Clinical Surgery

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1. What are the signs in the mouth of Hereditary telangiectasia?
Multiple telangiectasia around the mouth and on the tongue and lips
A carbuncle is an extensive infection of hair follicles by the same organism with involvement of adjacent follicles and development of draining sinuses. It is associated with diabetes and is treated with a combination of systemic antibiotics and surg
Three arteries - artery to vas deferens -testicular artery -cremasteric artery - Three nerves - ilioinguinal nerve on the front of the cord - nerve to cremaster and autonomic nerves - Three other structures - vas deferens - pampiniform plexus of vein
Urinary retention - Bruising - Pain - often very severe and patients should be discharged with adequate analgesia; chronic groin pain persists in 5% of patients - Haematoma - 10% - Ischaemic orchitis - 0.5%(prev. vasectomy predisposing cause and diss


2. What is a papilloma?
Treatment involves the use of artificial tears and saliva - use of systemic steroids and careful follow-up due to increased risk of lymphoma development
A papilloma is an over-growth of all layers of the skin with a central vascular core. They are increasingly common with age.
40 X increased risk of developing lymphoma - usually B-Cell non-Hodgkin's type
Traumatic - Iatrogenic(following angiography and bypass)


3. Surgical way too treat Varicose veins
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 -
Low approach - Lockwood - Transinguinal repair - Lotheissen - High approach - McEvedy
Defective gene on chromosome 17
Ligation of the incompetent SFJ or SPJ with stripping of the involved vein and stab avulsion of varicosities - Ligation of incompetent perforating vessels - Subcutaneous endoscopic perforator surgery


4. How would you investigate a patient who was referred with a carotid bruit?
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
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's
Ultrasound would be the first investigation - Abdo wall masses and extent of disease better seen with CT Scan - IV contrast enhance CT scanning to clarify lower abdominal and pelvic vasculature
The patient should have a full workup for atherosclerosis - General investigations : Urinalysis for proteinuria - marker of atherosclerotic renal disease - Blood tests: FBC for anemia - which might precipitate symptoms - Renal function for possible u


5. 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
Urinary retention - Bruising - Pain - often very severe and patients should be discharged with adequate analgesia; chronic groin pain persists in 5% of patients - Haematoma - 10% - Ischaemic orchitis - 0.5%(prev. vasectomy predisposing cause and diss
Traditionally -Bilateral subtotal thyroidectomy without need for postoperative replacement of thyroxine was recommended but more recently total thyroidectomy is the preferred procedure due to the risk of pathological change in the thyroid remnant nec
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation


6. What immunizations would you need to organize in the event of performing a splenectomy?

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7. What are the possible surgical techniques in the surgical treatment of a femoral hernia?
Low approach - Lockwood - Transinguinal repair - Lotheissen - High approach - McEvedy
Some surgeons would advocate that all patients should undergo Duplex scanning of the leg veins before any surgery is undertaken. Others would consider indications to be: Previous history of deep vein thrombosis - Any signs of chronic venous insuffici
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
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.


8. How is a Cimino-Brescia arteriovenous fistula fashioned?
Commonest in children and young adults(P for Paediatric)
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
Increase in size - Ulceration - Change in colour - Irritation - Bleeding - Halo of pigmentation - Satellite nodules - Enlarged local lymph nodes - Evidence of distant spread
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


9. What are the specific complications of a stoma?
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation
Bronchial carcionoma - Chronic suppurative lung disease(abscess -bronchiectasis -cystic fibrosis -empyema) - Fibrosing alveolitis - Mesothelioma
Symptomatic carotid stenosis of more than 70% - Trials demonstrated that for patients with severe stenosis surgery reduce the relative risk of disabling stroke by 48%
As the perfusion of the leg begins to decrease in a patient with peripheral vascular disease; the ratio begins to fall.


10. What do you know about thyroid cysts?
Simple mastectomy - Modified radical mastectomy(patey) - Radical mastectomy(Halsted mastectomy) - Extended radical mastectomy
The two main differential diagnoses to consider are; Benign - keratoacanthoma - especially if it is sloughing at its centre - Malignant -Squamous cell carcinoma - particularly the nodulo-ulcerative type with a rolled edge
VINTA MEDIC - Vascular - Iatrogenic - Neoplastic - Traumatic - Autoimmune - Metabolic - Endocrine - Degenerative - Inflammatory/Infective - Congenital
True cysts with a complete smooth wall are very rare - Most are composite lesions with colloid degeneration - necrosis or haemorrhage in benign or malignant tumours - Only benign if completely abolished by aspiration - Cytology can be false-negative


11. What is a fistula?
Ductal carcinoma which account for approximately 70% of cancers - Lobular carcinoma which accounts for 20% of cancers - Others such as mucinous -tubular -medullary which accounts for approximately 10% of cancers
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)
A carbuncle is an extensive infection of hair follicles by the same organism with involvement of adjacent follicles and development of draining sinuses. It is associated with diabetes and is treated with a combination of systemic antibiotics and surg
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


12. What is the pathology of Sjogren's syndrome?
Excess accumulation of fluid in the processus vaginalis.
Lymphocyte-mediated destruction of the exocrine glands secondary to B-cell hyper-reactivity and associated loss of suppressor T-Cell activity
Mainly teratoma or seminomas - other types are: Embryonal carcinoma - Choriocarcinoma - Yolk sac tumour - Leydig cell tumours - Sertoli cell tumours - Lymphoma
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


13. What are the non-surgical treatment options for an incisional hernia?
Congenital - Multiple arteriovenous fistulae - Traumatic
Use of truss or corset - Weight loss and management of other risk factors
Produces IgM - to capture and process foreign antigen - Filters especially encapsulated microorganisms e.g pneumococcus - Sequesters and removes old red blood cells and platelets - Recycles iron - Pools platelets(30% of total platelets within spleen)
Increased platelet count and large platelets - Increased neutrophils - Nucleated red cells with Howell-Jolly bodies and target cell - Tend to mount more of a leukocytosis in response to infection


14. Simple cysts are found in 33% of patients by the age of 60. How should they be managed?
Those related to anaesthesia
History and Clinical Examination - they usually present incidentally but occasionally with a renal mass or haematuria
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
End-to-end anastamosis - patching and the use of the left subclavian artery as a flap are all surgical options


15. What are the anatomical levels that leg amputations are usually found at?
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
Below Knee - Above Knee
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
State of the skin/subcutanaeous tissues - Sites of fascia defects - Site of incompetence(including the Trendelenburg and Tourniquet Tests)


16. What is a branchial cyst?
History - Examination - Special Investigations - Treatment
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
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
Congenital - Multiple arteriovenous fistulae - Traumatic


17. Which are the most benign parotid tumours?

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18. What is secondary lymphoedema?
Recurrence of the cyst - Developement of a chronic -discharging sinus
May require the placing of postoperative drains
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
It can be classified according to cause: Malignancy - Infections - e.g filiaris - tuberculosis - Post Surgery or Radiotherapy - axillary dissection in breast surgery and inguinal irradiation


19. What is the non-surgical treatment of venous ulcers?
Epigastric pain - which may increase after meals - May be acutely painful after physical exercise - Nausea and early satiety - Reflux and non-ulcer dyspepsia
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?
Chronic Liver disease - Right Heart Failure - Intra-abdominal Malignancy - Hypoalbuminaemia
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


20. What are the causes of splenomegaly

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21. What are the features of nodular melanoma?
0.5 to 0.8
Second most common type - Occurs most often on the trunk - Polypoid in shape and is raised - Smooth surface - Irregular edge - Frequently ulcerated
Trauma - Hypersplenism
Inspect - Protrusion of the tongue - Swallowing - Palpate(from the back) - Continue Accordingly(Neck Decision Circle)


22. What investigations would you perform to help you in your diagnosis?
Barium swallow Which is usually diagnostic - Rigid endoscopy if neoplasia suspected
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
Increased platelet count and large platelets - Increased neutrophils - Nucleated red cells with Howell-Jolly bodies and target cell - Tend to mount more of a leukocytosis in response to infection
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


23. What are the surgical treatment options for hydrocoele?

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24. What is the classification used in the definition of severe exarcerbation of inflammatory bowel disease?
Least common - Occurs on hairless skin - Irregular area of brown or black pigmentation
Early mobilization is important - They should keep the area clean and wash carefully -especially after the clip/sutures have been removed - They are able to bathe immediately - They may need to be off work for 6 weeks if their job involves heavy lift
May require the placing of postoperative drains
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


25. What is a useful mneumonic to remember what you have to present when examining a lump or swelling?
A hypervascular mas displacing the bifurcation of the carotid arteries
Trauma - Hypersplenism
Should The Children Ever Find Lumps Readily
SPRUE - Site of enlargement - from the left costal margin towards the umbilicus - Percussion note - dull - Respiration movement - it descends - Unable to get above it or ballot it(differentiating it from the kidney) - Edge - a notch may be palpable o


26. What are the features of a direct inguinal hernia?
Sunlight - Pre-existing skin lesions - Previous melanoma
All patients should undergo triple assessment that is Clinical Examination - Radiological assessment usually ultrasonographic - Pathological - most commonly cytological following FNAC
It is the result of a weak posterior wall to the inguinal canal - Arise medial to the inferior epigastric vessels at operation - This weakness causes the abdominal contents to bulge through the wall into the inguinal canal but the hernia is not withi
Non-surgically via aspiration and injection of sclerosant surgically via excision which may be partial ( to relieve symptoms) or complete as a one-stage procedure.


27. How would you demonstrate to an examiner that a mass in the right upper quadrant is indeed an enlarged liver(hepatomegaly)?
Have you noticed any change in the colour of your urine? Have you noticed any change in the colour of your stools? - Have you noticed yourself feeling itchy?
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
Psychological and social implications - Haematoma and wound infection - including gas gangrene - Deep vein thrombosis and pulmonary embolus - Phantom limb pain - due to the sensory cortex 'believing' the limb is still present - Skin necrosis
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


28. What investigations should one do in the management of a multinodular goitre?
Bronchial carcionoma - Chronic suppurative lung disease(abscess -bronchiectasis -cystic fibrosis -empyema) - Fibrosing alveolitis - Mesothelioma
Normal bilirubin is less than 17 mmol/L and it usually has to reach at least three times this before the sclera is discoloured(i.e >50mmol/L). Very high levels of bilirubin are usually associated with hepatic jaundice
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
Mnemonic: SNAiL - Superficial spreading - Nodular melanoma - Acral lentiginous melanoma - Lentigo maligna melanoma


29. What are the complications of atrial fibrillation?
Traumatic - Iatrogenic(following angiography and bypass)
Haemorrhage - Hoarseness - Hyperthyroidism
The major risk is embolic stroke(4% per year) which results from thrombus accumulating in an inefficiently contracting left atrium - Emboli can also lodge in the mesenteric vessel - causing intestinal ischaemia - Patients are also at risk from acute
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise


30. What are the causes of facial nerve palsy?
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
Use of gloves and discontinuing any predisposing drugs e.g beta blockers - Using warm pads in gloves and socks in the winter - Encourage patients to stop smoking
The procedure should be performed under sterile condition and if the ascites is not clinically apparent or easy to locate - it should be done by a radiologist under ultrasound guidance to prevent inadvertent injuries to intra-abdominal structures.
Intracranial - Intratemporal - Extratemporal


31. What is the differential diagnosis for a skin lesion?
Benign skin lesion: Keratoacanthoma - Infected seborrhoeic wart - Solar keratoses - Pyogenic Granuloma - Malignant skin lesion - Basal cell carcinoma - Malingnant melanoma - Congenital: Xeroderma pigmentosum - Acquired - Environmental agents - Pre-ex
Superior thyroid artery - Inferior thyroid artery - Thyroidea ima(in 3% of people)
Early mobilization is important - They should keep the area clean and wash carefully -especially after the clip/sutures have been removed - They are able to bathe immediately - They may need to be off work for 6 weeks if their job involves heavy lift
Duplex Ultrasound - Angiography - CT/MRI


32. What is the aetiology of varicocoeles?

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33. How would you treat a pharyngeal pouch?
Prolonged weight-bearing and mechanical shear forces act on areas of soft-tissues overlying bony prominences - leading to both occlusion and tearing of small blood vessels -reduced tissue perfusion and ischaemic necrosis.
Acute severe ulcerative colitis - MPS - toxic Megacolon - Perforation - rare in absence of toxic dilatation and raises possibility of Crohn's disease. The mortality is 40% - Severe gastrointestinal bleeding - Chronic ulcerative colitis - 3 Ms - Medic
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision


34. What do you know about Kaposi's Sarcoma?
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
Gumma of tertiary syphillis has a typical punched-out ulcer - over the anterior surface of the lower leg and has a yellow coloured 'wash leather' base. - Scalloped border
Derived from capillary endothelial cells or from fibrous tissue - It is linked to human herpes virus 8
Urine should be tested for raised bilirubin - Full Blood Count - Evidence of anemia in GI malignancies or associated infection - Renal function - any evidence for hepatorenal syndrome - Liver Function Tests -Clotting - functional assessment of hepati


35. What are the features of ulcers in syphillis?

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36. What are the surgical options for Raynauds?
A neurofibroma is a benign tumour derived from peripheral nerve elements.
Cervical sympathectomy and amputation of the affected phalanges - Cervical sympathectomy may not be a permanent solution and may only relieve symptoms for 2 years or less - Amputate only if digits are threatened with gangrene
The main points to mention are: testicular damage should be mentioned as a specific risk factor - the operation can be performed under local or general anaesthetic and often as a day case - The Royal College of Surgeons has recommended the Lichtenste
Parafollicular C Cells


37. What is neurofibromatosis?
Presence of multiple neurofibromas in a patient - in combination with other dermatological manifestations(six cafe-au-lait psots) - It is an autosomal dominant condition with two types: 1 and 2.
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema
Pregnancy - Ascites - Ovarian cysts - Fibroids - Bowel distension
Myelofibrosis - Chronic Myeloid Leukaemia - Malaria - Tropical splenomegaly - Kala-azar(visceral leishmaniasis)


38. What are the surgical treatment principles of incisional hernia?
Ligation of the incompetent SFJ or SPJ with stripping of the involved vein and stab avulsion of varicosities - Ligation of incompetent perforating vessels - Subcutaneous endoscopic perforator surgery
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
The incompetent vein is below the level of the tourniquest
Popliteal aneurysms represent 80% of all peripheral (non-aortic) aneurysms - The patient may have presented with a lump behind the knee if the aneurysm has grown to such a size that it has expanded beyond the popliteal fossa - 50% present with distal


39. Where is the midpoint of the inguinal ligament?
Produces IgM - to capture and process foreign antigen - Filters especially encapsulated microorganisms e.g pneumococcus - Sequesters and removes old red blood cells and platelets - Recycles iron - Pools platelets(30% of total platelets within spleen)
May require the placing of postoperative drains
They are often multiple and most commonly arise in the head of the epididymis. Occassionally they occur as a complication of vasectomy - in which case they are full of sperm and are termed spermatocoeles.
Halfway along inguinal ligament that is between pubic tubercle and ASIS Which is equal to the location of the deep inguinal ring


40. What are the late side-effects of radiotherapy?
Recurrence of the cyst - Developement of a chronic -discharging sinus
Skin : as above - Lungs : pneumonitis - pulmonary fibrosis - Heart : Ischemic heart disease - Arteries: radiation arteritis -Spinal cord : myelopathy - Gonadal damage : infertility - Thyroid : hypothyroidism due to depletion of follicular thyroid cel
History and Clinical Examination - Investigate if prominent nodule or features suspicious of malignancy such as cervical lymphadenopathy or recurrent laryngeal nerve palsy
Some surgeons would advocate that all patients should undergo Duplex scanning of the leg veins before any surgery is undertaken. Others would consider indications to be: Previous history of deep vein thrombosis - Any signs of chronic venous insuffici


41. How would you treat hidradenitis suppurativa?
Well-localized abscesses are treated by incision and drainage under antibiotic cover - Larger lesions are treated by radical excision and full-thickness skin grafting usually harvested from the groins or abdomen
Size - Tenderness - Mobility - Consistency
Within the lumen: Foreign body - oesophageal web - Plummer-Vinson syndrome - In the wall : Carcinoma of the oesophagus -oesophagitis -barrett's oesophagus - benign oesophageal stricture and post-radiation or chemical strictures - Outside the wall: re
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair


42. What is the difference between a false and a true aneurysm?
An aneurysm is an abnormal dilatation of a blood vessel - A true aneurysm involves all layers of the arterial wall - A false aneurysm follows a partial laceration of the vessel wall causing blood to leak out of the vessel into the surrounding tissues
Stroke is the third leading cause of death in the west and 85% of strokes are thromboembolic - caused by atherosclerosis at the carotid bifurcation or proximal (2-3cm) internal carotid artery.
Idiopathic(50%) - Myeloproliferative disorders - Autoimmune hepatitis - More common in males than females
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.


43. When considering the treatment of a disease in a surgical patients - What are the important modalities of treatment which should be considered?
Clinical examination - Fine-needle aspiration which would show an opalescent fluid containing cholesterol crystals or pus.
Recurrence of the cyst - Developement of a chronic -discharging sinus
Conservative - Medical - Surgical
Weight loss - Change in bowel habit - Loss of appetite - Back pain


44. How is 'matching' of transplanted kidneys performed?
The procedure should be performed under sterile condition and if the ascites is not clinically apparent or easy to locate - it should be done by a radiologist under ultrasound guidance to prevent inadvertent injuries to intra-abdominal structures.
Congenital ptosis - Myopathies - Syphillis
(H)infection - Hypoparathyroidism which leads to hypocalcemia
At two levels:ABO Compatibility - HLA Compatibility


45. What about umbilical herniae in children?
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
Cardiac and respiratory disease should be controlled first - Other risk-factors should be optimized - Preoperative weight loss should be encourage
Stoma diarrhoea - related to water and electrolyte imbalances - hypokalemia being the commonest and most important consequence - Nutritional disorders - Stones - both gall stones and renal stones increase in frequency following an ileostomy - Psychos
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


46. What is exopthalmos secondary to?
Tumour - parotid gland malignancy - Trauma - surgical - accidental e.g facial lacerations
If the ulcer fails to heal - careful consideration should be given to excluding other causes such as malignant Marjolin ulcer and the area may need to be biopsied - Otherwise a split skin graft should be considered with excision of the dead skin and
Vaginal Hydrocoele - fluid accumulates in the tunica vaginalis - Hydrocoele of the cord - fluid accumulates around the spermatic cord - Congenital Hydrocoele - Infantile Hydrocoele
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents


47. What are the features of infantile polycystic kidney disease?
Via the bloodstream(R is equal to red is equal to blood)
10% per year
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally
Traumatic - Iatrogenic(following angiography and bypass)


48. What is the 'reconstruction ladder'?
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
Often surgeons place two drains - one in the axilla and one at the site of surgery within the breast tissue - The drains are usually left for 3 to 5 days or until the drainage volume is less than 50mL in 1 day. - Patients can safely be sent home with
The insensitive - mechanically abnormal - dry foot is at risk from unperceived external trauma e.g from shoes and from repetitive painless injury e.g foreign body in shoe. Progressive skin loss and ulceration may occur.
Non-surgically via aspiration and injection of sclerosant surgically via excision which may be partial ( to relieve symptoms) or complete as a one-stage procedure.


49. How would you treat this condition?
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present
Dohlman's procedure - endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling with less risk of fistula formation and consequent mediastinitis
A caring and competent approach - A good examination technique - An ability to elicit and draw conclusions from physical signs
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.


50. What are the causes of venous ulcers?
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
Black discolouration of the skin
Any cause of deep venous insufficiency can lead to ulceration: Valvular disease - varicose veins - deep vein reflux - communicating vein reflux - Outflow tract obstruction - often post-DVT - Muscle pump failure - primary such as stroke and neuromuscu
Haemorrhage - Hoarseness - Hyperthyroidism