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Clinical Surgery

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Answer 50 questions in 15 minutes.
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1. How would you investigate a patient with hepatomegaly?
Blood Tests:FBC - to look for raised white cell count in infection - Liver function - to look out for hypoalbuminaemia or evidence of hepatic dysfunction - Clotting - functional hepatic impairment - CRP/ESR - increased in infection/inflammation and i
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
Site and size of varicosities - including the presence of saphena varix - Skin for changes and scars - Swelling of the ankle
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

2. What syndromes are associated with varicose veins?
Klippel-Trenaunay-Weber Syndrome - Parkes-Weber syndrome
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
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
Tissues with rapid turnover(epidermal layers of the skin - small intestine - bone marrow stem cells) - Tissues with a limited ability to repopulate(spinal cord and gonads)

3. How may pleural effusions be classified?
Collagen antibodies are present in 45% of patients - There is an association with HLA-B5 - Angiography has typical appearances of normal proximal vessels with distal occlusion and 'corkscrew' collaterals.
The 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
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
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present

4. What is the pathogenesis of Raynaud's phenomenon?
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
Mnemonic: DELFT(D) Feeding e.g feeding gastrostomy/jejunostomy - Lavage e.g appendicostomy - Decompression - bypass of an obstructing bowel lesion distal to the stom - Diversion - protection of a distal bowel anastamosis and urinary diversion followi
Wound complications - Recurrence - Damage to adjacent neurovascular structures
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

5. What is the Courvoisier's law?
The causes of pain in the leg can be divided into: Musculoskeletal such as pathologies of the knee -ankle or hip - Neurological such as spinal stenosis which leads to spinal claudication - Vascular such as intermittent claudication and deep vein thro
In the presence of jaundice if a mass(the gall bladder) is palpable in the right upper quadrant - the cause is unlikely to be due to gallstones.
Liver - fatty change - chronic active hepatitis -cirrhosis and amyloid deposition - Gall bladder and bile ducts - gallstones - sclerosing cholangitis - and cholangiocarcinoma
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

6. What investigations are appropriate for deep venous disease?
Definition - Incidence - Sex - Geography - Aetiology - Pathogenesis - Macroscopic Pathology - Microscopic Pathology - Prognosis - Symptoms - Signs - Investigations - Treatment
The commonest presentation is a painless lump or a dull ache in one testis in a young man - Occasionally there is a history of trauma accompanying the discovery of the mass - 10% present with an acutely painful testis - If para-aortic nodes have beco
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
Less than 0.5

7. What is a secondary hydrocoele?
Simple colloid goitre - Graves' disease - Thyroiditis
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma
Tenderness over the graft - Reduction in urine output - Rising creatinine

8. What is the differential diagnosis in basal cell carcinoma?
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
Physical preparation - marking of side - explanation of procedure - anaesthetic work up - Pyschological preparation - Breast care nurse preoperatively and discussion of reasons for mastectomy - option of reconstructive surgery
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer
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

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

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10. What is the embryological origin of a thyroglossal cyst?
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
Pleomorphic adenoma(commonest) and Warthin's tumour
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland
Familial e.g 'hazel nails' - pachydermoperiostitis - Graves' disease - Unilaterally seen in axillary artery aneurysm and brachial arteriovenous malformation

11. What are the appearances of the blood film after a splenectomy?
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.
Bilateral subtotal thyroidectomy leaving approximately 4g of thyroid tissue on each side of the trachea
Increased platelet count and large platelets - Increased neutrophils - Nucleated red cells with Howell-Jolly bodies and target cell - Tend to mount more of a leukocytosis in response to infection
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion

12. In patients with gynaecomastia - what would make you concerned the patient may have a breast cancer?
Colour changes - Trophic changes - Vascular angle
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland
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
Wound complications - Recurrence - Damage to adjacent neurovascular structures

13. What are the causes of a mass in the left iliac fossa?
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.
Similar to those in the right iliac fossa except for the bowel where a mass in the Left iliac fossa could indicate: Diverticular mass Which is often tender - Carcinoma of the colon - Faecal mass
It helps to give an indication as to What the exact aetiology is.
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

14. What do you know about Kaposi's Sarcoma?
Excision for the main lesion with varying margins depending on the size of the lesion. - If there is nodal spread - Fine Needle Aspiration Cytology or Lymph node biopsy - Therapeutic Block Dissection(if palpable lymph nodes) - Palliation adjuvant th
Derived from capillary endothelial cells or from fibrous tissue - It is linked to human herpes virus 8
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
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.

15. What would you tell patients about their recovery from inguinal hernia repair?
Early mobilization is important - They should keep the area clean and wash carefully -especially after the clip/sutures have been removed - They are able to bathe immediately - They may need to be off work for 6 weeks if their job involves heavy lift
Those related to anaesthesia
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
Anxiety - Hyperthyroidism - Hyperhidrosis erythematosus traumatica - Phaeochromocytoma

16. What are the 3 objectives that one should look out for in the inspection of varicose veins?
Treatment involves the use of artificial tears and saliva - use of systemic steroids and careful follow-up due to increased risk of lymphoma development
Defective gene on chromosome 22 with variable penetrance - Cutaneous signs are less often seen in this type.
Site and size of varicosities - including the presence of saphena varix - Skin for changes and scars - Swelling of the ankle
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

17. With which conditions would an ascitic transudate be expected?
A papilloma is an over-growth of all layers of the skin with a central vascular core. They are increasingly common with age.
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
Least common - Occurs on hairless skin - Irregular area of brown or black pigmentation
Cardiac failure - Tricuspid regurgitation - Constrictive pericarditis

18. What are the three objectives to be taken note of in the inspection part of the arterial examination?
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
Carcinoma of the stomach and oesophagus - lymphomas and with endocrine disorders such as acromegaly - Cushing's - diabetes complicated by severe insulin resistance
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)
Colour changes - Trophic changes - Vascular angle

19. What are the two main classifications for thyroid enlargement?
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
Neuropathic - 45 to 60% of ulcers - Ischaemic due to peripheral occlusive arterial disaese - 10% of ulcers - Mixed neuroischaemic - 25-45% of ulcers
A furuncle results from infection of hair follicles with Staphylococcus aureus
Diffuse enlargement - smooth or nodular - Solitary nodule

20. In the tourniquet test - What do rapid filling of the collapsed veins below the tourniquet indicate?
Hyperthyroidism - Recurrent - Hypothyroidism - Hypertrophic scarring
Scar confined to wound margins - It is found across flexor surfaces and skin creases
Commonest form of thyroid abnormality - Secondary to hyperplasia of the gland to meet physiological demand for thyroxine - Secondary to defective production of thyroid hormone
The incompetent vein is below the level of the tourniquest

21. How would you perform a hernia repair?
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
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma
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
The procedure should be performed under sterile condition and if the ascites is not clinically apparent or easy to locate - it should be done by a radiologist under ultrasound guidance to prevent inadvertent injuries to intra-abdominal structures.

22. What are the seven 'D's of nipple signs?
Wound complications - Recurrence - Damage to adjacent neurovascular structures
Discolouration - Discharge - Depression - Deviation - Displacement - Destruction - [Duplication - unlikely in the exam]
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
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

23. What are the contents of the spermatic cord?
malignant change?
Three arteries - artery to vas deferens -testicular artery -cremasteric artery - Three nerves - ilioinguinal nerve on the front of the cord - nerve to cremaster and autonomic nerves - Three other structures - vas deferens - pampiniform plexus of vein
Commonest form of thyroid abnormality - Secondary to hyperplasia of the gland to meet physiological demand for thyroxine - Secondary to defective production of thyroid hormone
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

24. What is the most common type of malignant melanoma?
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
Parafollicular C Cells
Superficial spreading at 70% of malignant melanomas
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.

25. What is the aim of cardiopulmonary bypass?
Myelofibrosis - Chronic Myeloid Leukaemia - Malaria - Tropical splenomegaly - Kala-azar(visceral leishmaniasis)
Commonest form of thyroid abnormality - Secondary to hyperplasia of the gland to meet physiological demand for thyroxine - Secondary to defective production of thyroid hormone
The aim of bypass is to provide a systemic circulation while the heart is stopped and emptied of blood.
Mean age is 50 years at presentation(F for fifty)

26. What are the surgical problems associated with AF?
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
Less than 0.5
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
Dohlman's procedure - endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling with less risk of fistula formation and consequent mediastinitis

27. What are the causes of a false aneurysm?
Traumatic - Iatrogenic(following angiography and bypass)
Hyperkeratosis - Acanthosis - Hyperplasia of variably pigmented basaloid cells
More common in females - Occur most commonly in the fourth or fifth decade - 10% in middle-aged are malignant but 50% are malignat in the young and the elderly - FNAC is the most important investigation
Epigastric pain - which may increase after meals - May be acutely painful after physical exercise - Nausea and early satiety - Reflux and non-ulcer dyspepsia

28. What conditions increase the risk of developing pressure sores?
Immobility and prolonged bed-rest are the most important factors - particulary secondary to conditions such as: Cardiopulmonary disease - Trauma - Neurological disease such as paraplegia - Bone and joint disease - Prolonged operative procedures - And
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
Investigation and treatment of concurrent abnormalities - Management of hypertension
Unilateral total lobectomy and isthmusectomy

29. What points should be elicited when taking a pain history in a surgical patient?
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.
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
SRSN -OPD -RAT - Site - Radiation - Severity - Nature - Onset - Periodicity - Duration - Relieved by - Accentuated by - Timing
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

30. How should one conclude a thyroid examination after examining the patient from the back?
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
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis
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)
Auscultation - Percussion of the thyroid gland and downwards for retrosternal extension

31. What is the differential diagnosis of a ganglion?
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
Bilateral subtotal thyroidectomy leaving approximately 4g of thyroid tissue on each side of the trachea
Immobility and prolonged bed-rest are the most important factors - particulary secondary to conditions such as: Cardiopulmonary disease - Trauma - Neurological disease such as paraplegia - Bone and joint disease - Prolonged operative procedures - And
State of the skin/subcutanaeous tissues - Sites of fascia defects - Site of incompetence(including the Trendelenburg and Tourniquet Tests)

32. 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
Mneumonic : BEDD - Base - Edge - Describe structure visualized at the base of the ulcer - Discharge
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
Similar to those in the right iliac fossa except for the bowel where a mass in the Left iliac fossa could indicate: Diverticular mass Which is often tender - Carcinoma of the colon - Faecal mass

33. What is the non-surgical treatment of a ganglion?

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34. What are the indications of mastectomy?
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 -
Lymphocyte-mediated destruction of the exocrine glands secondary to B-cell hyper-reactivity and associated loss of suppressor T-Cell activity
Least common - Occurs on hairless skin - Irregular area of brown or black pigmentation
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

35. What are the secondary causes of Raynauds?
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
Mnemonic: BADCaT - Blood disorders e.g polycythemia - Arterial e.g atherosclerosis - thrombangiitis obliterans - Drugs e.g beta blockers - oral contraceptive pill - Connective tissue disorders e.g rheumatoid arthritis - systemic lupus erythematosus -
Temperature - Capillary Refill - Peripheral Pulses
Cervical sympathectomy and amputation of the affected phalanges - Cervical sympathectomy may not be a permanent solution and may only relieve symptoms for 2 years or less - Amputate only if digits are threatened with gangrene

36. What is Adiposis dolorosa or Dercum's disease associated with?
Size - Tenderness - Mobility - Consistency
Peripheral Neuropathy
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation
In the presence of jaundice if a mass(the gall bladder) is palpable in the right upper quadrant - the cause is unlikely to be due to gallstones.

37. How would you treat a dermatofibroma?
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
Onset and Continuous Symptoms - When did you first notice it? - What made you notice it? - Predisposing events? - How does it bother you? - What symptoms does it cause? - Has it changed since you first noticed it ? - Have you noticed any other lumps?
Excision for the main lesion with varying margins depending on the size of the lesion. - If there is nodal spread - Fine Needle Aspiration Cytology or Lymph node biopsy - Therapeutic Block Dissection(if palpable lymph nodes) - Palliation adjuvant th
Non-Surgical : leave alone if asymptomatic and if patient does not want intervention - Surgical : Simple excision followed by histology

38. What are the seven signs in the hands that one should look for when assessing the thyroid status?
Increased sweating - Palmar erythema - Thyroid acropachy - Onycholysis - Areas of vitiligo - Pulse - Fine Tremor
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
Onset and Continuous Symptoms - When did you first notice it? - What made you notice it? - Predisposing events? - How does it bother you? - What symptoms does it cause? - Has it changed since you first noticed it ? - Have you noticed any other lumps?
Cervical sympathectomy and amputation of the affected phalanges - Cervical sympathectomy may not be a permanent solution and may only relieve symptoms for 2 years or less - Amputate only if digits are threatened with gangrene

39. When should the drains be removed post-surgery?
Wounds associated with - Infection - Trauma - Burns - Tension especially over the sternum such as after CABG - Wounds on certain areas of the body
Size - Tenderness - Mobility - Consistency
Epidermal Cyst - Trichilemmal Cyst
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

40. What is the definition of an enterocutaneous fistula?
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
Cirrhosis - Malignancy - Lymphatic rupture or damage
A enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and the skin
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma

41. What is the origin of lymphangiomas?
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
Lead shields to protect the eyes and gonads - Dose-fractionation - Prior chemotherapy - Regional hypothermia - Radiolabelled antibodies
Derived from capillary endothelial cells or from fibrous tissue - It is linked to human herpes virus 8
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 two main systems which need to be examining thyroid status in a surgical patient?
Hands and Eyes
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
Recurrence of the cyst - Developement of a chronic -discharging sinus
The procedure should be performed under sterile condition and if the ascites is not clinically apparent or easy to locate - it should be done by a radiologist under ultrasound guidance to prevent inadvertent injuries to intra-abdominal structures.

43. What are the causes of unilateral ptosis?

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44. What is a solar keratoses?
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
Mnemonic : SNAPP - Sepsis elimination : open or percutaneous drainage of collections; administration of appropriate antimicrobials - Nutritional resuscitation/optimization : patients may be fluid and electrolyte depleted and malnourished. Resuscitati
Similar to those in the right iliac fossa except for the bowel where a mass in the Left iliac fossa could indicate: Diverticular mass Which is often tender - Carcinoma of the colon - Faecal mass
Solar keratosses are squamous cell carcinoma in situ

45. What do you know about the pathophysiology of varicose veins?
Small red capillary naevus - Develops on the trunk in middle-age - No clinical significance
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
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
Fibrous tissue invades the tunica intima and media of the vein and breaks up the smooth muscle - preventing the maintenance of adequate vascular tone. These changes are patchy and may not affect adjacent segments of vein.

46. What are the causes of neuropathic ulcers?
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
Plasma alpha feto-protein and beta-HCG - raised levels may indicate a testicular tumor - Testosterone and LH levels to demonstrate hypogonadism - Thyroid function tests
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
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.

47. What are the sensory branches of the facial nerve?
Immobility and prolonged bed-rest are the most important factors - particulary secondary to conditions such as: Cardiopulmonary disease - Trauma - Neurological disease such as paraplegia - Bone and joint disease - Prolonged operative procedures - And
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
Uncommon sensory component of facial nerve carrying cutaneous impulses from the anterior wall of the external auditory meatus known as nervus intermedius or pars intermedia of Wrisberg
Ulcer is distal to the fistula - Shallow indolent ulcers

48. What are the medical options for Raynauds?
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
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
An abnormal protrusion of abdominal contents through a defect in the linea alba - usually halfway between the xiphoid process and umbilicus
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists

49. What is the differential diagnosis of swollen legs?
Hyperkeratoses(thickening of the keratin layer) - Focal parakeratosis - Irregular acanthosis - Basal layer atypia only
Central causes - RHF - hypoalbuminaemia -nephrotic syndrome and hypothyroidism - Peripheral - venous disease such as DVT - Klippel-Trenaunay syndrome - chronic venous insufficiency or post-phlebitic limb - Rare - angio-oedema - arteriovenous malforma
Non-Surgical : Leave alone if asymptomatic(particularly in young patients) - Surgical : Complete excision of lesion with histology(.
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)

50. What are the features of ulcers in pyoderma gangrenosum?
State of the skin/subcutanaeous tissues - Sites of fascia defects - Site of incompetence(including the Trendelenburg and Tourniquet Tests)
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present
Similar to those in the right iliac fossa except for the bowel where a mass in the Left iliac fossa could indicate: Diverticular mass Which is often tender - Carcinoma of the colon - Faecal mass
Undermined edge - Violaceous - Necrotic ulcer with hypertrophic margins