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Clinical Surgery

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Answer 50 questions in 15 minutes.
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1. What do you know about the pathophysiology of varicose veins?
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.
More than five is considered as pathological in chronic liver disease
History - Examination - Special Investigations - Treatment
Pressure effects - Deafness with involvement of the 8th cranial nerve - Sarcomatous transformation - Intra-abdominal effects - Skeletal changes

2. What is the surgical treatment of varicocoele?
Palomo operation
Hidradenitis suppurative - also known as acne inversa - is now considered a disease of follicular occlusion rather than an inflammatory or infectious process of the apocrine glands. Abscesses form recurrently and this causes the characteristic perman
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives
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

3. What are the acquired predisposing factors for basal cell carcinomas?
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion
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.
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
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

4. What are the causes of gangrene?

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5. What will the Fine Needle Aspiration Cytology show you in the investigation of Cervical Lymphadenopathy?
Via the bloodstream(R is equal to red is equal to blood)
It will show you if it is malignant or inflammatory
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
May affect people from puberty to 30 years - Females are more affected than males - Black and Hispanic Races are effected the most.

6. How do you harvest a skin graft?
Using hand-held skin graft knives or electric or gas powered dermatomes - the latter producing a graft of even thickness from almost any site - with little expertise needed for operation. The donor site is usually one that can be easily concealed for
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
History and Clinical Examination - Investigate if prominent nodule or features suspicious of malignancy such as cervical lymphadenopathy or recurrent laryngeal nerve palsy
True cysts with a complete smooth wall are very rare - Most are composite lesions with colloid degeneration - necrosis or haemorrhage in benign or malignant tumours - Only benign if completely abolished by aspiration - Cytology can be false-negative

7. What are the different histological subtypes of a sebaceous cyst?
Diffuse enlargement - smooth or nodular - Solitary nodule
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's
Congenital ptosis - Myopathies - Syphillis
Epidermal Cyst - Trichilemmal Cyst

8. What symptoms - a patient with an epigastric hernia might have complained of at presentation?
There are two pathological systems in use: Clark's level of invasion based mostly on the depth/extent of tumour and Breslow's thickness Which is based mostly on the thickness of malignant melanoma. Breslow's thickness is a better prognostic indicator
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
Epigastric pain - which may increase after meals - May be acutely painful after physical exercise - Nausea and early satiety - Reflux and non-ulcer dyspepsia
Painless - Associated with normal appearance of the surrounding skin - Associated with local sensory loss

9. Lipomas do not undergo...
Lead shields to protect the eyes and gonads - Dose-fractionation - Prior chemotherapy - Regional hypothermia - Radiolabelled antibodies
malignant change?
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present
Mnemonic : NO SPECS - No signs or symptoms - Only signs of upper lid retraction and stare - with or without lid lag and exopthalmos - Soft-tissue involvement - Proptosis - Exopthalmos - Corneal Involvement - Slight loss due to optic nerve involvemen

10. How would you rehabilitate a patient following the placement of a stoma?
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
Non-Surgical - Reassure and 'Watch and Wait' - Surgical - Reason : Pain/Cosmesis and this is done with suction lipolysis via a small - remote incision Which is performed under local anaesthetic as a day case.
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
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

11. How would you treat a cystic hygroma?
Hyperthyroidism - Recurrent - Hypothyroidism - Hypertrophic scarring
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
Non-surgically via aspiration and injection of sclerosant surgically via excision which may be partial ( to relieve symptoms) or complete as a one-stage procedure.
Aneurysms are most common in: Men - Aged more than 60 years - Smokers - Hypertensive patients - Often strong family history

12. What is the differential diagnosis of intermittent claudication?
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
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
More than five is considered as pathological in chronic liver disease
Infections within the oesophagus especially candidiasis and herpes simplex - Pharyngitis - Occasionally ulceration over the lower third of the oesophagus

13. What are the hepatobiliary complications of IBD?
Halfway along inguinal ligament that is between pubic tubercle and ASIS Which is equal to the location of the deep inguinal ring
Gangrene is the result of irreversible tissue necrosis and has a number of causes: Diabetes - Embolus and thrombosis - Raynaud's syndrome - Thrombangiitis obliterans - Ergot poisoning - Vessel injury secondary to extreme cold -heat -trauma or pressur
Liver - fatty change - chronic active hepatitis -cirrhosis and amyloid deposition - Gall bladder and bile ducts - gallstones - sclerosing cholangitis - and cholangiocarcinoma
Resection of a lobe including its bronchial origin with re-anastamosis of the proximal and distal bronchus

14. What does minimally invasive surgery involve in the surgical treatment of a pharyngeal pouch?

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15. What are the indications of mastectomy?
Inspect - Protrusion of the tongue - Swallowing - Palpate(from the back) - Continue Accordingly(Neck Decision Circle)
Angiolipomas - Hibernomas - Bannayan-Zonana Syndrome
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 -
Congenital - Multiple arteriovenous fistulae - Traumatic

16. What is a sinus?
Tumours raised above the skin : excision with 0.5cm margin(maximum) - Tumours not raised above the skin - Wider margin of excision - particularly if at inner canthus of eye -nasolabial fold and ear. A frozen section may be necessary to ensure adequat
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
Motor - Secretomotor - Taste - Sensory
A blind-ending track -typically lined by epithelial or granulation tissue - which opens onto an epithelial surface

17. What is the defective gene in type 1 NF?
Defective gene on chromosome 17
Site and size of varicosities - including the presence of saphena varix - Skin for changes and scars - Swelling of the ankle
Demographics - Presenting Complaint - History of Presenting Complaint - Medical and Surgical History - Drugs and any other allergies - Family History - Social History - Systemic Enquiry
Pre-hepatic - Hepatic - Post-hepatic

18. What are the causes of ischaemic ulcers?
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
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
These can be divided into large and small vessel arterial disease: Large vessel - atherosclerosis and thrombangiitis obliterans - Small vessel - Diabetes Mellitus - Polyarteritis nodosa and rheumatoid arthritis
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

19. What is the surgical treatment of venous ulcers?
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
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)
Mayo's 'vest-over-pants' operation is the most widely accepted repair for these herniae
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

20. What is the differential diagnosis for a skin lesion?
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
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
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
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

21. What are the 'transudate' causes of a pleural effusion?
Heamolysis - Hereditary e.g : gilbert's syndrome
Cardiac failure - Metabolic disorders leading to hypoalbuminaemia such as Cirrhosis and Nephrotic syndrome
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's
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

22. What are the different types of mastectomy that can be performed?
Mneumonic : LIST Lymphoma and Leukaemia - Infection(further subdivided into Bacterial - Viral - Protozoal and Toxoplasmosis) - Sarcoidosis - Tumours
Simple mastectomy - Modified radical mastectomy(patey) - Radical mastectomy(Halsted mastectomy) - Extended radical mastectomy
Hyperthyroidism - Late Hypothyroidism - Later Hyperparathyroidism
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.

23. What is the surgical treatment of a multinodular goitre?
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
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
Superficial spreading at 70% of malignant melanomas
Traditionally -Bilateral subtotal thyroidectomy without need for postoperative replacement of thyroxine was recommended but more recently total thyroidectomy is the preferred procedure due to the risk of pathological change in the thyroid remnant nec

24. What is jaundice?
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
Heamolysis - Hereditary e.g : gilbert's syndrome
These are due to a defect through the linea alba adjacent to the umbilicus and usually due to obesity stretching the fibres.
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.

25. How should you organize information when talking about a disease?
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery
Pleomorphic adenoma(commonest) and Warthin's tumour
Definition - Incidence - Sex - Geography - Aetiology - Pathogenesis - Macroscopic Pathology - Microscopic Pathology - Prognosis - Symptoms - Signs - Investigations - Treatment
Blood Tests:Haematological - FBC - ESR - Biochemical : TFT - ACE Levels(raised in sarcoidosis) - Serological : 'monospot' or Paul-Bunnell test looking for atypical mononuclear cells in infectious mononucleosis - Radiological : Ultrasound - CT Scan an

26. What are the features of ulcers in syphillis?

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27. 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
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 -
Non-surgical : Watch and wait - a small hydrocoele may require no treatment other than reassurance - but an underlying malignancy should be excluded. Aspiration - the hydrocoele fluid can be aspirated to relieve symptoms; tends to reaccumulate
May affect people from puberty to 30 years - Females are more affected than males - Black and Hispanic Races are effected the most.

28. What are the causes of gynaecomastia?
Causes may be classified as the 3 Ps: Physiological - Pathological - decreased androgens - androgen resistance - increased secretion -increased peripheral aromatization - Potions that is drugs such as recreational drugs - GI drugs - cardiovascular dr
Gangrene is the result of irreversible tissue necrosis and has a number of causes: Diabetes - Embolus and thrombosis - Raynaud's syndrome - Thrombangiitis obliterans - Ergot poisoning - Vessel injury secondary to extreme cold -heat -trauma or pressur
The Branham-Nicoladoni sign indicates the degree of shunting and cardiac impairment resulting from a large AV fistula - The carotid pulse is palpated and then a tourniquet placed around the proximal affected limb and inflated above systolic pressure
Bronchial carcionoma - Chronic suppurative lung disease(abscess -bronchiectasis -cystic fibrosis -empyema) - Fibrosing alveolitis - Mesothelioma

29. What is a hydrocoele?
Recurrence of the cyst - Developement of a chronic -discharging sinus
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.
Excess accumulation of fluid in the processus vaginalis.
Epidermal Cyst - Trichilemmal Cyst

30. What points should be elicited when taking a pain history in a surgical patient?
Have you noticed any change in the colour of your urine? Have you noticed any change in the colour of your stools? - Have you noticed yourself feeling itchy?
SRSN -OPD -RAT - Site - Radiation - Severity - Nature - Onset - Periodicity - Duration - Relieved by - Accentuated by - Timing
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.
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

31. How is anaplastic carcinoma treated?
Use of truss or corset - Weight loss and management of other risk factors
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
Treatment with radiotherapy and doxorubicin gives best survival of 1 year
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

32. What would you tell to a lady with varicose veins about the proposed surgery?
Procedure usually performed as a day case - Need to wear tight-fitting stockings for 6 weeks preoperatively - No driving for 1 week - Does not alter the skin changes - including skin flares - May not improve symptoms such as aching - Risk of recurren
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
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
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.

33. What is the treatment of Sjogren's syndrome?
Treatment involves the use of artificial tears and saliva - use of systemic steroids and careful follow-up due to increased risk of lymphoma development
Temperature - Capillary Refill - Peripheral Pulses
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
Indications for amputation can be remembered as the 4Ds: Dead - ischemic - peripheral vascular disease - thromboangiitis obliterans - AV fistulae - Damaged - trauma - unsalvageable limbs - burns - frostbite - Dangerous - Malignancy - bone and soft ti

34. What level does the serum bilirubin need to rise to before jaundice can be detected on clinical examination?
The aim of bypass is to provide a systemic circulation while the heart is stopped and emptied of blood.
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
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
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

35. What is the differential diagnosis of a malignant melanoma?
General : malaise -fatigue - loss of appetite - nausea and vomiting - Skin : as above - Bone marrow suppression : particular if irradiation to the pelvis and long bones - Gastrointestinal : diarrhoea
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
Benign skin lesions: Moles -freckles -lentigo -pigmented seborrhoeic keratoses - dermatofibromas and thrombosed haemangiomas - When it comes to malignant skin lesions - pigmented basal cell carcinomas
A chemodectoma is a tumour of the paraganglion cells of the carotid body located at the bifurcation of the common carotid artery. They are usually benign(but locally invasive) - but occassionally - they are malignant with potential to metastasize to

36. What are the features of acral lentiginous melanoma?
Least common - Occurs on hairless skin - Irregular area of brown or black pigmentation
Cirrhosis - Malignancy - Lymphatic rupture or damage
Scar confined to wound margins - It is found across flexor surfaces and skin creases
Cyanotic congenital heart disease - Infective endocarditis - Atrial myxoma (rare)

37. What is the non-surgical treatment of pressure sores?
Trauma - Hypersplenism
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
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
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

38. What is a lipoma?
A lipoma is a benign tumour consisting of mature fat cells.
Non-surgically via aspiration and injection of sclerosant surgically via excision which may be partial ( to relieve symptoms) or complete as a one-stage procedure.
Simple mastectomy - Modified radical mastectomy(patey) - Radical mastectomy(Halsted mastectomy) - Extended radical mastectomy
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review

39. What is the embryological origin of a thyroglossal cyst?
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland
All patients should undergo triple assessment that is Clinical Examination - Radiological assessment usually ultrasonographic - Pathological - most commonly cytological following FNAC
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
Congenital Which is rare and Acquired Which is very common.

40. What important questions should you ask in a patient with jaundice?
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
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
Neo-rectum is created in a pelvic reservoir - Stage 1 : resection of colon and/or rectum - Stage 2 : Construction of an ileal reservoir - Which is anastamosed to the anus - this is usually covered with a diverting loop ileostomy proximal to the pouch
Have you noticed any change in the colour of your urine? Have you noticed any change in the colour of your stools? - Have you noticed yourself feeling itchy?

41. What is lid lag secondary to ?
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
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
Pigmented freckles around the lips and inside the mouth - associated with intestinal intussusception and gastrointestinal bleeding from colonic polyps
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris

42. What are the non-surgical treatment options for hydrocoele?
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
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
Non-surgical : Watch and wait - a small hydrocoele may require no treatment other than reassurance - but an underlying malignancy should be excluded. Aspiration - the hydrocoele fluid can be aspirated to relieve symptoms; tends to reaccumulate
Hyperthyroidism - Late Hypothyroidism - Later Hyperparathyroidism

43. How is 'matching' of transplanted kidneys performed?
40 X increased risk of developing lymphoma - usually B-Cell non-Hodgkin's type
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
At two levels:ABO Compatibility - HLA Compatibility
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

44. What is a carbuncle?
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
A carbuncle is an extensive infection of hair follicles by the same organism with involvement of adjacent follicles and development of draining sinuses. It is associated with diabetes and is treated with a combination of systemic antibiotics and surg
The incompetent vein is below the level of the tourniquest
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

45. What are the risk factors for arterial disease
Below Knee - Above Knee
Non-Surgical : May be left alone if small and asymptomatic - Surgical : To prevent recurrence - complete excision of the cyst and its contents is required and this is done through the removal of an elliptical portion of skin containing the punctum.
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally

46. How do testicular tumours usually present?
End-to-end anastamosis - patching and the use of the left subclavian artery as a flap are all surgical options
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
Reflux Trahere transplantation - Kistner's operation - Obstruction: Palma Operation - Warren Bypass
Patients are usually symptom-free for a long period of time followed by dysphagia and hoarseness - associated with regurgitation of undigested foods - and associated weight-loss

47. What are the treatment options of false aneurysms?
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
Painless - Associated with normal appearance of the surrounding skin - Associated with local sensory loss
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
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review

48. What is a ganglion?
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
A cystic swelling related to a synovial lined caivity - either a joint or a tendon sheath
Characteristic cold-induced changes associated with vasospasm
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.

49. What is a keratoacanthoma?
Non-Surgical - Reassure and 'Watch and Wait' - Surgical - Reason : Pain/Cosmesis and this is done with suction lipolysis via a small - remote incision Which is performed under local anaesthetic as a day case.
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
The simplest surgical technique is to excise the papilloma with a sharp pair of scissors - controlling bleeding from the central vascular component with a single suture. Alternatively - diathermy can be used to control the bleeding at the same time a
A keratoacanthoma is a benign overgrowth of hair follicle cells that produces a central plug of keratin. It is rapidly growing - forming within 6 weeks and regressing after 6 weeks - leaving a depressed scar. Clinically and cytologically they may loo

50. What does a keloid scar look like?
A hypervascular mas displacing the bifurcation of the carotid arteries
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.
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.
Non-Surgical - mechanical pressure therapy(day and night for up to 1 year) and topical silicone gel sheets - Surgical : Revision of scar with closure by direct suturing - local Z-plasty or skin grafting to avoid excessive tension - Intralesional ster