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Clinical Surgery

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. What is the pathogenesis of thromboangiitis obliterans?
Cyanotic congenital heart disease - Infective endocarditis - Atrial myxoma (rare)
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
Superior thyroid artery - Inferior thyroid artery - Thyroidea ima(in 3% of people)
It is a collagen vascular disease - caused by infiltrate of plasma cells into the arterial wall - This leads to luminal thrombosis and affects small and medium-sized arteries of the lower limb - Eventually - collagen is deposited and forms a thick fi

2. What is the origin of lymphangiomas?
Hidradenitis suppurative - also known as acne inversa - is now considered a disease of follicular occlusion rather than an inflammatory or infectious process of the apocrine glands. Abscesses form recurrently and this causes the characteristic perman
Hyperkeratosis - Acanthosis - Hyperplasia of variably pigmented basaloid cells
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
Hepatitis - Decompensated chronic liver disease - Drugs

3. What is a furuncle?
Situations where skin grafts will not take - When the aim is to reconstruct the tissue that is 'like-for-like'(bone -joint -tendon -nerve -epithelial lining -etc) to promote optimal structure - function and cosmesis - When blood supply has to be impo
Reduction of the contents of the sac - Excision of the sac - Repair of the defect - taking care not to narrow the femoral vein while tightening up the femoral canal
Simple colloid goitre - Graves' disease - Thyroiditis
A furuncle results from infection of hair follicles with Staphylococcus aureus

4. What are the features of ulcers in patients with arteriovenous fistulae?
Ulcer is distal to the fistula - Shallow indolent ulcers
Motor - Secretomotor - Taste - Sensory
Defined as portal vein pressure of more than 10mmHg(normal 5-10). Portal blood flow through the liver is greatly reduced or even reversed in the most severe cases
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.

5. What is the aetiology of diabetic foot ulcers?
Duration and change in size - Cosmetic symptoms - Discomfort during swallowing/dysphagia - Dyspnoea - Hoarseness - Pain
Neuropathic - 45 to 60% of ulcers - Ischaemic due to peripheral occlusive arterial disaese - 10% of ulcers - Mixed neuroischaemic - 25-45% of ulcers
Immobility and prolonged bed-rest are the most important factors - particulary secondary to conditions such as: Cardiopulmonary disease - Trauma - Neurological disease such as paraplegia - Bone and joint disease - Prolonged operative procedures - And
malignant change?

6. What is a skin graft?

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7. What is the surgical treatment of varicocoele?
Epigastric pain - which may increase after meals - May be acutely painful after physical exercise - Nausea and early satiety - Reflux and non-ulcer dyspepsia
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation
Palomo operation
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.

8. What is the definition of an enterocutaneous fistula?
A enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and the skin
Collagen antibodies are present in 45% of patients - There is an association with HLA-B5 - Angiography has typical appearances of normal proximal vessels with distal occlusion and 'corkscrew' collaterals.
The incompetent vein is at or above the level of the tourniquet
Sacrum - Greater trochanter - Heel - Lateral Malleolus - Ischial Tuberosity - Occiput

9. What is Sjogren's syndrome?
Autoimmune condition - Intermittent or constant swelling of one or all of the salivary glands
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
Benign skin lesions: Moles -freckles -lentigo -pigmented seborrhoeic keratoses - dermatofibromas and thrombosed haemangiomas - When it comes to malignant skin lesions - pigmented basal cell carcinomas
Via the lymphatic route(Y for yellow = lymph)

10. What is the classification of liposarcoma?
Unilateral total lobectomy and isthmusectomy
The major differential diagnoses would be with a renal tumour and adult polcystic kidney disease and if there is any doubt of a tumour - then the cyst fluid may be sent for cytological analysis
Well-differentiated - Myxoid and round cell - Pleomorphic liposarcoma
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise

11. In the tourniquet test - What do collapsed veins below the tourniquet indicate?
History and Clinical Examination - Investigate if prominent nodule or features suspicious of malignancy such as cervical lymphadenopathy or recurrent laryngeal nerve palsy
The incompetent vein is at or above the level of the tourniquet
Chest x-ray to map the caudal extent of the cystic hygroma - CT/MRI scanning especially if it is complex
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

12. What are the causes of bilateral ptosis?
Congenital ptosis - Myopathies - Syphillis
Is there evidence of a new or old stoma site? Is there evidence of a small incision to one side of the scar(from a drain - this may have been due to a bowel operation) - Are there also scars in the groins? - Are there striae gravidarum
Autoimmune condition - Intermittent or constant swelling of one or all of the salivary glands
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

13. How are the side-effects of radiotherapy minimized?
Malignancy - Primary lung tumour - Cardiovascular : Pulmonary embolus/infarct or Dressler's syndrome - Infections such as Pneumonia - Tuberculosis or Subphrenic abscess - Systemic diseases such as rheumatoid arthritis and SLE
Venous disease
A blind-ending track -typically lined by epithelial or granulation tissue - which opens onto an epithelial surface
Lead shields to protect the eyes and gonads - Dose-fractionation - Prior chemotherapy - Regional hypothermia - Radiolabelled antibodies

14. What are the categorical causes of digital clubbing?
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
Neuropathic - 45 to 60% of ulcers - Ischaemic due to peripheral occlusive arterial disaese - 10% of ulcers - Mixed neuroischaemic - 25-45% of ulcers
It is a collagen vascular disease - caused by infiltrate of plasma cells into the arterial wall - This leads to luminal thrombosis and affects small and medium-sized arteries of the lower limb - Eventually - collagen is deposited and forms a thick fi
Idiopathic Which is the most common - Gastrointestinal - Respiratory - Cardiac - Rare causes

15. What is a branchial cyst?
Tumours raised above the skin : excision with 0.5cm margin(maximum) - Tumours not raised above the skin - Wider margin of excision - particularly if at inner canthus of eye -nasolabial fold and ear. A frozen section may be necessary to ensure adequat
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
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
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.

16. What are the complications of atrial fibrillation?
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
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
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
50%

17. What are the congenital predisposing factors for malignant melanomas?
Parafollicular C Cells
The pain is caused by a reduced blood supply to the distal aspects of the limb. The pain gets worse at night because the perfusion of the limb is further reduced when the patient is lying down - This is due to: Decreased cardiac output at night - Red
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives
Ultrasound will show: Presence of underlying liver disease - Degree of dilatation of the common bile duct(>8mm is abnormal) - Presence of gall stones - Presence of lymphadenopathy or a pancreatic mass - CT Scan - ERCP - MRCP

18. What elements are ascertained in a thyroid history with regards to symptoms arising from the swelling?
Duration and change in size - Cosmetic symptoms - Discomfort during swallowing/dysphagia - Dyspnoea - Hoarseness - Pain
Temperature - Capillary Refill - Peripheral Pulses
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)
10% per year

19. What are the elements of the reconstruction ladder?
Benign skin lesions: Moles -freckles -lentigo -pigmented seborrhoeic keratoses - dermatofibromas and thrombosed haemangiomas - When it comes to malignant skin lesions - pigmented basal cell carcinomas
Healing by secondary intention - Skin graft - Local flap - Distant flap - Composite flap - Island flaps vs pedicled flaps - Free tissue transfer - Composite neurovascular free tissue transfer
Bronchial carcionoma - Chronic suppurative lung disease(abscess -bronchiectasis -cystic fibrosis -empyema) - Fibrosing alveolitis - Mesothelioma
Bursae - Cystic protrusions from the synovial cavity of arthritic joints - Benign giant cell tumors of the flexor sheath - Rarely : Malignant swelling e.g synovial sarcoma

20. What are the other types of arteriovenous fistula?
Congenital - Multiple arteriovenous fistulae - Traumatic
Diffuse enlargement - smooth or nodular - Solitary nodule
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.
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's

21. Raynaud's disease
Primary disease occurring in isolation
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.
The incompetent vein is at or above the level of the tourniquet
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm

22. Assuming a patient has obstructive jaundice - how should this patient be investigated?
The aorta is narrowed below the origin of the left subclavian artery and therefore blood flow to the abdomen and legs is reduced - The prominent vessels over the back are large collateral that have developed to bypass the obstruction and supply the l
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
Non-Surgical - mechanical pressure therapy(day and night for up to 1 year) and topical silicone gel sheets - Surgical : Revision of scar with closure by direct suturing - local Z-plasty or skin grafting to avoid excessive tension - Intralesional ster
Non-Surgical : leave alone if asymptomatic and if patient does not want intervention - Surgical : Simple excision followed by histology

23. What are the majore causes of hepatic jaundice?
Hepatitis - Decompensated chronic liver disease - Drugs
Multiple telangiectasia around the mouth and on the tongue and lips
Low approach - Lockwood - Transinguinal repair - Lotheissen - High approach - McEvedy
Medical : treat underlying condition - saline cleansing - high-dose oral or intralesional steroids plus/minus cyclosporin - Surgical : serial allograft followed by autologous skin graft or muscle flap coverage when necessary

24. How can the extent of the obstruction be determined?
The pressure cuff is inflated over the upper arm and the systolic pressure measured at the brachial artery using a Doppler probe - The cuff is then placed over the calf. - When the dorsalis pedis pulse has been located with the Doppler - the cuff is
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
An intravenous injection of contrast into the veins in the arm can illustrate the degree of obstruction - A CT Scan of the thorax may demonstrate the cause of the obstruction and the length of the SVC affected
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.

25. What should be done prior to surgery in the surgical treatment of an incisional hernia?
Haemorrhage - Hoarseness - Hyperthyroidism
Cardiac and respiratory disease should be controlled first - Other risk-factors should be optimized - Preoperative weight loss should be encourage
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
More worrying features for a tumour would include: Thick or irregular wall - Extensive calcification within the cavity or wall of the cyst - Multilocular cysts

26. How might a patient with a popliteal aneurysms present?
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
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.
The face can be affected in patients with: Syringomyelia - Frey's syndrome
It helps to give an indication as to What the exact aetiology is.

27. How would you treat a branchial cyst?

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28. What are the two main systems which need to be examining thyroid status in a surgical patient?
The cyst may be surgically excised - whole if possible - although this may be difficult if there has been previous infection - Bonney's blue dye can be injected into the fistula/sinus allowing accurate surgical excision and therefore reduces recurren
Non-surgical - same as in incisional hernia with possible investigations : LFTs - H.pylori serology and Upper GI endoscopy
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
Hands and Eyes

29. What are the risk factors for arterial disease
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
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
Iodine deficiency - Increased physiological demand - Goitrogens(less common) - Defects of thyroid hormone production
Rolled or raised edge - Often on sun-damaged skin

30. What would you tell patients about their recovery from inguinal hernia repair?
Rapid growth and pain(on history) - Hyperemic hot skin - Hard consistency - Fixed to skin and underlying muscle - Irregular surface or ill-defined edge - Facial nerve involvement
Blood Tests:Haematological - FBC - ESR - Biochemical : TFT - ACE Levels(raised in sarcoidosis) - Serological : 'monospot' or Paul-Bunnell test looking for atypical mononuclear cells in infectious mononucleosis - Radiological : Ultrasound - CT Scan an
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
The advantages of having surgery are a six-fold reduction in the rate of stroke at 3 years - The operative risk of stroke is 2% and operative mortality 1-2% - Specific risks of haematoma -hypoglossal nerve injury and numbness of the ipsilateral earlo

31. What do you know about simple colloid goitres?
Commonest form of thyroid abnormality - Secondary to hyperplasia of the gland to meet physiological demand for thyroxine - Secondary to defective production of thyroid hormone
Increased sweating - Palmar erythema - Thyroid acropachy - Onycholysis - Areas of vitiligo - Pulse - Fine Tremor
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema
Are you having difficulties swallowing liquids - or solids - or both? - Did the problem start suddenly or was the onset gradual? - Do you ever regurgitate food? - Can you eat a full meal? - How long have you had this problem for? - Where does the foo

32. What does minimally invasive surgery involve in the surgical treatment of a pharyngeal pouch?

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33. How should one conclude a thyroid examination after examining the patient from the back?
Congenital - Multiple arteriovenous fistulae - Traumatic
Anxiety - Hyperthyroidism - Hyperhidrosis erythematosus traumatica - Phaeochromocytoma
Auscultation - Percussion of the thyroid gland and downwards for retrosternal extension
Temperature - Capillary Refill - Peripheral Pulses

34. What are the features of a femoral hernia?
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
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
Hyperthyroidism - Late Hypothyroidism - Later Hyperparathyroidism
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

35. What other conditions cause odynophagia?
Liver - fatty change - chronic active hepatitis -cirrhosis and amyloid deposition - Gall bladder and bile ducts - gallstones - sclerosing cholangitis - and cholangiocarcinoma
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
Infections within the oesophagus especially candidiasis and herpes simplex - Pharyngitis - Occasionally ulceration over the lower third of the oesophagus
Non-surgical : can be left alone on patient's wishes as it is a benign lesion - Surgical : as the keratoses lies above the level of the surrounding normal epidermis - it can be treated by superficial shaving or cautery.

36. What are the treatment options available for Basal Cell Carcinoma?
Second most common type - Occurs most often on the trunk - Polypoid in shape and is raised - Smooth surface - Irregular edge - Frequently ulcerated
Mnemonic : CHIASMA - Congestive : cardiac failure - Haematological : reticuloses - Infection : viral -bacterial -protozoal - Amyloid - Storage disorders : Wilson's disease - haemochromatosis - Masses: primary/secondary neoplasia - Autoimmune/alcohol
Tumours raised above the skin : excision with 0.5cm margin(maximum) - Tumours not raised above the skin - Wider margin of excision - particularly if at inner canthus of eye -nasolabial fold and ear. A frozen section may be necessary to ensure adequat
A blind-ending track -typically lined by epithelial or granulation tissue - which opens onto an epithelial surface

37. What is the differential diagnosis for an enlarged kidney?
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
Extrahepatic : caused by increased resistance to flow e.g : portal or splenic vein thrombosis - Intrahepatic : due to cirrhosis - right heart failure - sarcoidosis and schistosomiasis(the latter is the most important cause worldwide - ova of the para
Congenital : Cystic disease - horseshoe kidney - hypertrophic single kidney - Acquired : Diseases specific to the kidney such as solitary cysts - tumours - hydronephrosis - pyonephrosis - perinephric abscess and renal vein thrombosis and diseases as
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

38. What are the two types of ptosis?
Unilateral - Bilateral
Ischaemic ulcers can be extremely painful and even removing the bandages from around the ulcer can cause pain that lasts for several hours. The analgesic ladder would be appropriate in this situation starting from simple oral agents -stronger oral ag
Via the lymphatic route(Y for yellow = lymph)
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair

39. Where is the midinguinal point?
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
Recurrence of the cyst - Developement of a chronic -discharging sinus
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery
Hypertrophic scars tend to appear soon after injury and usually regress spontaneously - while keloid scars appear months after injury and continue to grow

40. How should one treat a sebaceous cyst?
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
Non-Surgical : May be left alone if small and asymptomatic - Surgical : To prevent recurrence - complete excision of the cyst and its contents is required and this is done through the removal of an elliptical portion of skin containing the punctum.
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma
A caring and competent approach - A good examination technique - An ability to elicit and draw conclusions from physical signs

41. What will you observe on angiography of a chemodectoma?
A blind-ending track -typically lined by epithelial or granulation tissue - which opens onto an epithelial surface
A hypervascular mas displacing the bifurcation of the carotid arteries
Extrahepatic : caused by increased resistance to flow e.g : portal or splenic vein thrombosis - Intrahepatic : due to cirrhosis - right heart failure - sarcoidosis and schistosomiasis(the latter is the most important cause worldwide - ova of the para
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

42. What are the venous symptoms in thoracic outlet obstruction more commonly due to?
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
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
The aim of bypass is to provide a systemic circulation while the heart is stopped and emptied of blood.
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery

43. What are the major causes of post-hepatic jaundice?
Sacrum - Greater trochanter - Heel - Lateral Malleolus - Ischial Tuberosity - Occiput
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.
Gall stones - Carcinoma head of pancreas - Lymph nodes
Motor - Secretomotor - Taste - Sensory

44. What are the causes of gangrene?

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45. What investigations would you do when investigating parotid tumours?
Fine-needle aspiration cytology for diagnosis - MRI to exclude deep-lobe involvement
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
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.

46. What are the signs in the mouth of Peutz-Jegher disease?
Elderly(A for Aged)
Simple colloid goitre - Graves' disease - Thyroiditis
The elective mortality from open AAA repair is 5% but this figure may be lower in specialist centres - If the patient suffers a ruptured aneurysm and reaches the hospital - their operative mortality rises to 50% - but only 50% of patients reach hospi
Pigmented freckles around the lips and inside the mouth - associated with intestinal intussusception and gastrointestinal bleeding from colonic polyps

47. How would you demonstrate to an examiner that a mass in the right upper quadrant is indeed an enlarged liver(hepatomegaly)?
Irregular or nodular surface - Poorly defined edge with areas which are more like normal breast tissue in between more abnormal areas - Consistency : breast tumours are usually firm - rather than hard - Tenderness : usually non-tender - Fluctuation :
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.
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
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

48. It is know that the pulses are preserved in the diabetic - why is this?
Coarctation may be associated with:Bicuspid aortic valcves - Aortic stenosis - Aneurysms in the circle of Wilis
Black discolouration of the skin
Commonest in children and young adults(P for Paediatric)
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

49. What are the features of spider naevi?
Anxiety - Hyperthyroidism - Hyperhidrosis erythematosus traumatica - Phaeochromocytoma
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
malignant change?
Less than 0.5

50. How is 'matching' of transplanted kidneys performed?
Ischaemic ulcers can be extremely painful and even removing the bandages from around the ulcer can cause pain that lasts for several hours. The analgesic ladder would be appropriate in this situation starting from simple oral agents -stronger oral ag
At two levels:ABO Compatibility - HLA Compatibility
Treatment is essentially surgical - Operation of choice is Sistrunk's operation - Inject patent track with dye at the start of the operation - Excise cyst and the patent or fibrous track which runs through the central portion of the hyoid bone(Which
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