Clinical Surgery

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1. How does radiotherapy work?
Less than 0.5
Lord's plication - Jaboulay's operation
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
Mneumonic : LIST Lymphoma and Leukaemia - Infection(further subdivided into Bacterial - Viral - Protozoal and Toxoplasmosis) - Sarcoidosis - Tumours


2. What are the features of an indirect inguinal hernia?
1
Remnants of a patent processus vaginalis - Arise from the abdominal cavity lateral to the inferior epigastric vessels at operation - passing obliquely through the deep inguinal ring and travelling along the inguinal canal with the spermatic cord - Ma
Sunlight - Pre-existing skin lesions - Previous melanoma
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


3. What are the surgical treatment principles of incisional hernia?
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
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
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


4. Assuming a patient has obstructive jaundice - how should this patient be investigated?
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological
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
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
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


5. What are the two main categories of causes of dysphagia?
Mechanical obstruction - Coordination abnormalities
A pharyngeal pouch is formed by the herniation of pharyngeal mucosa(known as a pulsion diverticulum) through its muscular coat at its weakest point(Killian's dehiscence) between the thyropharyngeal and cricopharyngeal muscles that make up the inferio
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
Mnemonic : L-SHAPE - Lymph node/Lipoma of the cord - Sapheno-varix/Skin lesions(sebaceous cyst/lipoma -etc) - Hernia - inguinal or femoral - Aneurysmal dilatation of the femoral artery - Psoas abscess or bursa - Ectopic/undescended testes


6. What are the indications for preoperative Duplex ultrasound scanning
Non-surgical - same as in incisional hernia with possible investigations : LFTs - H.pylori serology and Upper GI endoscopy
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
Cardiac failure - Metabolic disorders leading to hypoalbuminaemia such as Cirrhosis and Nephrotic syndrome
Affect any age - Males = females - All races may be affected


7. What do you know about thyroid cysts?
Non-Surgical - Reassure and 'Watch and Wait' - Surgical - Reason : Pain/Cosmesis and this is done with suction lipolysis via a small - remote incision Which is performed under local anaesthetic as a day case.
Soft-tissues(lipoma -dental cyst) - Dental origin(infection) - Muscular origin(hypertrophy of masseter muscle) - Bony origin(winged mandible -transverse process of atlas/axis) - Neoplasia(infratemporal fossa and parapharyngeal tumours)
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
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


8. Simple cysts are found in 33% of patients by the age of 60. How should they be managed?
Increased sweating - Palmar erythema - Thyroid acropachy - Onycholysis - Areas of vitiligo - Pulse - Fine Tremor
Klippel-Trenaunay-Weber Syndrome - Parkes-Weber syndrome
Conservative - Medical - Surgical
History and Clinical Examination - they usually present incidentally but occasionally with a renal mass or haematuria


9. What are the two types of ptosis?
These can be divided into large and small vessel arterial disease: Large vessel - atherosclerosis and thrombangiitis obliterans - Small vessel - Diabetes Mellitus - Polyarteritis nodosa and rheumatoid arthritis
Hyperkeratoses(thickening of the keratin layer) - Focal parakeratosis - Irregular acanthosis - Basal layer atypia only
Low approach - Lockwood - Transinguinal repair - Lotheissen - High approach - McEvedy
Unilateral - Bilateral


10. How would you treat a pyogenic granuloma?
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological
Non-surgical : regression is uncommon - except those arising in pregnancy and so they are best treated surgically - though occassionally a silver nitrate stick can be attempted - Surgical : curettage with diathermy of the base or complete excision b
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists
Intracranial - Intratemporal - Extratemporal


11. What are the surgical treatment options for hydrocoele?

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12. What are the important elements in the description of an ulcer?
Via greater superficial petrosal nerve to lacrimal - nasal and palatine glands
Mneumonic : BEDD - Base - Edge - Describe structure visualized at the base of the ulcer - Discharge
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s
Duplex Ultrasound - Angiography - CT/MRI


13. What are the three objectives to be taken note of in the palpation part of the arterial examination?
Small red capillary naevus - Develops on the trunk in middle-age - No clinical significance
A furuncle results from infection of hair follicles with Staphylococcus aureus
Temperature - Capillary Refill - Peripheral Pulses
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection


14. What are the functions of the spleen?
Discolouration - Discharge - Depression - Deviation - Displacement - Destruction - [Duplication - unlikely in the exam]
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
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
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)


15. What are the indications for an amputation?
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
Pigmented freckles around the lips and inside the mouth - associated with intestinal intussusception and gastrointestinal bleeding from colonic polyps
The face can be affected in patients with: Syringomyelia - Frey's syndrome
Lymphangiomas can be:Cystic - Solid or diffuse - Cutaneous


16. What features of the lump would make you suspicious that it is breast cancer?
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 :
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
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s
They are known as adiposis dolorosa or Dercum's disease.


17. What is a cystic hygroma?
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.
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.
Site and size of varicosities - including the presence of saphena varix - Skin for changes and scars - Swelling of the ankle
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


18. What is the surgical treatment of lymphoedema?
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
Debulking or bypass procedures - Direct lymphovenous anastamosis - Stripping a piece of intestinal mucosa - exposing the rich submucosal plexus - this can then be used to replace a leg lymph node which then forms new connections with distal lymphatic
Palomo operation
Multinodular goitre - Toxic - Simple colloid goitre - Thyroiditis - Neoplasia


19. What are the two main types of aetiologies in the differential diagnosis of a unilateral swelling of the parotid gland?
Arising inside the parotid gland - Arising outside the parotid gland
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.
(H)infection - Hypoparathyroidism which leads to hypocalcemia
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema


20. How might you be aware the transplant rejection is occurring?
Peripheral Neuropathy
Tenderness over the graft - Reduction in urine output - Rising creatinine
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
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.


21. What is primary lymphoedema?
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
Xeroderma pigmentosum - Gorlin's syndrome
Refers to congenital disease or primary lymphatic failure. It is three times more common in women and the pathology originates from within the lymphatics. It is also known as Milroys disease.
Auscultation - Percussion of the thyroid gland and downwards for retrosternal extension


22. What is the differential diagnosis for an enlarged kidney?
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.
Commoner in females - Results from polyclonal immunoglobulins against thyroid-stimulating hormone receptor Which bind and stimulate the receptor - these antibodies are found in 90% of patients - Hyperthyroidism with goitre - Thyroid eye disease - Thy
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair
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


23. What is lid lag secondary to ?
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
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
For patients who refuse radiation therapy or relapse after an adequate course - pregnant patients or those wishing to become pregnant within 4 years - patients under the age of 40 years and those with nodular or large goitres
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


24. What are the main points that doctors are looking for during the Surgical OSCEs?
A caring and competent approach - A good examination technique - An ability to elicit and draw conclusions from physical signs
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
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
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


25. What is the embryological origin of a thyroglossal cyst?
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation
Lymphangiomas can be:Cystic - Solid or diffuse - Cutaneous


26. What are the surgical options available for deep venous occlusion/reflux

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27. What are the mechanical obstruction causes of dysphagia?

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28. What are the features of ulcers in patients with squamous cell carcinoma?
Mouth and lips are hyperpigmented
Chest infection due to pulmonary aspiration - Diverticular neoplasia in less than 1% of cases
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
Rolled or raised edge - Often on sun-damaged skin


29. What is a chemodectoma?
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
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
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
Cardiac failure - Tricuspid regurgitation - Constrictive pericarditis


30. What is a lipoma?
A lipoma is a benign tumour consisting of mature fat cells.
Complications should be divided into specific to the amputation and general for any operation - and also immediate within 24 hours - early up to 1 month and late beyond 1 month
History and Clinical Examination - they usually present incidentally but occasionally with a renal mass or haematuria
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.


31. What is a fistula?
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)
Hands and Eyes
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
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


32. What are the rare causes of digital clubbing?

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33. In the tourniquet test - What do rapid filling of the collapsed veins below the tourniquet indicate?
The incompetent vein is below the level of the tourniquest
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
Mnemonic : CHIASMA - Congestive : cardiac failure - Haematological : reticuloses - Infection : viral -bacterial -protozoal - Amyloid - Storage disorders : Wilson's disease - haemochromatosis - Masses: primary/secondary neoplasia - Autoimmune/alcohol
Testicular tumours can be mimicked by chronic or old infection leading to scarring such as in orchitis or tuberculosis - Occasionally a long-standing hydrocoele may develop calcification and become harder - clinically similar to a tumour - Tumours oc


34. What would you tell to a lady with varicose veins about the proposed surgery?
A pharyngeal pouch is formed by the herniation of pharyngeal mucosa(known as a pulsion diverticulum) through its muscular coat at its weakest point(Killian's dehiscence) between the thyropharyngeal and cricopharyngeal muscles that make up the inferio
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
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
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


35. What are the major causes of pre-hepatic jaundice?

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36. It is know that the pulses are preserved in the diabetic - why is this?
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
Non-Surgical : leave alone if asymptomatic and if patient does not want intervention - Surgical : Indicated only if malignant growth suspected; post-excision - local regrowth is common as neurofibromata cannot be surgically detached from underlying n
Gall stones - Carcinoma head of pancreas - Lymph nodes
More than five is considered as pathological in chronic liver disease


37. What is portal hypertension?
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
It is due to forced implantation of skin into subcutaneous tissues following an injury. Normally found in areas of the body prone to injury such as fingers. Suspect if you see an adult in exam.
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
Venous gangrene is a rare complication of deep vein thrombosis in the iliofemoral segment and presents in three phases: 1 - Phlegmasia alba dolens - white leg 2 - Phlegmasia cerulea dolens - blue leg 3 - Gangrene - occurs as a consequence of acute is


38. What is Adiposis dolorosa or Dercum's disease associated with?
Primary disease occurring in isolation
Peripheral Neuropathy
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


39. What types of wounds are prone to hypertrophic and keloid scar formation?
Wounds associated with - Infection - Trauma - Burns - Tension especially over the sternum such as after CABG - Wounds on certain areas of the body
Unilateral - Bilateral
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
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.


40. How should epididymal cysts be managed?
Classic Kaposi's sarcoma - AIDS-associated Kaposi's sarcoma - Endemic(central African) variety - Transplantation-associated Kaposi's sarcoma
Non-surgical - if the cyst is not troublesome - it should not be removed - especially in younger men - because there is risk of operative damage and postoperative fibrosis causing subfertility - Surgical - very large or painful cysts can be removed a
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
Raynaud's phenomenon - Thrombangiitis obliterans - Takayasu's arteritis


41. How would you treat hidradenitis suppurativa?
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
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
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
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


42. What are the specific early complications of amputations?

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43. What is the differential diagnosis of hyperhidrosis?
Lymphangiomas can be:Cystic - Solid or diffuse - Cutaneous
Affect any age - Males = females - All races may be affected
Anxiety - Hyperthyroidism - Hyperhidrosis erythematosus traumatica - Phaeochromocytoma
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


44. How would you treat solar keratoses?
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)
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
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin
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


45. What are the medical options for Raynauds?
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation
Rare - Worldwide distribution - Equally common in males and females - Rarely present at birth - 40% present in the first decade and can even present late in the ninth decade
Debulking or bypass procedures - Direct lymphovenous anastamosis - Stripping a piece of intestinal mucosa - exposing the rich submucosal plexus - this can then be used to replace a leg lymph node which then forms new connections with distal lymphatic
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists


46. What are the acquired predisposing factors for basal cell carcinomas?
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.
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion
Clinical examination - Fine-needle aspiration which would show an opalescent fluid containing cholesterol crystals or pus.
Inflammation : inflammatory bowel disease -especially Crohn's disease - Diverticular disease - tuberculosis - Malignancy : Often following spontaneous rupture and abscess formation by the tumour - Radiotherapy : Pelvic irradiation can damage the inte


47. What are the causes of bilateral ptosis?
Inspect - Protrusion of the tongue - Swallowing - Palpate(from the back) - Continue Accordingly(Neck Decision Circle)
Congenital ptosis - Myopathies - Syphillis
Epidermal Cyst - Trichilemmal Cyst
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


48. What do you know about thyroid malignancy?
Third cranial nerve palsy - complete ptosis - Horner's syndrome - partial ptosis - Syphillis
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives
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 incidence is low approximately 4 per 100 -000 per year - The histological varieties are papillary -follicular -medullary - anaplastic and lymphoma(malignant) with papillary being the most common at 70% of the cases.(Mnemonic : MAL-FP)


49. How would you treat a papilloma?
The simplest surgical technique is to excise the papilloma with a sharp pair of scissors - controlling bleeding from the central vascular component with a single suture. Alternatively - diathermy can be used to control the bleeding at the same time a
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
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
The mainstay of treatment of ascites is to treat the underlying condition and to place the patient on a weight reduction program - with the help of diuretic - and a low-sodium diet.


50. What are the general complications of a stoma?
Remnants of a patent processus vaginalis - Arise from the abdominal cavity lateral to the inferior epigastric vessels at operation - passing obliquely through the deep inguinal ring and travelling along the inguinal canal with the spermatic cord - Ma
Thyroidectomy
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
Discolouration - Discharge - Depression - Deviation - Displacement - Destruction - [Duplication - unlikely in the exam]