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Clinical Surgery

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1. What are the indications for preoperative Duplex ultrasound scanning
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
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
Vascular - Cerebrovascular accident - Tumour - acoustic neuroma - Infection - Meningitis(rarely
Stroke is the third leading cause of death in the west and 85% of strokes are thromboembolic - caused by atherosclerosis at the carotid bifurcation or proximal (2-3cm) internal carotid artery.

2. What is the pathogenesis of umbilical herniae?
These are due to a defect through the linea alba adjacent to the umbilicus and usually due to obesity stretching the fibres.
Essentially to treat complications not amenable to medical therapy such as:Intra-abdominal abscesses that cannot be drained radiologically - Enterocutaneous fistulae - Stenosis causing obstructive symptoms - Control of acute/chronic bleeding
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.
Treatment with radiotherapy and doxorubicin gives best survival of 1 year

3. How is Sjogren's clinically diagnosed?
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)
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.
Clinical diagnosis if at least two or the following triad is present: Keratoconjunctivitis sicca(dry eyes) - Xerostomia(dry mouth) - Associated connective tissue disorders such as rheumatoid arthritis(50% of cases) - scleroderma -SLE -Polymyositis or
Prehepatic jaundice can occur due to haemolysis - especially following a transfusion - Hepatic jaundice can result from the use of halogenated anaesthetics - sepsis or intra- or postoperative hypotension - Post-hepatic jaundice can occur due to bilia

4. What are the signs in the mouth of Addison's disease?
Mouth and lips are hyperpigmented
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin
Chest x-ray to map the caudal extent of the cystic hygroma - CT/MRI scanning especially if it is complex
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

5. How do you treat this condition?
Lord's plication - Jaboulay's operation
Reassurance - if symptoms are not distressing for the patient Medical - aluminium hexachloride solution painting for axillary hyperhidrosis Surgical - Axillary - excise hair bearing/intradermal Botulinum A Neurotoxin - Palmar - cervical sympathectomy
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
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

6. What is a cystic hygroma?
It helps to give an indication as to What the exact aetiology is.
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
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.
Simple mastectomy - Modified radical mastectomy(patey) - Radical mastectomy(Halsted mastectomy) - Extended radical mastectomy

7. What is the order of skin changes seen in Raynaud's?
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis
Mnemonic: WBC - White - blanching of digits - Blue - cyanosis of pain - Crimson - reactive hyperaemia - fingers turn red in colour
SRSN -OPD -RAT - Site - Radiation - Severity - Nature - Onset - Periodicity - Duration - Relieved by - Accentuated by - Timing

8. How is hypersplenism brought about?

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9. What is the operative mortality of amputations?
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
Superior thyroid artery - Inferior thyroid artery - Thyroidea ima(in 3% of people)
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's
20%

10. What is the prophylactic treatment of pressure sores?
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
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 -
Pre-hepatic - Hepatic - Post-hepatic
'Watch and wait' or aspiration followed by 3 weeks of immobilzation

11. What are the predisposing factors for Raynaud's phenomenon?
Simple colloid goitre - Graves' disease - Thyroiditis
Acute severe ulcerative colitis - MPS - toxic Megacolon - Perforation - rare in absence of toxic dilatation and raises possibility of Crohn's disease. The mortality is 40% - Severe gastrointestinal bleeding - Chronic ulcerative colitis - 3 Ms - Medic
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
Primary Raynauds is due to vasomotor malformation - Secondary Raynauds occurs as a consequence of pathology affecting the vessel wall

12. What is the difference between a false and a true aneurysm?
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
Myelofibrosis - Chronic Myeloid Leukaemia - Malaria - Tropical splenomegaly - Kala-azar(visceral leishmaniasis)
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
An aneurysm is an abnormal dilatation of a blood vessel - A true aneurysm involves all layers of the arterial wall - A false aneurysm follows a partial laceration of the vessel wall causing blood to leak out of the vessel into the surrounding tissues

13. What tissues do skin graft not take on?
Unhealthy -necrotic and infected tissue - Irradiated tissue - Exposed cortical bone without periosteum - Tendon without peritendon - Cartilage without perichondrium
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
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
Pigmented freckles around the lips and inside the mouth - associated with intestinal intussusception and gastrointestinal bleeding from colonic polyps

14. What radiological investigations would be helpful in distinguishing the different causes?
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.
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
Mainly teratoma or seminomas - other types are: Embryonal carcinoma - Choriocarcinoma - Yolk sac tumour - Leydig cell tumours - Sertoli cell tumours - Lymphoma
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

15. What is the treatment of a chemodectoma?
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
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
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
Surgical excision with preoperative embolizatoin if the tumour is large - Ultrasonic surgical dissection may also be used - Radiotherapy is used for patients unfit for surgery or for large tumours

16. What are the surgical principles in the treatment of a femoral hernia?
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
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation
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
A pyogenic granuloma is a rapidly growing capillary haemangioma whic usually measures less than 1cm in diameter

17. What are the causes of facial nerve palsy?
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
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
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.
Intracranial - Intratemporal - Extratemporal

18. What is a ganglion?
Preoperative - Age -Immunocompromised state -obesity -malignancy -abdominal distension from obstruction or ascites - Operate - Poor technical closure of the wound -placing drains through wounds - Postoperative - wound infection or haematoma - early m
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
Thyroid function tests - hyperthyroid - Ultrasound - dimensions of goitre and nodules looking for dominant nodules or cysts for FNAC - Chest X-ray as a retrosternal goitre may compress the trachea
A cystic swelling related to a synovial lined caivity - either a joint or a tendon sheath

19. What is the causes of the carotid artery aneurysms?
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms
True aneurysms are uncommon and are generally caused by atherosclerosis - and occasionally by dissection -trauma -previous carotid surgery or infection - When a true aneurysm has been excluded - the patient can be reassured and discharged. - Dilated
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
Below Knee - Above Knee

20. What are the taste branches of the facial nerve?
Via chorda tympani to anterior two-thirds of the tongue
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
Early - haematoma - Intermediate - Infection and nerve damage e.g saphenous in stripping - Late - Recurrence
General - Specific

21. Which patients should have their aneurysms repaired?
Size - Tenderness - Mobility - Consistency
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)
1
Ultrasound - first line - Which is used to define the liver architecture and give an idea of the size and may identify the pathology - Contrast-enhanced CT may also be useful - especially to further investigate solid lesions

22. What is the operative mortality of AAA repair?
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
Patient must be standing up as he or she must be able to see the stoma - The stoma must be within the rectus abdominis muscle - Away from scars or skin creases - Away from bony points or waistline of clothes - At a site that is easily accessible to t
Superficial spreading at 70% of malignant melanomas
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

23. What are the motor branches of the facial nerve?
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present
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
Increase in size - Ulceration - Change in colour - Irritation - Bleeding - Halo of pigmentation - Satellite nodules - Enlarged local lymph nodes - Evidence of distant spread
Nerve to stapedius - Nerve to posterior belly of digastric - Five divisions within the parotid gland - temporal - zygomatic - buccal - mandibular and cervical

24. How would you treat a congenital dermoid cyst?
Grade 3 compression stockings to apply 40mmHg pressure at the ankles - Intermittent pneumatic compression device - Cellulitis should be treated - Advise patient to elevate their leg as much as possible and stress the importance of cleanliness and car
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
Surgical treatment involved complete excision but the full extent of the cyst should be established with suitable radiographic views such as x-ray or CT scan.
A cystic swelling related to a synovial lined caivity - either a joint or a tendon sheath

25. What are the medical options for Raynauds?
A horizontal ellipse of stretched supra or infra-umbilical skin is excised - deeping the incision to the rectus sheath and identifying the fibrous band Which is the neck of the sac - The sac is dissected free from the surrounding tissues - which may
As the perfusion of the leg begins to decrease in a patient with peripheral vascular disease; the ratio begins to fall.
Mean age is 50 years at presentation(F for fifty)
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists

26. What are the types of lung resection?
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection
Wound complications - Recurrence - Damage to adjacent neurovascular structures
Mneumonic : I - CHUM - Infection(frequent) - Calcification - Ulceration - sebaceous Horn formation - Malignant change
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

27. What is a hydrocoele?
Infection - acute and chronic otitis media - herpes zoster(ramsay hunt syndrome) - Idiopathic - Bell's Palsy - Trauma - surgical -accidental - e.g basal skull fracture - Tumour - paraganglioma - squamous cell carcinoma of external or middle ear - met
Excess accumulation of fluid in the processus vaginalis.
Cardiac and respiratory disease should be controlled first - Other risk-factors should be optimized - Preoperative weight loss should be encourage
Solar keratosses are squamous cell carcinoma in situ

28. How would you prepare a patient who is going for surgery which will involve forming a stoma?
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.
Psychosocial and physical preparation - Explanation of indications and complication - Involving a Clinical Nurse Specialist in Stoma Care preoperatively who would normally mark the site - Marking of the stoma site
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
40 X increased risk of developing lymphoma - usually B-Cell non-Hodgkin's type

29. What are the non-surgical treatment options for lymphoedema?
Grade 3 compression stockings to apply 40mmHg pressure at the ankles - Intermittent pneumatic compression device - Cellulitis should be treated - Advise patient to elevate their leg as much as possible and stress the importance of cleanliness and car
White lines and streaks inside the mouth
Black discolouration of the skin
Superficial spreading at 70% of malignant melanomas

30. What other investigations can be done for Sjogren's syndrome?

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31. What are the features of superficial spreading melanoma?
Hands and Eyes
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
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
Occurs most often on the legs of women and the backs of men - Red -white and blue in colour - Irregular edge - Usually palpable but thin

32. What are the 'transudate' causes of a pleural effusion?
Cardiac failure - Metabolic disorders leading to hypoalbuminaemia such as Cirrhosis and Nephrotic syndrome
Surgical treatment involves complete excision of the cyst.
Epigastric pain - which may increase after meals - May be acutely painful after physical exercise - Nausea and early satiety - Reflux and non-ulcer dyspepsia
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

33. What do you know about thyroid malignancy?
Xeroderma pigmentosum - Gorlin's syndrome
Congenital - Usually due to a cervical rib(arising from the seventh cervical vertebra) and the subclavian artery is compressed between the rib and either the scalenus anterior muscle or the clavicle - Acquired - The obstruction may also follow a frac
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)
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s

34. What are the indications of median sternotomy?
The patient should have a full workup for atherosclerosis - General investigations : Urinalysis for proteinuria - marker of atherosclerotic renal disease - Blood tests: FBC for anemia - which might precipitate symptoms - Renal function for possible u
They are known as adiposis dolorosa or Dercum's disease.
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
Emergency procedures e.g following penetrating chest trauma - Cardiac surgery - Resection of lung cancer

35. 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
Patient must be standing up as he or she must be able to see the stoma - The stoma must be within the rectus abdominis muscle - Away from scars or skin creases - Away from bony points or waistline of clothes - At a site that is easily accessible to t
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion
Diffuse enlargement - smooth or nodular - Solitary nodule

36. How do you classify skin flaps?
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
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
Often surgeons place two drains - one in the axilla and one at the site of surgery within the breast tissue - The drains are usually left for 3 to 5 days or until the drainage volume is less than 50mL in 1 day. - Patients can safely be sent home with
Bilateral subtotal thyroidectomy leaving approximately 4g of thyroid tissue on each side of the trachea

37. What are the two main systems which need to be examining thyroid status in a surgical patient?
An aneurysm is an abnormal dilatation of a blood vessel - A true aneurysm involves all layers of the arterial wall - A false aneurysm follows a partial laceration of the vessel wall causing blood to leak out of the vessel into the surrounding tissues
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.
Hands and Eyes
Conservative - Medical - Surgical

38. What do you know about the epidemiology of keloid scars?
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
May affect people from puberty to 30 years - Females are more affected than males - Black and Hispanic Races are effected the most.
More worrying features for a tumour would include: Thick or irregular wall - Extensive calcification within the cavity or wall of the cyst - Multilocular cysts

39. What are the complications of a cystic hygroma?
Complications include cosmetic symptoms but important problems are encountered in the perinatal period: Before delivery it may obstruct delivery - After delivery : respiratory obstruction and obstruction of swallowing
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.
It can be classified according to cause: Malignancy - Infections - e.g filiaris - tuberculosis - Post Surgery or Radiotherapy - axillary dissection in breast surgery and inguinal irradiation
Mechanical obstruction - Coordination abnormalities

40. What are the 3 objectives that one should look out for in the palpation of varicose veins?
Venous disease
State of the skin/subcutanaeous tissues - Sites of fascia defects - Site of incompetence(including the Trendelenburg and Tourniquet Tests)
Mneumonic : BEDD - Base - Edge - Describe structure visualized at the base of the ulcer - Discharge
Lymphocyte-mediated destruction of the exocrine glands secondary to B-cell hyper-reactivity and associated loss of suppressor T-Cell activity

41. What are the signs in the mouth of acanthosis nigricans?
Lord's plication - Jaboulay's operation
The characteristic presentation is insidious with progressive weight-loss and dysphagia - The patient initally hass difficulty swallowing solids and often describes the food getting stuck in the lower part of the oesophagus - They may also describe o
Black discolouration of the skin
Angiolipomas - Hibernomas - Bannayan-Zonana Syndrome

42. Where does a liposarcoma arise from?
Often surgeons place two drains - one in the axilla and one at the site of surgery within the breast tissue - The drains are usually left for 3 to 5 days or until the drainage volume is less than 50mL in 1 day. - Patients can safely be sent home with
The 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
It arises de novo
It is often advised as the problem usually gets worse with age and there is risk of infertility.

43. How would you treat this condition?

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44. What are the neurological symptoms in thoracic outlet obstruction more commonly due to?

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45. What will the Fine Needle Aspiration Cytology show you in the investigation of Cervical Lymphadenopathy?
Reassurance - if symptoms are not distressing for the patient Medical - aluminium hexachloride solution painting for axillary hyperhidrosis Surgical - Axillary - excise hair bearing/intradermal Botulinum A Neurotoxin - Palmar - cervical sympathectomy
It will show you if it is malignant or inflammatory
Nephrotic syndrome - Tuberculosis - Chylous ascites
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

46. What are the causes of superior vena cava obstruction?
Least common - Occurs on hairless skin - Irregular area of brown or black pigmentation
Usually occurs in the over 50s although it may affect younger patients. It is the most common causes of a renal mass in women of childbearing age - Beck's Triad of: Haematuria - Mass - Loin Pain
Causes can be divided into pathology within and outside the SVC. Within the SVC obstruction tends to be as a consequence of thrombosis within intravenous jugular or subclavian lines(CPV Lines) - especially when hyperosmolar solutions are infused for
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

47. What are the surgical options in Crohns disease?
Intra-abdominal abscesses should be drained - Colonic defunctioning using a loop ileostomy may be needed for patients who have failed medical therapy - Occasionally a subtotal colectomy and permanent ileostomy may be needed - Pouch surgery is general
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
Essentially to treat complications not amenable to medical therapy such as:Intra-abdominal abscesses that cannot be drained radiologically - Enterocutaneous fistulae - Stenosis causing obstructive symptoms - Control of acute/chronic bleeding
10% per year

48. What is the normal ABPI?
1
History and Clinical Examination - they usually present incidentally but occasionally with a renal mass or haematuria
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision
Via chorda tympani to anterior two-thirds of the tongue

49. What are the seven signs in the eyes that one should look out for when assessing the thyroid status?
Treatment with radiotherapy and doxorubicin gives best survival of 1 year
Loss of hair on outer-third of eyebrows - Lid retraction - Lid lag - Ophthalmoplegia - Exophthalmos - Chemosis - Proptosis
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
Gumma of tertiary syphillis has a typical punched-out ulcer - over the anterior surface of the lower leg and has a yellow coloured 'wash leather' base. - Scalloped border

50. What is the differential diagnosis of a dermatofibroma?
It is important to exclude malignant tumours such as: Malignant melanoma - Basal cell carcinoma
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
Weight loss - Change in bowel habit - Loss of appetite - Back pain
Thyroidectomy

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