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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 do you know about thyroid adenomas?
Primary disease occurring in isolation
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
Dohlman's procedure - endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling with less risk of fistula formation and consequent mediastinitis
Almost all are follicular adenomas - Usually 2 to 4 cm and encapsulated at presentation - Indistinguishable from carcinomas on FNAC - as the presence of a capsule cannot be demonstrated - Surgical excision is needed to confirm diagnosis

2. Why do these neuropathic ulcers form?
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
Patient preference - Clinical evidence of multifocal/multicentric disease - Large lump is small breast tissue - this depends of the size of the breast but often defined as a lump more than 4cm - Large area ( more than 4cm) ductal carcinoma in situ -
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.
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

3. What are the features of adult polycystic kidney disease?
Should The Children Ever Find Lumps Readily
Tumour - parotid gland malignancy - Trauma - surgical - accidental e.g facial lacerations
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s
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

4. How would you treat a furuncle?
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland
Non-surgical : risk factor modification such as establishment of good diabetic control and for recurrent infections eradication of nasal carriage of staphylococcus aureus with antiseptics and/or antibiotics such as chlorhexidine and mupirocin - Surgi
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
Increased sweating - Palmar erythema - Thyroid acropachy - Onycholysis - Areas of vitiligo - Pulse - Fine Tremor

5. What are the venous symptoms in thoracic outlet obstruction more commonly due to?
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
If the vessels are normal in calibre - the clinical features may be caused by relatively overactive alpha receptors in the wall - leading to abnormal smooth muscle contraction or changes in elasticity
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery

6. What is an incisional hernia?
Extrusion of peritoneum and abdominal contents through a weak scar of accidental wound on the abdominal wall - Represents a partial wound dehiscence where the skin remains intact
Primary disease occurring in isolation
State of the skin/subcutanaeous tissues - Sites of fascia defects - Site of incompetence(including the Trendelenburg and Tourniquet Tests)
At two levels:ABO Compatibility - HLA Compatibility

7. What are the two types of complications of thyroidectomy?
Should The Children Ever Find Lumps Readily
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
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
General - Specific

8. What are the risk factors for arterial disease
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
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
Arising inside the parotid gland - Arising outside the parotid gland
10% per year

9. What is the prophylactic treatment of pressure sores?
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery
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
Via greater superficial petrosal nerve to lacrimal - nasal and palatine glands
Thyroidectomy

10. What are the surgical principles in the treatment of a femoral hernia?
Duplex Ultrasound - Angiography - CT/MRI
CHIASMA - Congestive : portal hypertension - hepatic vein obstruction - Haematological : reticuloses - Infection : Viral - bacterial - protozoal - Amyloid - Storage disorders : Gaucher's disease - Masses : primary/secondary neoplasia - Autoimmune : F
Increased sweating - Palmar erythema - Thyroid acropachy - Onycholysis - Areas of vitiligo - Pulse - Fine Tremor
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

11. What is the differential diagnosis of a lump in the groin?
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
Plasma alpha feto-protein and beta-HCG - raised levels may indicate a testicular tumor - Testosterone and LH levels to demonstrate hypogonadism - Thyroid function tests
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
Lymphangiomas can be:Cystic - Solid or diffuse - Cutaneous

12. How would you demonstrate a patient's ankle brachial pressure index?
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
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.
Non-surgical - same as in incisional hernia with possible investigations : LFTs - H.pylori serology and Upper GI endoscopy
Treatment involves the use of artificial tears and saliva - use of systemic steroids and careful follow-up due to increased risk of lymphoma development

13. What are the features of ulcers in pyoderma gangrenosum?
Notching on the underside of the ribs may be seen on a chest x-ray - this sign is caused by erosion by the intercostal collateral vessels - On the chest x-ray the aorta may be abnormal - it contains two bulges - the 'three sign' - A barium swallow sh
Undermined edge - Violaceous - Necrotic ulcer with hypertrophic margins
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection
50%

14. How do you classify skin flaps?
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
The Branham-Nicoladoni sign indicates the degree of shunting and cardiac impairment resulting from a large AV fistula - The carotid pulse is palpated and then a tourniquet placed around the proximal affected limb and inflated above systolic pressure
Ulcer is distal to the fistula - Shallow indolent ulcers
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.

15. What is the defective gene in type 1 NF?
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
Defective gene on chromosome 17
Sturge-Weber syndrome is the association of a facial port-wine stain with a corresponding haemangioma in the brain - leading to contralateral focal fits.
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

16. What are the specific complications of a stoma?
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
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
Third cranial nerve palsy - complete ptosis - Horner's syndrome - partial ptosis - Syphillis

17. What are the three basic questions that need to be asked in a peripheral arterial system history?
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
Transfemoral radiological embolization of the testicular vein - using either a spring coil or sclerosant
Vascular symptoms - Risk factors for arterial disease - Fitness for surgery
Rolled or raised edge - Often on sun-damaged skin

18. What are the main points to be elicited during a clerking of the surgical patient?
Demographics - Presenting Complaint - History of Presenting Complaint - Medical and Surgical History - Drugs and any other allergies - Family History - Social History - Systemic Enquiry
Sturge-Weber syndrome is the association of a facial port-wine stain with a corresponding haemangioma in the brain - leading to contralateral focal fits.
Haemorrhage - Hoarseness - Hyperthyroidism
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

19. What questions should one ask to someone with dysphagia?
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
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.
Mnemonic : PACT - Prominent nodule in a multinodular goitre - Adenoma - Cyst/Carcinoma/Lymphoma - Thyroiditis
Duplex - shows area of reflux and deep venous occlusion - Venography - ascending which identifies deep venous patency and perforator incompetence and descending which identifies areas of reflux - Varicography - shows sites of communication - Ambulato

20. What are the signs of chronic venous insufficiency?
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema
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
Epidermal Cyst - Trichilemmal Cyst
The aneurysm is surgically repaired by either an excision bypass -where the popliteal artery is ligated above and below the diseased segment and a graft interposed - or a simple resection and anastamoses without the use of a graft - Acute ischemia ca

21. What are patients with Sjogren's syndrome at risk of?

22. How would you treat solar keratoses?
Angiolipomas - Hibernomas - Bannayan-Zonana Syndrome
Cardiac disease - hypertension -myocardial infarction -ischaemia -mitral valve disease - cardiomyopathy -endocarditis - Respiratory disease - Pneumonia - lung cancer - sarcoidosis - Other: Hypothyroidism and idiopathic ( lone AF)
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin
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

23. What should one do in the general examination of the surgical patient?
Wash Hands - Observe from end of bed - Start examination from right-hand side - Look for JACCOL which means jaundice -anaemia -cyanosis -clubbing -oedema and lymphadenopathy - Observation -Palpation -Percussion and Auscultation
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
Diffuse enlargement - smooth or nodular - Solitary nodule
Motor - Secretomotor - Taste - Sensory

24. What is the definition of an enterocutaneous fistula?
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
Elderly(A for Aged)
Pressure effects - Deafness with involvement of the 8th cranial nerve - Sarcomatous transformation - Intra-abdominal effects - Skeletal changes
A enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and the skin

25. What are the main features of splenomegaly in the clinical examination?
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema
Auscultation - Percussion of the thyroid gland and downwards for retrosternal extension
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 is a skin flap?
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms
The primary lesion could be treated with excision with 1cm margin and Moh's staged chemosurgery with histological assessment of margins and electrodessication - for lesions of the eyelids -ears and nasolabial folds. Radiotherapy is applied for unrese
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
A skin flap consists of tissue - or tissues - transferred from one site of the body to another - while maintaining a continuous blood supply through a vascular pedicle.

27. What are the specific late complications of amputations?
Osteomyelitis - infection transmitted to the bone through the stump - Stump ulceration - can be caused by pressure from the prosthesis - Stump neuroma - Swelling of the distal nerve as it tries to regrow following division; during the initial procedu
Epidermal Cyst - Trichilemmal Cyst
It arises de novo
Lined by stratified squamous or ciliated pseudostratified columnar epithelium - May also contain thyroid or lymphoid tissue - which can undergo malignant change - If malignancy occurs - usually of thyroid papillary type.

28. Why are diabetics particularly prone to foot pathology?
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair
Defective gene on chromosome 22 with variable penetrance - Cutaneous signs are less often seen in this type.
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.
Diabetic neuropathy and peripheral occlusive arterial disease are the major aetiological factors for the development of ulceration and may act alone - together or in combination with other factors such as microvascular disease - biomechanical abnorma

29. Simple cyst Investigations
Urine cytology -blood tests would be expected to be normal and a renal ultrasound scan which shows a cyst with a smooth outline -sharply defined thin wall and no internal echoes(which imply solid components)
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.
The protein content of a sample of effusion fluid is measured and the classification depends on this value:Transudate is equal to a protein value of less than 30g/L - Exudate is equal to a protein value of more than 30g/L
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

30. What other non-surgical treatments are available for ischaemic ulcers?
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise
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
Gangrene is the result of irreversible tissue necrosis and has a number of causes: Diabetes - Embolus and thrombosis - Raynaud's syndrome - Thrombangiitis obliterans - Ergot poisoning - Vessel injury secondary to extreme cold -heat -trauma or pressur
Anaesthesia is more complicated because of the increased risk of stroke - In addition - patients with AF may be anticoagulated and if on warfarin - this medication needs to be discontinued prior to elective surgery - Patients with controlled AF may d

31. What are the causes of venous ulcers?
Cardiac and respiratory disease should be controlled first - Other risk-factors should be optimized - Preoperative weight loss should be encourage
Mouth and lips are hyperpigmented
Intracranial - Intratemporal - Extratemporal
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

32. What do you know about simple colloid goitres?
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
Commonest form of thyroid abnormality - Secondary to hyperplasia of the gland to meet physiological demand for thyroxine - Secondary to defective production of thyroid hormone
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma
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

33. What are the functions of the spleen?
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)
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
Autoimmune condition - Intermittent or constant swelling of one or all of the salivary glands
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer

34. What is the commonest cause of unilateral ankle oedema?
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
Diffuse enlargement - smooth or nodular - Solitary nodule
Black discolouration of the skin
Venous disease

35. What is the pathogenesis of peripheral neuropathy?
Peripheral neuropathy has several effects: Slowly progressive sensory loss - with numbness and tingling of the feet and sometimes also hands. The sensory loss is often glove-and-stocking in distribution and may also be associated with motor impairmen
They can be caused by any disease that leads to a peripheral sensory neuropathy - or by causes of spinal cord disease. Causes of peripheral neuropathy include: Systemic disease - diabetes -vasculitis -hypothyroidism and Vitamin B12 deficiency - Drugs
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
At two levels:ABO Compatibility - HLA Compatibility

36. How do you harvest a skin graft?
Using hand-held skin graft knives or electric or gas powered dermatomes - the latter producing a graft of even thickness from almost any site - with little expertise needed for operation. The donor site is usually one that can be easily concealed for
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
Wound complications - Recurrence - Damage to adjacent neurovascular structures
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise

37. What is Sjogren's syndrome?
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
Autoimmune condition - Intermittent or constant swelling of one or all of the salivary glands
Triple assessment which consists of: Clinical : history and physical examination - Radiological : ultrasound or mammography - Pathological : cytology(fine-needle aspiration) or histological(tru-cut biopsy)
Donor renal artery is anastamosed to either the internal or external iliac artery - The donor renal vein is anastamosed to the external iliac vein - The ureter is anastamosed seperately to the patient's bladder - The renal pelvis the most anterior st

38. How would you treat an acquired dermoid cyst?
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
Chronic Liver disease - Right Heart Failure - Intra-abdominal Malignancy - Hypoalbuminaemia
Auscultation - Percussion of the thyroid gland and downwards for retrosternal extension
Surgical treatment involves complete excision of the cyst.

39. How do you stage malignant melanomas?

40. What are the specific early complications of amputations?

41. What is the significance of the ankle brachial pressure index?
Derived from capillary endothelial cells or from fibrous tissue - It is linked to human herpes virus 8
As the perfusion of the leg begins to decrease in a patient with peripheral vascular disease; the ratio begins to fall.
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.
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

42. What is the differential diagnosis for a skin lesion?
Peripheral neuropathy has several effects: Slowly progressive sensory loss - with numbness and tingling of the feet and sometimes also hands. The sensory loss is often glove-and-stocking in distribution and may also be associated with motor impairmen
Temperature - Capillary Refill - Peripheral Pulses
Idiopathic(50%) - Myeloproliferative disorders - Autoimmune hepatitis - More common in males than females
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

43. What is the surgical treatment of Graves disease?
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
Bilateral subtotal thyroidectomy leaving approximately 4g of thyroid tissue on each side of the trachea
The reason for repairing abdominal aortic aneurysm is to avoid complications - The following aneurysms should be repaired: Symptomatic aneurysms(back pain - tenderness over the aneurysm on palpation -distal embolic events - ruptured/leaked aneurysms)
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

44. What does a hypertrophic scar look like?
Parafollicular C Cells
Scar confined to wound margins - It is found across flexor surfaces and skin creases
Multinodular goitre - Toxic - Simple colloid goitre - Thyroiditis - Neoplasia
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.

45. How is hypersplenism brought about?

46. What are the specific complications of a Cimino-Brescia fistula?
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 :
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
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents
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.

47. How should one examine a lump or swelling?
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
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.
Cervical spondylosis - Pancoast's tumour - Cervical disc protrusions - Ulnar nerve neuropathy
VINTA MEDIC - Vascular - Iatrogenic - Neoplastic - Traumatic - Autoimmune - Metabolic - Endocrine - Degenerative - Inflammatory/Infective - Congenital

48. What are the different histological subtypes of a sebaceous cyst?
Treatment involves the use of artificial tears and saliva - use of systemic steroids and careful follow-up due to increased risk of lymphoma development
Epidermal Cyst - Trichilemmal Cyst
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
A dermoid cyst is a skin-lined cyst deep to the skin. They may be congenital or acquired.

49. What is the surgical treatment of lymphoedema?
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
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological
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
Diet should be normal - Bag should be changed once or twice a day(needs to be emptied more frequently than this if it is urine or fluid faeces) - Ileostomies should have the base plate under the bag changed every 5 days and the bag changed daily - Ps

50. What are the main features of type 2 NF?
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise
Defective gene on chromosome 22 with variable penetrance - Cutaneous signs are less often seen in this type.
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's
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)