cholesterol stones <10% of gallstones
Single, smooth surface
Most have variable amounts of bile pigments and calcium but
>70% are cholesterol by weight
Ursodeoxycholic acid can be used to “melt” this kind of
stone

44. PIGMENT STONES
<20% cholesterol, dark because of calcium bilirubinate
Black stones
• Supersaturation of minerals
• Secondary to hemolytic disorders mostly
Brown stones
• Usually secondary to infection caused by bile stasis

45. CHOLECYSTITIS
Acute
• Pain ruq and epigastric more than 24hrs
• Murphy’s sign (pathognomonic)
• May radiate to shoulder/back
Chronic
• Recurrent colicky ruq and epigastric pain
• May not present with murphy’s sign
Read on Mirrizzi’s syndrome

46. TREATMENT
Cholecystectomy
• Open Cholecystectomy
• Less expensive, but longer time to recover and longer time in
hospital
• Also pain is more severe
• Lap Cholecystectomy
• Gold standard
• Short time to recover and time in hospital
• More expensive

47. Absolute contraindications for lap chole
• Uncontrolled coagulopathy
• End stage liver disease
• Pulmonary disease COPD or ejection function of <20% are
Conversion to open
• 5% of elective procedure and 10 to 30% of emergency
procedure
• Usually due to difficult to identify anatomy or no progress over
set period of time

48. Choledocholithiasis
• 1st choice is ERCP
• If not available/expensive/stone not extracted from ERCP
• Common bile duct exploration and stone extraction is 2nd
choice
• Usually in an open cholecystectomy setting but can be
done laparoscopically

49. Read on
• Courvoisier gallbladder
• in the presence of an enlarged gallbladder which is nontender
and accompanied with mild jaundice, the cause is unlikely to
be gallstones

50. THAT’S MY PART
Disclaimer: most data came from schwartz some from other
materials I used as a resident. Listen to your review lectures
in the coming days, they’ll contain more.
If there are any info wrong, contact me/correct me.
Reproduce with caution.

51. END!
GOODLUCK!