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Clinical Surgery

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1. Why are diabetics particularly prone to foot pathology?
Chest x-ray to map the caudal extent of the cystic hygroma - CT/MRI scanning especially if it is complex
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
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
'Watch and wait' or aspiration followed by 3 weeks of immobilzation

2. What kinds of analgesia would be appropriate for this patient?
A blepharoplasty can be performed where excess skin and fat are removed.
Found below the inguinal ligament - Usually not reducible - Commoner in women - but inguinal herniae are still commoner in women than femoral hernias. Risk of strangulation is high - Cough impulse usually absent
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair
Ischaemic ulcers can be extremely painful and even removing the bandages from around the ulcer can cause pain that lasts for several hours. The analgesic ladder would be appropriate in this situation starting from simple oral agents -stronger oral ag

3. What tissues do skin graft not take on?
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
Unhealthy -necrotic and infected tissue - Irradiated tissue - Exposed cortical bone without periosteum - Tendon without peritendon - Cartilage without perichondrium
Injection sclerotherapy with 1% sodium tetradecyl sulphate - this has a high recurrence rate and indicated for postoperative recurrence of veins - below knee varicosities if the long saphenous vein and short saphenous vein are not involved.
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.

4. What are the features of superficial spreading melanoma?
Non-Surgical : leave alone if asymptomatic and if patient does not want intervention - Surgical : Simple excision followed by histology
Halfway along inguinal ligament that is between pubic tubercle and ASIS Which is equal to the location of the deep inguinal ring
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
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer

5. What is secondary lymphoedema?
Urinary retention - Bruising - Pain - often very severe and patients should be discharged with adequate analgesia; chronic groin pain persists in 5% of patients - Haematoma - 10% - Ischaemic orchitis - 0.5%(prev. vasectomy predisposing cause and diss
Varicocoeles are dilated tortuous 'varicose' veins in the pampiniform plexus - the network of veins that drains the testis - They usually occur in 15% of younger men - often around puberty - and are thought to have an anatomical basis - If they appea
Nerve to stapedius - Nerve to posterior belly of digastric - Five divisions within the parotid gland - temporal - zygomatic - buccal - mandibular and cervical
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

6. What are the causes of atrial fibrillation?
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
Found below the inguinal ligament - Usually not reducible - Commoner in women - but inguinal herniae are still commoner in women than femoral hernias. Risk of strangulation is high - Cough impulse usually absent
Cardiac disease - hypertension -myocardial infarction -ischaemia -mitral valve disease - cardiomyopathy -endocarditis - Respiratory disease - Pneumonia - lung cancer - sarcoidosis - Other: Hypothyroidism and idiopathic ( lone AF)
Investigation and treatment of concurrent abnormalities - Management of hypertension

7. What syndrome is associated with a port-wine stain?
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
Barium swallow may be useful - If diagnosis is in doubt - endoscopy with biopsies and brushings should be performed to exclude a carcinoma - Physiological function could be tested using 24-hour oesophageal pH studies to exclude reflux and manometry
Sturge-Weber syndrome is the association of a facial port-wine stain with a corresponding haemangioma in the brain - leading to contralateral focal fits.
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

8. What investigations may help confirm the diagnosis of thoracic outlet obstruction?
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
A pharyngeal pouch is formed by the herniation of pharyngeal mucosa(known as a pulsion diverticulum) through its muscular coat at its weakest point(Killian's dehiscence) between the thyropharyngeal and cricopharyngeal muscles that make up the inferio
It helps to give an indication as to What the exact aetiology is.
Cervical rib or prominent transverse process of the Chest X-ray or thoracic outlet views - Doppler examination may be useful in quantifying the postural changes and post-stenotic dilatation - Arteriograms of the subclavian artery may show a marked ki

9. What is a skin flap?
Dohlman's procedure - endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling with less risk of fistula formation and consequent mediastinitis
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
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.
This removes the possibility of recurrent disease appears to improves the outcome for patietns with significant eye disease and eliminates the need for annual TFT monitoring to assess remnant function. It does - of course - demand thyroxine replaceme

10. What are the secretomotor branches of the facial nerve?
Injection sclerotherapy with 1% sodium tetradecyl sulphate - this has a high recurrence rate and indicated for postoperative recurrence of veins - below knee varicosities if the long saphenous vein and short saphenous vein are not involved.
Via greater superficial petrosal nerve to lacrimal - nasal and palatine glands
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.
Multinodular goitre - Toxic - Simple colloid goitre - Thyroiditis - Neoplasia

11. Why is total thyroidectomy preferred in the surgical treatment of Graves' disease?
Well-differentiated - Myxoid and round cell - Pleomorphic liposarcoma
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
An abnormal protrusion of abdominal contents through a defect in the linea alba - usually halfway between the xiphoid process and umbilicus
This removes the possibility of recurrent disease appears to improves the outcome for patietns with significant eye disease and eliminates the need for annual TFT monitoring to assess remnant function. It does - of course - demand thyroxine replaceme

12. What are the three main options available for the treatment of malignant melanoma?
A papilloma is an over-growth of all layers of the skin with a central vascular core. They are increasingly common with age.
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
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
Hands and Eyes

13. What is the absolute pressure that is used in some definitions of critical ischemia?
Rapid growth and pain(on history) - Hyperemic hot skin - Hard consistency - Fixed to skin and underlying muscle - Irregular surface or ill-defined edge - Facial nerve involvement
Necrotizing vasculitis - Purpuric -haemorrhagic bullae
An absolute pressure of less than 50mmHg
A enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and the skin

14. What is a secondary hydrocoele?
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 vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair
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
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

15. What are the non-surgical options for Raynauds
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
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
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
Mnemonic : CHIASMA - Congestive : cardiac failure - Haematological : reticuloses - Infection : viral -bacterial -protozoal - Amyloid - Storage disorders : Wilson's disease - haemochromatosis - Masses: primary/secondary neoplasia - Autoimmune/alcohol

16. What is the treatment of medullary carcinoma?
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
A skin graft involves the transfer of skin from a donor site to a recipient site independent of a blood supply. The graft 'takes' by acquiring a blood supply from a healthy donor bed. Skin grafts may either be full thickness or partial thickness - bu
Treatment is radical surgery with follow-up using sequent calcitonin assays
Use of truss or corset - Weight loss and management of other risk factors

17. Where is the midinguinal point?
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
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation
Renal transplantation is indicated in end stage renal failure - the commonest reasons in the UK are:Diabetes mellitus - Hypertensive renal disease - Glomerulonephritis - Polycystic kidney disease

18. How does follicular carcinoma spread?
Via the bloodstream(R is equal to red is equal to blood)
Should The Children Ever Find Lumps Readily
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
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents

19. What is the pathogenesis of peripheral neuropathy?
Urinary retention - Bruising - Pain - often very severe and patients should be discharged with adequate analgesia; chronic groin pain persists in 5% of patients - Haematoma - 10% - Ischaemic orchitis - 0.5%(prev. vasectomy predisposing cause and diss
May require the placing of postoperative drains
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
Sturge-Weber syndrome is the association of a facial port-wine stain with a corresponding haemangioma in the brain - leading to contralateral focal fits.

20. Do you know of any infectious agents associated with AAA?
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
Treatment is essentially surgical - Operation of choice is Sistrunk's operation - Inject patent track with dye at the start of the operation - Excise cyst and the patent or fibrous track which runs through the central portion of the hyoid bone(Which
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
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms

21. How would you demonstrate to an examiner that a mass in the right upper quadrant is indeed an enlarged liver(hepatomegaly)?
Injection sclerotherapy with 1% sodium tetradecyl sulphate - this has a high recurrence rate and indicated for postoperative recurrence of veins - below knee varicosities if the long saphenous vein and short saphenous vein are not involved.
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
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
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

22. What investigations would you perform in a suspected case of Inflammatory Bowel Disease?
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
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
Multiple telangiectasia around the mouth and on the tongue and lips
Transfemoral radiological embolization of the testicular vein - using either a spring coil or sclerosant

23. What are the complications of a pharyngeal pouch?
Chest infection due to pulmonary aspiration - Diverticular neoplasia in less than 1% of cases
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
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland
Derived from capillary endothelial cells or from fibrous tissue - It is linked to human herpes virus 8

24. What is a ganglion?
A cystic swelling related to a synovial lined caivity - either a joint or a tendon sheath
Anxiety - Hyperthyroidism - Hyperhidrosis erythematosus traumatica - Phaeochromocytoma
Conservative - Medical - Surgical
Simple mastectomy - Modified radical mastectomy(patey) - Radical mastectomy(Halsted mastectomy) - Extended radical mastectomy

25. What are the causes of massive splenomegaly?
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.
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
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital
Myelofibrosis - Chronic Myeloid Leukaemia - Malaria - Tropical splenomegaly - Kala-azar(visceral leishmaniasis)

26. What are the four commonest types of malignant melanoma?
May affect people from puberty to 30 years - Females are more affected than males - Black and Hispanic Races are effected the most.
Found below the inguinal ligament - Usually not reducible - Commoner in women - but inguinal herniae are still commoner in women than femoral hernias. Risk of strangulation is high - Cough impulse usually absent
Antithyroid drugs - to inhibit thyroid peroxidase - Beta-blockers - to reduce the effect of excess circulating thyroxine on the cardiac system - Radioiodine - Treatment of choice - Single oral dose of 131 Iodine causes direct radiation damage to the
Mnemonic: SNAiL - Superficial spreading - Nodular melanoma - Acral lentiginous melanoma - Lentigo maligna melanoma

27. How do true umbilical herniae occur?
True umbilical herniae occur through the umbilical scar and are usually congenital in origin and particulary common in patients of Afro-Caribbean origin
Use of gloves and discontinuing any predisposing drugs e.g beta blockers - Using warm pads in gloves and socks in the winter - Encourage patients to stop smoking
The incompetent vein is at or above the level of the tourniquet
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

28. What is the differential diagnosis of intermittent claudication?
Mneumonic : LIST Lymphoma and Leukaemia - Infection(further subdivided into Bacterial - Viral - Protozoal and Toxoplasmosis) - Sarcoidosis - Tumours
This removes the possibility of recurrent disease appears to improves the outcome for patietns with significant eye disease and eliminates the need for annual TFT monitoring to assess remnant function. It does - of course - demand thyroxine replaceme
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
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

29. What are the causes of bilateral ptosis?
Mechanical obstruction - Coordination abnormalities
Congenital ptosis - Myopathies - Syphillis
Hyperkeratosis - Acanthosis - Hyperplasia of variably pigmented basaloid cells
Wound complications - Recurrence - Damage to adjacent neurovascular structures

30. What are the causes of a mass in the left iliac fossa?
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
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 :
If the ulcer fails to heal - careful consideration should be given to excluding other causes such as malignant Marjolin ulcer and the area may need to be biopsied - Otherwise a split skin graft should be considered with excision of the dead skin and
Barium swallow may be useful - If diagnosis is in doubt - endoscopy with biopsies and brushings should be performed to exclude a carcinoma - Physiological function could be tested using 24-hour oesophageal pH studies to exclude reflux and manometry

31. What are the features of a direct inguinal hernia?
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
The incompetent vein is at or above the level of the tourniquet
It is the result of a weak posterior wall to the inguinal canal - Arise medial to the inferior epigastric vessels at operation - This weakness causes the abdominal contents to bulge through the wall into the inguinal canal but the hernia is not withi
Iodine deficiency - Increased physiological demand - Goitrogens(less common) - Defects of thyroid hormone production

32. What are the acquired predisposing factors for basal cell carcinomas?
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion
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.
A blind-ending track -typically lined by epithelial or granulation tissue - which opens onto an epithelial surface
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review

33. How should one examine a lump or swelling?
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.
Cardiac failure - Tricuspid regurgitation - Constrictive pericarditis
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.

34. What are the other types of arteriovenous fistula?
Urinary retention - Bruising - Pain - often very severe and patients should be discharged with adequate analgesia; chronic groin pain persists in 5% of patients - Haematoma - 10% - Ischaemic orchitis - 0.5%(prev. vasectomy predisposing cause and diss
Well-differentiated - Myxoid and round cell - Pleomorphic liposarcoma
Congenital - Multiple arteriovenous fistulae - Traumatic
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally

35. What are the non-surgical treatment options for lymphoedema?
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.
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
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
Lymphangiomas can be:Cystic - Solid or diffuse - Cutaneous

36. How is anaplastic carcinoma treated?
Loss of hair on outer-third of eyebrows - Lid retraction - Lid lag - Ophthalmoplegia - Exophthalmos - Chemosis - Proptosis
Third cranial nerve palsy - complete ptosis - Horner's syndrome - partial ptosis - Syphillis
Treatment with radiotherapy and doxorubicin gives best survival of 1 year
The incompetent vein is below the level of the tourniquest

37. What are the different types of mastectomy that can be performed?
Congenital - Multiple arteriovenous fistulae - Traumatic
Simple mastectomy - Modified radical mastectomy(patey) - Radical mastectomy(Halsted mastectomy) - Extended radical mastectomy
Barrett's oesophagus - Stricture especially chemical - Achalasia - Plummer-Vinson Syndrome
More than five is considered as pathological in chronic liver disease

38. What are the complications with regards to the surgical treatment of a ganglion?
Wound complications - Recurrence - Damage to adjacent neurovascular structures
Less than 0.5
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
Optimize tissue perfusion and oxygenation - Treat infection as it arises - Use topical dressings as required and provide nutritional support specifically vitamin C - zinc and multivitamins. - Other techniques include hyperbaric oxygen -hydrotherapy a

39. What level does the serum bilirubin need to rise to before jaundice can be detected on clinical examination?
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
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
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
Pressure effects - Deafness with involvement of the 8th cranial nerve - Sarcomatous transformation - Intra-abdominal effects - Skeletal changes

40. What are the characteristics that suggest malignancy in skin lesions?
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
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
Increase in size - Ulceration - Change in colour - Irritation - Bleeding - Halo of pigmentation - Satellite nodules - Enlarged local lymph nodes - Evidence of distant spread
A dermoid cyst is a skin-lined cyst deep to the skin. They may be congenital or acquired.

41. What are the two main classifications for thyroid enlargement?
Iodine deficiency - Increased physiological demand - Goitrogens(less common) - Defects of thyroid hormone production
Diffuse enlargement - smooth or nodular - Solitary nodule
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery
Bright-red raised strawberry-like lesion - Present from birth - but 60% undergo spontaneous resolution by the age of 3 years - Only treated if obscuring a visual field or spontaneous resolution not occurring.

42. What are the features of Graves' disease?
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
1
Healing by secondary intention - Skin graft - Local flap - Distant flap - Composite flap - Island flaps vs pedicled flaps - Free tissue transfer - Composite neurovascular free tissue transfer
Hyperthyroidism - Late Hypothyroidism - Later Hyperparathyroidism

43. What are the two types of complications of thyroidectomy?
Treatment is essentially surgical - Operation of choice is Sistrunk's operation - Inject patent track with dye at the start of the operation - Excise cyst and the patent or fibrous track which runs through the central portion of the hyoid bone(Which
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
Commonest form of thyroid abnormality - Secondary to hyperplasia of the gland to meet physiological demand for thyroxine - Secondary to defective production of thyroid hormone
General - Specific

44. Describe the vascular supply of the transplanted kidney?

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45. What is the defective gene in type 1 NF?
Defective gene on chromosome 17
Arising from the skin and soft tissues - sebaceous cysts -sarcoma -lipoma -epigastric hernia - Arising from the gastrointestinal tract - carcinoma of the stomach -hepatomegaly -pancreatic ca - pancreatic pseudocyst - Arising from the vascular system
Gall stones - Carcinoma head of pancreas - Lymph nodes
Infections within the oesophagus especially candidiasis and herpes simplex - Pharyngitis - Occasionally ulceration over the lower third of the oesophagus

46. Where are pressure sores most commonly found?
Transfemoral radiological embolization of the testicular vein - using either a spring coil or sclerosant
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
Sacrum - Greater trochanter - Heel - Lateral Malleolus - Ischial Tuberosity - Occiput
Unilateral total lobectomy and isthmusectomy

47. What is the 'reconstruction ladder'?
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
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
This is the array of plastic surgeon techniques of increasing complexity that is available to the surgeon and Which is used according to their suitability for individual patients
Loss of hair on outer-third of eyebrows - Lid retraction - Lid lag - Ophthalmoplegia - Exophthalmos - Chemosis - Proptosis

48. What is the operative mortality of AAA repair?
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
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
Defective gene on chromosome 17
Resection of a lobe including its bronchial origin with re-anastamosis of the proximal and distal bronchus

49. What are the causes of facial nerve palsy?
Intracranial - Intratemporal - Extratemporal
Via the bloodstream(R is equal to red is equal to blood)
It is often advised as the problem usually gets worse with age and there is risk of infertility.
Form of telangiectasias - Central arteriole with leg-like branches Which blanch on central pressure - Found over upper torso - head and neck in adults - Associated with chronic liver disease and pregnancy

50. What are the features of a multinodular goitre?

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