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Clinical Surgery

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1. What is the signifcance of an arterial bruit or venous hum over the liver?
Defective gene on chromosome 17
Those related to anaesthesia
'Watch and wait' or aspiration followed by 3 weeks of immobilzation
An arterial bruit may indicate alcoholic hepatits and carcinoma. A venous hum is associated with portal hypertension and if this is secondary to cirrhosis with a patent umbilical vein(or varices in the falciform ligament) - this is known as the Cruve

2. What is the differential diagnosis of an epigastric mass?
Arising from the skin and soft tissues - sebaceous cysts -sarcoma -lipoma -epigastric hernia - Arising from the gastrointestinal tract - carcinoma of the stomach -hepatomegaly -pancreatic ca - pancreatic pseudocyst - Arising from the vascular system
Commonest form of thyroid abnormality - Secondary to hyperplasia of the gland to meet physiological demand for thyroxine - Secondary to defective production of thyroid hormone
Palomo operation
Vascular - Cerebrovascular accident - Tumour - acoustic neuroma - Infection - Meningitis(rarely

3. What is acanthosis nigricans associated with?

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4. What is the differential diagnosis of swollen legs?
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision
Central causes - RHF - hypoalbuminaemia -nephrotic syndrome and hypothyroidism - Peripheral - venous disease such as DVT - Klippel-Trenaunay syndrome - chronic venous insufficiency or post-phlebitic limb - Rare - angio-oedema - arteriovenous malforma
Cervical rib or prominent transverse process of the Chest X-ray or thoracic outlet views - Doppler examination may be useful in quantifying the postural changes and post-stenotic dilatation - Arteriograms of the subclavian artery may show a marked ki
Patient must be standing up as he or she must be able to see the stoma - The stoma must be within the rectus abdominis muscle - Away from scars or skin creases - Away from bony points or waistline of clothes - At a site that is easily accessible to t

5. What is a cystic hygroma?
Grade 3 compression stockings to apply 40mmHg pressure at the ankles - Intermittent pneumatic compression device - Cellulitis should be treated - Advise patient to elevate their leg as much as possible and stress the importance of cleanliness and car
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.
Hyperthyroidism - Late Hypothyroidism - Later Hyperparathyroidism
History - Examination - Special Investigations - Treatment

6. How are the causes of jaundice classified?
Pre-hepatic - Hepatic - Post-hepatic
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
Nerve to stapedius - Nerve to posterior belly of digastric - Five divisions within the parotid gland - temporal - zygomatic - buccal - mandibular and cervical
Excess accumulation of fluid in the processus vaginalis.

7. How do you classify skin flaps?
Causes can be divided into pathology within and outside the SVC. Within the SVC obstruction tends to be as a consequence of thrombosis within intravenous jugular or subclavian lines(CPV Lines) - especially when hyperosmolar solutions are infused for
Classic Kaposi's sarcoma - AIDS-associated Kaposi's sarcoma - Endemic(central African) variety - Transplantation-associated Kaposi's sarcoma
Via the bloodstream(R is equal to red is equal to blood)
According to site - contents and if it is random or axial. When it comes to site - you consider where it is local or distant(Which is also known as a free flap). You have to also consider the contents which can contain any tissue capable of transfer

8. What are the secondary causes of Raynauds?
Motility disorders - diffuse oesophageal spasm and achalasia - Neurological disease such as myaesthenia gravis - bulbar palsy including MND and cerebrovascular accident with involvement of the 9th -10th and 12th cranial nerves.
Mnemonic: BADCaT - Blood disorders e.g polycythemia - Arterial e.g atherosclerosis - thrombangiitis obliterans - Drugs e.g beta blockers - oral contraceptive pill - Connective tissue disorders e.g rheumatoid arthritis - systemic lupus erythematosus -
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.
Via greater superficial petrosal nerve to lacrimal - nasal and palatine glands

9. What are the pathological features of thyroglossal cyst?
It arises de novo
Lined by stratified squamous or ciliated pseudostratified columnar epithelium - May also contain thyroid or lymphoid tissue - which can undergo malignant change - If malignancy occurs - usually of thyroid papillary type.
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
Scar confined to wound margins - It is found across flexor surfaces and skin creases

10. What are the variants of lipoma?
Angiolipomas - Hibernomas - Bannayan-Zonana Syndrome
Remove goitrogens from diet(e.g cabbage) - Thyroxine 0.1/0.3 mg per day - If thyrotoxicosis treat as in Graves' disease - Aspiration of cysts with cytology to exclude malignancy - Radioiodine for elderly patients - particularly those unfit for surger
Onset and Continuous Symptoms - When did you first notice it? - What made you notice it? - Predisposing events? - How does it bother you? - What symptoms does it cause? - Has it changed since you first noticed it ? - Have you noticed any other lumps?
Black discolouration of the skin

11. How would you determine clinically the degree of shunt by a large fistula?
Preoperative - Age -Immunocompromised state -obesity -malignancy -abdominal distension from obstruction or ascites - Operate - Poor technical closure of the wound -placing drains through wounds - Postoperative - wound infection or haematoma - early m
(H)infection - Hypoparathyroidism which leads to hypocalcemia
Derived from capillary endothelial cells or from fibrous tissue - It is linked to human herpes virus 8
The Branham-Nicoladoni sign indicates the degree of shunting and cardiac impairment resulting from a large AV fistula - The carotid pulse is palpated and then a tourniquet placed around the proximal affected limb and inflated above systolic pressure

12. What is a pharyngeal pouch?

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13. What are the causes of splenomegaly

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14. What is the pathogenesis of Raynaud's phenomenon?
They are known as adiposis dolorosa or Dercum's disease.
If the vessels are normal in calibre - the clinical features may be caused by relatively overactive alpha receptors in the wall - leading to abnormal smooth muscle contraction or changes in elasticity
Indications for amputation can be remembered as the 4Ds: Dead - ischemic - peripheral vascular disease - thromboangiitis obliterans - AV fistulae - Damaged - trauma - unsalvageable limbs - burns - frostbite - Dangerous - Malignancy - bone and soft ti
Almost all are follicular adenomas - Usually 2 to 4 cm and encapsulated at presentation - Indistinguishable from carcinomas on FNAC - as the presence of a capsule cannot be demonstrated - Surgical excision is needed to confirm diagnosis

15. What are the features of lentigo maligna melanoma?
Hyperthyroidism - Late Hypothyroidism - Later Hyperparathyroidism
Arises in a lentigo maligna - Occurs most often on the face or dorsum of the hands and forearms - Underlying lesion is flat and brown-to-black in colour with an irregular outline - Malignant area in the lesion is usually thicker - and darker in colou
The principles of surgery are that the sac is excised completely or inverted - and the defect in the linea alba repaired - The fat contained within the hernia can be excised or reduced - The site of the defect should be marked with the patient lying
Using hand-held skin graft knives or electric or gas powered dermatomes - the latter producing a graft of even thickness from almost any site - with little expertise needed for operation. The donor site is usually one that can be easily concealed for

16. What is the medical treatment of Graves disease?
It is important to exclude malignant tumours such as: Malignant melanoma - Basal cell carcinoma
Antithyroid drugs - to inhibit thyroid peroxidase - Beta-blockers - to reduce the effect of excess circulating thyroxine on the cardiac system - Radioiodine - Treatment of choice - Single oral dose of 131 Iodine causes direct radiation damage to the
Xeroderma pigmentosum - Gorlin's syndrome
Males represent 1% of all breast cancers. Features that would be suspicious would be: Older age - Unilateral gynaecomastia - Firm or hard nodules within the breast tissue - Remember to examine the axillary and supraclavicular fossae for lymphadenopat

17. What are the specific and immediate complications of thyroidectomy?
A skin graft involves the transfer of skin from a donor site to a recipient site independent of a blood supply. The graft 'takes' by acquiring a blood supply from a healthy donor bed. Skin grafts may either be full thickness or partial thickness - bu
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
Haemorrhage - Hoarseness - Hyperthyroidism
Procedure usually performed as a day case - Need to wear tight-fitting stockings for 6 weeks preoperatively - No driving for 1 week - Does not alter the skin changes - including skin flares - May not improve symptoms such as aching - Risk of recurren

18. What are the features of infantile polycystic kidney disease?
Xeroderma pigmentosum - Gorlin's syndrome
Clinical examination - Fine-needle aspiration which would show an opalescent fluid containing cholesterol crystals or pus.
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally
Minor defects in neonates are common but usually repair spontaneously. In children - umbilical herniae are mor common; they tend to have a narrow neck and folds of peritoneum stuck within this neck - which can occassionally strangulate. Most cases re

19. What is a cyst?
Klippel-Trenaunay-Weber Syndrome - Parkes-Weber syndrome
According to site - contents and if it is random or axial. When it comes to site - you consider where it is local or distant(Which is also known as a free flap). You have to also consider the contents which can contain any tissue capable of transfer
0.5 to 0.8
An abnormal sac containing gas -fluid or semisolid material - with an epithelial lining

20. How should one examine a lump or swelling?
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.
Causes may be classified as the 3 Ps: Physiological - Pathological - decreased androgens - androgen resistance - increased secretion -increased peripheral aromatization - Potions that is drugs such as recreational drugs - GI drugs - cardiovascular dr
Dohlman's procedure - endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling with less risk of fistula formation and consequent mediastinitis
Renal transplantation is indicated in end stage renal failure - the commonest reasons in the UK are:Diabetes mellitus - Hypertensive renal disease - Glomerulonephritis - Polycystic kidney disease

21. What do you know about thyroid adenomas?
Almost all are follicular adenomas - Usually 2 to 4 cm and encapsulated at presentation - Indistinguishable from carcinomas on FNAC - as the presence of a capsule cannot be demonstrated - Surgical excision is needed to confirm diagnosis
Debridement of dead tissue which can be performed by the tissue viability nurse since it does not require anaesthesia and reconstruction using a variety of fascial and muscle-containing composite flaps.
A pyogenic granuloma is a rapidly growing capillary haemangioma whic usually measures less than 1cm in diameter
Low approach - Lockwood - Transinguinal repair - Lotheissen - High approach - McEvedy

22. What is a branchial cyst?
A branchial cyst is thought to develop because of a failure of fusion of the embryonic second and third branchial arches. An alternative - and currently - popular - hypothesis is that it is an acquired condition due to cystic degeneration in cervical
Use of truss or corset - Weight loss and management of other risk factors
Truelove classification - Gastrointestinal symptoms : passage of bloody stools more than 6 times per day - Systemic signs : tachycardia and pyrexia - Laboratory findings : anaemia and CRP more than 30
Solar keratosses are squamous cell carcinoma in situ

23. What is an incisional hernia?
Extrusion of peritoneum and abdominal contents through a weak scar of accidental wound on the abdominal wall - Represents a partial wound dehiscence where the skin remains intact
Bronchial carcionoma - Chronic suppurative lung disease(abscess -bronchiectasis -cystic fibrosis -empyema) - Fibrosing alveolitis - Mesothelioma
A neurofibroma is a benign tumour derived from peripheral nerve elements.
True aneurysms are uncommon and are generally caused by atherosclerosis - and occasionally by dissection -trauma -previous carotid surgery or infection - When a true aneurysm has been excluded - the patient can be reassured and discharged. - Dilated

24. What are the acquired predisposing factors for malignant melanomas?
Skin and soft tissues such as a sebaceous cyst -lipoma or sarcoma - Bowel - ca caecum - crohns mass in terminal ileum - TB terminal ileum - appendicular mass or abscess - Gynaecological organs - ovarian tumours or fibroid uterus - Male Reproductive S
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
Sunlight - Pre-existing skin lesions - Previous melanoma

25. What investigations would you perform to help you in your diagnosis?
Barium swallow Which is usually diagnostic - Rigid endoscopy if neoplasia suspected
Calcification of the walls of the vessel preserves the pulses until late in the natural history of disease - and prevent the sphygmomanometer from compressing the vessels. This tends to lead to an abnormally(and reassuringly) high ankle brachial pres
10% per year
Left spermatic vein is more vertical where it connects to the left renal vein - The left renal vein can be compressed by the colon - The left testicular vein is longer than the right - It frequently lack a terminal valve which serves to try to preven

26. What investigations would you perform in your diagnosis of a chemodectoma?
Varicocoeles are dilated tortuous 'varicose' veins in the pampiniform plexus - the network of veins that drains the testis - They usually occur in 15% of younger men - often around puberty - and are thought to have an anatomical basis - If they appea
Mnemonic: DELFT(D) Feeding e.g feeding gastrostomy/jejunostomy - Lavage e.g appendicostomy - Decompression - bypass of an obstructing bowel lesion distal to the stom - Diversion - protection of a distal bowel anastamosis and urinary diversion followi
Duplex Ultrasound - Angiography - CT/MRI
A lipoma is a benign tumour consisting of mature fat cells.

27. What are telangiectasias?
The Branham-Nicoladoni sign indicates the degree of shunting and cardiac impairment resulting from a large AV fistula - The carotid pulse is palpated and then a tourniquet placed around the proximal affected limb and inflated above systolic pressure
Inspect - Protrusion of the tongue - Swallowing - Palpate(from the back) - Continue Accordingly(Neck Decision Circle)
Dilatation of normal capillaries - Can be secondary to skin irradiation - Can be part of hereditary haemorrhagic telangiectasia
This removes the possibility of recurrent disease appears to improves the outcome for patietns with significant eye disease and eliminates the need for annual TFT monitoring to assess remnant function. It does - of course - demand thyroxine replaceme

28. What are the specific complications of a Cimino-Brescia fistula?
The tourniquet test is designed to reveal the presence and site of incompetent veins - especially at the sites of connection between the superficial and deep venous systems.
Thrombosis during or just after haemodialysis - which may be due to relative hypotension and damage to the intima of the vein - Venous hypertension in the hand causes swelling and ischemia of the fingertips. This should be avoided by the ligation of
True umbilical herniae occur through the umbilical scar and are usually congenital in origin and particulary common in patients of Afro-Caribbean origin
Almost all are follicular adenomas - Usually 2 to 4 cm and encapsulated at presentation - Indistinguishable from carcinomas on FNAC - as the presence of a capsule cannot be demonstrated - Surgical excision is needed to confirm diagnosis

29. What are the causes of superior vena cava obstruction?
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis
Dissection of the hernial sac from surrounding tissues and definitioni of tissue bordering the defect on all sides to 2-3cm - Closing the defect(if small) and/or using mesh overlapping adequately( more than 5 to 8cm) over normal tissues to allows for
Causes can be divided into pathology within and outside the SVC. Within the SVC obstruction tends to be as a consequence of thrombosis within intravenous jugular or subclavian lines(CPV Lines) - especially when hyperosmolar solutions are infused for
Thrombosis during or just after haemodialysis - which may be due to relative hypotension and damage to the intima of the vein - Venous hypertension in the hand causes swelling and ischemia of the fingertips. This should be avoided by the ligation of

30. What are the early side-effects of radiotherapy?
1
Primary disease occurring in isolation
It will show you if it is malignant or inflammatory
General : malaise -fatigue - loss of appetite - nausea and vomiting - Skin : as above - Bone marrow suppression : particular if irradiation to the pelvis and long bones - Gastrointestinal : diarrhoea

31. What are the main features of type 2 NF?
Defective gene on chromosome 22 with variable penetrance - Cutaneous signs are less often seen in this type.
High-energy X-rays interact with tissues to release electrons of high kinetic energy - which cause secondary damage to adjacent DNA via an oxygen-dependent mechanism. The damage is either repairable or non-repairable - the latter manifesting itself a
Found below the inguinal ligament - Usually not reducible - Commoner in women - but inguinal herniae are still commoner in women than femoral hernias. Risk of strangulation is high - Cough impulse usually absent
Paraumbilical herniae occur around the umbilical scar. They are uncommon before the age of 40 years and can become large. Peristalsis can be observed through the skin when the defect is large. The neck of the sac is often tight and held with a fibrou

32. What are the features of spider naevi?
Form of telangiectasias - Central arteriole with leg-like branches Which blanch on central pressure - Found over upper torso - head and neck in adults - Associated with chronic liver disease and pregnancy
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation
Some 50% are present at birth and they are thought to represent a congenital abnormality during the evolution of embryonic lymph nodes into the adult type
Uncommon sensory component of facial nerve carrying cutaneous impulses from the anterior wall of the external auditory meatus known as nervus intermedius or pars intermedia of Wrisberg

33. What are the medical options for Raynauds?
Essentially to treat complications not amenable to medical therapy such as:Intra-abdominal abscesses that cannot be drained radiologically - Enterocutaneous fistulae - Stenosis causing obstructive symptoms - Control of acute/chronic bleeding
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists
As the perfusion of the leg begins to decrease in a patient with peripheral vascular disease; the ratio begins to fall.
The tumour arises from epidermal cells that normally migrate to the skin surface to form the superficial keratinizing squamous layer. Full-thickness epidermal atypia is seen and tumour cells are seen to extend in all directions into the deep dermis a

34. What do you know about the pathology of Squamous Cell Carcinoma of the skin?
Pregnancy - Ascites - Ovarian cysts - Fibroids - Bowel distension
Affect any age - Males = females - All races may be affected
Liver - fatty change - chronic active hepatitis -cirrhosis and amyloid deposition - Gall bladder and bile ducts - gallstones - sclerosing cholangitis - and cholangiocarcinoma
The tumour arises from epidermal cells that normally migrate to the skin surface to form the superficial keratinizing squamous layer. Full-thickness epidermal atypia is seen and tumour cells are seen to extend in all directions into the deep dermis a

35. How do paraumbilical herniae occur?
Paraumbilical herniae occur around the umbilical scar. They are uncommon before the age of 40 years and can become large. Peristalsis can be observed through the skin when the defect is large. The neck of the sac is often tight and held with a fibrou
Iodine deficiency - Increased physiological demand - Goitrogens(less common) - Defects of thyroid hormone production
Stool tests: Stool Culture - in new cases of IBD to exclude infection - Blood tests - Full blood count - may show anemia and leukocytosis - Electrolytes may show evidence of dehydration or hypokalemia - Liver function tests - CRP and ESR may be raise
Excess accumulation of fluid in the processus vaginalis.

36. What is seborrhoeic keratosis?
White lines and streaks inside the mouth
Arising from the skin and soft tissues - sebaceous cysts -sarcoma -lipoma -epigastric hernia - Arising from the gastrointestinal tract - carcinoma of the stomach -hepatomegaly -pancreatic ca - pancreatic pseudocyst - Arising from the vascular system
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.
May require the placing of postoperative drains

37. Do you know of any infectious agents associated with AAA?
It is due to development inclusion of epidermis along lines of fusion of skin dermatomes and are therefore commonly at: The medial and lateral ends of the eyebrows - The midline of the nose - The midline of the neck and trunk - Suspect if you see a c
Small red capillary naevus - Develops on the trunk in middle-age - No clinical significance
Renal transplantation is indicated in end stage renal failure - the commonest reasons in the UK are:Diabetes mellitus - Hypertensive renal disease - Glomerulonephritis - Polycystic kidney disease
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms

38. What is the 'reconstruction ladder'?
Via the bloodstream(R is equal to red is equal to blood)
Mnemonic : SNAPP - Sepsis elimination : open or percutaneous drainage of collections; administration of appropriate antimicrobials - Nutritional resuscitation/optimization : patients may be fluid and electrolyte depleted and malnourished. Resuscitati
There are two pathological systems in use: Clark's level of invasion based mostly on the depth/extent of tumour and Breslow's thickness Which is based mostly on the thickness of malignant melanoma. Breslow's thickness is a better prognostic indicator
This is the array of plastic surgeon techniques of increasing complexity that is available to the surgeon and Which is used according to their suitability for individual patients

39. How is a Cimino-Brescia arteriovenous fistula fashioned?
The reason for repairing abdominal aortic aneurysm is to avoid complications - The following aneurysms should be repaired: Symptomatic aneurysms(back pain - tenderness over the aneurysm on palpation -distal embolic events - ruptured/leaked aneurysms)
The procedure can be performed under a regional(brachial plexus) - local or general anaesthesia - A longitudinal incision 3-4cm in length is made over the distal third of the forearm midway between the radial artery and the cephalic vein - The cephal
It is known also as auriculotemporal syndrome and it brings about increased sweating of the facial skin when eating - due to reinnervation of the divided sympathetic nerves to the facial skin by fibres of the secretomotor branch of the auriculotempor
If the vessels are normal in calibre - the clinical features may be caused by relatively overactive alpha receptors in the wall - leading to abnormal smooth muscle contraction or changes in elasticity

40. What are the signs in the mouth of acanthosis nigricans?
Black discolouration of the skin
A skin graft involves the transfer of skin from a donor site to a recipient site independent of a blood supply. The graft 'takes' by acquiring a blood supply from a healthy donor bed. Skin grafts may either be full thickness or partial thickness - bu
90% of lung resections in the Western world are performed for bronchial carcinoma. Other indications include traumatic injury - bronchiectasis - chronic infection including tuberculosis - benign tumours e.g carcinoid and metastatic tumour
Excessive dryness of skin - Compensatory sweating around trunk ( in up to 50% of patients) - Horner's syndrome( a consequence of damage to the stellate ganglion) - 0.1% - Pneumothorax/haemothorax - Important to warn of the risk of a general anaesthet

41. What are the signs in the mouth of Peutz-Jegher disease?
Pigmented freckles around the lips and inside the mouth - associated with intestinal intussusception and gastrointestinal bleeding from colonic polyps
Rolled or raised edge - Often on sun-damaged skin
Thyroid function tests - hyperthyroid - Ultrasound - dimensions of goitre and nodules looking for dominant nodules or cysts for FNAC - Chest X-ray as a retrosternal goitre may compress the trachea
Mouth and lips are hyperpigmented

42. What other non-surgical treatments are available for ischaemic ulcers?
80% of salivary gland tumours occurs in the parotid gland - 80% of these parotid tumours being benign - with 80% of these benign tumours being pleomorphic adenomas
Depends on local guidelines but essentially: Pneumococcal vaccine - Haemophilus influenzae type B vaccine - Meningococcal vaccine - Annual 'flu' vaccine - Consideration for lifelong penicillin or penicillin as required when infection present - Warn a
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents
Risk factor modification - stopping smoking - good diabetic and hypertensive control and optimized serum lipid levels - Symptom modification - avoidance of drugs which might worsen symptoms - commencement of low-dose aspirin daily -IV prostaglandins

43. What are the causes of bilateral ptosis?
Loss of hair on outer-third of eyebrows - Lid retraction - Lid lag - Ophthalmoplegia - Exophthalmos - Chemosis - Proptosis
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital
Excision of an entire lung
Congenital ptosis - Myopathies - Syphillis

44. How may pleural effusions be classified?
The protein content of a sample of effusion fluid is measured and the classification depends on this value:Transudate is equal to a protein value of less than 30g/L - Exudate is equal to a protein value of more than 30g/L
Barrett's oesophagus - Stricture especially chemical - Achalasia - Plummer-Vinson Syndrome
Essentially to treat complications not amenable to medical therapy such as:Intra-abdominal abscesses that cannot be drained radiologically - Enterocutaneous fistulae - Stenosis causing obstructive symptoms - Control of acute/chronic bleeding
Males represent 1% of all breast cancers. Features that would be suspicious would be: Older age - Unilateral gynaecomastia - Firm or hard nodules within the breast tissue - Remember to examine the axillary and supraclavicular fossae for lymphadenopat

45. How do you stage malignant melanomas?

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46. What investigations should one do in the management of a multinodular goitre?
Motility disorders - diffuse oesophageal spasm and achalasia - Neurological disease such as myaesthenia gravis - bulbar palsy including MND and cerebrovascular accident with involvement of the 9th -10th and 12th cranial nerves.
Donor renal artery is anastamosed to either the internal or external iliac artery - The donor renal vein is anastamosed to the external iliac vein - The ureter is anastamosed seperately to the patient's bladder - The renal pelvis the most anterior st
Arising from the skin and soft tissues - sebaceous cysts -sarcoma -lipoma -epigastric hernia - Arising from the gastrointestinal tract - carcinoma of the stomach -hepatomegaly -pancreatic ca - pancreatic pseudocyst - Arising from the vascular system
Thyroid function tests - hyperthyroid - Ultrasound - dimensions of goitre and nodules looking for dominant nodules or cysts for FNAC - Chest X-ray as a retrosternal goitre may compress the trachea

47. What are the complications of incisional hernia?
Patients are usually symptom-free for a long period of time followed by dysphagia and hoarseness - associated with regurgitation of undigested foods - and associated weight-loss
Non-surgical : Watch and wait - a small hydrocoele may require no treatment other than reassurance - but an underlying malignancy should be excluded. Aspiration - the hydrocoele fluid can be aspirated to relieve symptoms; tends to reaccumulate
Mnemonic : SPRUE - Site of enlargement : from the right costal margin towards the right iliac fossa - Percussion Note : dull - Respiration Movement: it descends - Unable to get above it - Edge : may be smooth or irregular
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation

48. What are the anatomical levels that leg amputations are usually found at?
Immediate : Facial nerve transection - Reactionary haemorrhage - Early : Wound infection - Temporary facial weakness -salivary fistula and division of the greater auricular nerve which means loss of sensation to the pinna - Late : Wound dimple - Frey
High success - 50 to 70% will heal at 3 months - 80 to 90% at 12 months - The patient should be warned to avoid trauma to the affected area - Four-layer compression bandaging - Encourage rest and elevation of leg - Once healed - grade 2 compression s
Below Knee - Above Knee
Regular skin inspection - Frequent turning of immobile patients( 2 to 4 hourly) - Massage - Toileting - The use of special mattresses and cushion which redistribute the pressure on at-risk areas

49. Why are 98% of varicocoeles left-side?
A chemodectoma is a tumour of the paraganglion cells of the carotid body located at the bifurcation of the common carotid artery. They are usually benign(but locally invasive) - but occassionally - they are malignant with potential to metastasize to
Left spermatic vein is more vertical where it connects to the left renal vein - The left renal vein can be compressed by the colon - The left testicular vein is longer than the right - It frequently lack a terminal valve which serves to try to preven
Pressure effects - Deafness with involvement of the 8th cranial nerve - Sarcomatous transformation - Intra-abdominal effects - Skeletal changes
Using hand-held skin graft knives or electric or gas powered dermatomes - the latter producing a graft of even thickness from almost any site - with little expertise needed for operation. The donor site is usually one that can be easily concealed for

50. Sclerotherapy To treat varocose veins
Leave alone if asymptomatic and if patient does not want intervention - Intervene only when extensive or for cosmetic reasons with local radiotherapy and/or chemotherapy using interferon-alpha -doxorubicin and intralesional vinblastine.
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.
The incompetent vein is below the level of the tourniquest
Injection sclerotherapy with 1% sodium tetradecyl sulphate - this has a high recurrence rate and indicated for postoperative recurrence of veins - below knee varicosities if the long saphenous vein and short saphenous vein are not involved.