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Clinical Surgery

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1. What are the three objectives to be taken note of in the inspection part of the arterial examination?
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer
Colour changes - Trophic changes - Vascular angle
Other risk factors and cardiovascular disease elsewhere would be excluded and the neck imaged with a duplex scan or occasionally on intravenous digital subtraction angiogram
It is due to forced implantation of skin into subcutaneous tissues following an injury. Normally found in areas of the body prone to injury such as fingers. Suspect if you see an adult in exam.

2. What is secondary lymphoedema?
Venous disease
Hyperkeratosis - Acanthosis - Hyperplasia of variably pigmented basaloid cells
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
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La

3. Lobectomy
A branchial cyst is thought to develop because of a failure of fusion of the embryonic second and third branchial arches. An alternative - and currently - popular - hypothesis is that it is an acquired condition due to cystic degeneration in cervical
Debulking or bypass procedures - Direct lymphovenous anastamosis - Stripping a piece of intestinal mucosa - exposing the rich submucosal plexus - this can then be used to replace a leg lymph node which then forms new connections with distal lymphatic
Excision of a single lobe of the lung
50%

4. How should epididymal cysts be managed?
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
Surgical treatment is superficial parotidectomy(if superfical lobe of gland only involved) or total parotidectomy with preservation of the facial nerve(if deep lobe of gland or both lobes involved)
Complications include cosmetic symptoms but important problems are encountered in the perinatal period: Before delivery it may obstruct delivery - After delivery : respiratory obstruction and obstruction of swallowing
Elderly(A for Aged)

5. What are the main points to be elicited during a clerking of the surgical patient?
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
Demographics - Presenting Complaint - History of Presenting Complaint - Medical and Surgical History - Drugs and any other allergies - Family History - Social History - Systemic Enquiry
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
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally

6. What is the surgical treatment of venous ulcers?
Tumour - parotid gland malignancy - Trauma - surgical - accidental e.g facial lacerations
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
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
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

7. What are the treatment options of false aneurysms?
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.
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review
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
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital

8. How would you determine clinically the degree of shunt by a large fistula?
A neurofibroma is a benign tumour derived from peripheral nerve elements.
These are due to a defect through the linea alba adjacent to the umbilicus and usually due to obesity stretching the fibres.
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
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

9. What are the surgical principles in Mayo's operation?
Donor renal artery is anastamosed to either the internal or external iliac artery - The donor renal vein is anastamosed to the external iliac vein - The ureter is anastamosed seperately to the patient's bladder - The renal pelvis the most anterior st
A horizontal ellipse of stretched supra or infra-umbilical skin is excised - deeping the incision to the rectus sheath and identifying the fibrous band Which is the neck of the sac - The sac is dissected free from the surrounding tissues - which may
Mneumonic : I - CHUM - Infection(frequent) - Calcification - Ulceration - sebaceous Horn formation - Malignant change
A cystic swelling related to a synovial lined caivity - either a joint or a tendon sheath

10. What does four-layer compression bandaging comprise of?
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.
Venous disease
Chest x-ray to map the caudal extent of the cystic hygroma - CT/MRI scanning especially if it is complex
Non-adherent dressing over ulcer plus wool bandage - Crepe bandage - Blue-line bandage - Adhesive bandage to prevent the other layers from slipping

11. What do you know about the epidemiology of keloid scars?
May affect people from puberty to 30 years - Females are more affected than males - Black and Hispanic Races are effected the most.
Purple-blue naevus found on face -lips and mucous membrane of the mouth - Present from birth and does not change in size thereafter - Found on limbs in association with Klippel-Trenaunay syndrome.
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
Soft-tissues(lipoma -dental cyst) - Dental origin(infection) - Muscular origin(hypertrophy of masseter muscle) - Bony origin(winged mandible -transverse process of atlas/axis) - Neoplasia(infratemporal fossa and parapharyngeal tumours)

12. What are the complications of a pharyngeal pouch?
Chest infection due to pulmonary aspiration - Diverticular neoplasia in less than 1% of cases
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
Least common - Occurs on hairless skin - Irregular area of brown or black pigmentation
All patients should undergo triple assessment that is Clinical Examination - Radiological assessment usually ultrasonographic - Pathological - most commonly cytological following FNAC

13. What is the pathogenesis of Raynaud's phenomenon?
Size - Tenderness - Mobility - Consistency
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
Minor defects in neonates are common but usually repair spontaneously. In children - umbilical herniae are mor common; they tend to have a narrow neck and folds of peritoneum stuck within this neck - which can occassionally strangulate. Most cases re
It is due to forced implantation of skin into subcutaneous tissues following an injury. Normally found in areas of the body prone to injury such as fingers. Suspect if you see an adult in exam.

14. What are the causes of superior vena cava obstruction?
Hyperthyroidism - Recurrent - Hypothyroidism - Hypertrophic scarring
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present
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
Halfway along inguinal ligament that is between pubic tubercle and ASIS Which is equal to the location of the deep inguinal ring

15. What is the mean age for presentation of follicular carcinoma of the thyroid?
Mean age is 50 years at presentation(F for fifty)
'Watch and wait' or aspiration followed by 3 weeks of immobilzation
Aneurysms are most common in: Men - Aged more than 60 years - Smokers - Hypertensive patients - Often strong family history
Complete excision to include the neck of the ganglion at its site of origin

16. What is the non-surgical treatment of a patient with an epigastric hernia?
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
Emergency procedures e.g following penetrating chest trauma - Cardiac surgery - Resection of lung cancer
Non-surgical - same as in incisional hernia with possible investigations : LFTs - H.pylori serology and Upper GI endoscopy
Ductal carcinoma which account for approximately 70% of cancers - Lobular carcinoma which accounts for 20% of cancers - Others such as mucinous -tubular -medullary which accounts for approximately 10% of cancers

17. Why is surgical treatment advised in the treatment of varicocoele?
Raynaud's phenomenon - Thrombangiitis obliterans - Takayasu's arteritis
It is often advised as the problem usually gets worse with age and there is risk of infertility.
Less than 0.5
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

18. What is a papilloma?
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)
Treatment is radical surgery with follow-up using sequent calcitonin assays
A papilloma is an over-growth of all layers of the skin with a central vascular core. They are increasingly common with age.
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

19. What is the pathogenesis of a congenital dermoid cyst?
0.5 to 0.8
It is due to development inclusion of epidermis along lines of fusion of skin dermatomes and are therefore commonly at: The medial and lateral ends of the eyebrows - The midline of the nose - The midline of the neck and trunk - Suspect if you see a c
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.
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

20. What is the medical treatment of Graves disease?
Multiple telangiectasia around the mouth and on the tongue and lips
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery
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
Excision of an entire lung

21. How is 'matching' of transplanted kidneys performed?
Well-localized abscesses are treated by incision and drainage under antibiotic cover - Larger lesions are treated by radical excision and full-thickness skin grafting usually harvested from the groins or abdomen
The procedure can be performed under a regional(brachial plexus) - local or general anaesthesia - A longitudinal incision 3-4cm in length is made over the distal third of the forearm midway between the radial artery and the cephalic vein - The cephal
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 :
At two levels:ABO Compatibility - HLA Compatibility

22. What are the features of lentigo maligna melanoma?
Hypertrophic scars tend to appear soon after injury and usually regress spontaneously - while keloid scars appear months after injury and continue to grow
The face can be affected in patients with: Syringomyelia - Frey's syndrome
The pain is caused by a reduced blood supply to the distal aspects of the limb. The pain gets worse at night because the perfusion of the limb is further reduced when the patient is lying down - This is due to: Decreased cardiac output at night - Red
Arises in a lentigo maligna - Occurs most often on the face or dorsum of the hands and forearms - Underlying lesion is flat and brown-to-black in colour with an irregular outline - Malignant area in the lesion is usually thicker - and darker in colou

23. How is a Cimino-Brescia arteriovenous fistula fashioned?
Preoperative - Age -Immunocompromised state -obesity -malignancy -abdominal distension from obstruction or ascites - Operate - Poor technical closure of the wound -placing drains through wounds - Postoperative - wound infection or haematoma - early m
The procedure can be performed under a regional(brachial plexus) - local or general anaesthesia - A longitudinal incision 3-4cm in length is made over the distal third of the forearm midway between the radial artery and the cephalic vein - The cephal
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
Unhealthy -necrotic and infected tissue - Irradiated tissue - Exposed cortical bone without periosteum - Tendon without peritendon - Cartilage without perichondrium

24. Under what circumstances would patients (with popliteal aneurysms) they be treated?
Intracranial - Intratemporal - Extratemporal
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
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
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling

25. What is the difference in the clinical course of hypertrophic and keloid scars?
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
Non-adherent dressing over ulcer plus wool bandage - Crepe bandage - Blue-line bandage - Adhesive bandage to prevent the other layers from slipping
Hypertrophic scars tend to appear soon after injury and usually regress spontaneously - while keloid scars appear months after injury and continue to grow
Rare - Worldwide distribution - Equally common in males and females - Rarely present at birth - 40% present in the first decade and can even present late in the ninth decade

26. What are the 'transudate' causes of a pleural effusion?
Autoimmune condition - Intermittent or constant swelling of one or all of the salivary glands
Cardiac failure - Metabolic disorders leading to hypoalbuminaemia such as Cirrhosis and Nephrotic syndrome
Debridement of dead tissue which can be performed by the tissue viability nurse since it does not require anaesthesia and reconstruction using a variety of fascial and muscle-containing composite flaps.
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation

27. What associations of coarctation are you aware of?
Defective gene on chromosome 22 with variable penetrance - Cutaneous signs are less often seen in this type.
It will show you if it is malignant or inflammatory
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
Coarctation may be associated with:Bicuspid aortic valcves - Aortic stenosis - Aneurysms in the circle of Wilis

28. What are possible useful investigations in gynaecomastia?
Hyperkeratoses(thickening of the keratin layer) - Focal parakeratosis - Irregular acanthosis - Basal layer atypia only
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
Plasma alpha feto-protein and beta-HCG - raised levels may indicate a testicular tumor - Testosterone and LH levels to demonstrate hypogonadism - Thyroid function tests
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

29. What are the extratemporal causes of facial nerve palsy?
Chest x-ray to map the caudal extent of the cystic hygroma - CT/MRI scanning especially if it is complex
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
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
Tumour - parotid gland malignancy - Trauma - surgical - accidental e.g facial lacerations

30. What are the causes of portal hypertension?
True umbilical herniae occur through the umbilical scar and are usually congenital in origin and particulary common in patients of Afro-Caribbean origin
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
They are often multiple and most commonly arise in the head of the epididymis. Occassionally they occur as a complication of vasectomy - in which case they are full of sperm and are termed spermatocoeles.
Congenital Which is rare and Acquired Which is very common.

31. What are the predisposing factors for Raynaud's phenomenon?
Diffuse enlargement - smooth or nodular - Solitary nodule
Scar confined to wound margins - It is found across flexor surfaces and skin creases
Defined as portal vein pressure of more than 10mmHg(normal 5-10). Portal blood flow through the liver is greatly reduced or even reversed in the most severe cases
Primary Raynauds is due to vasomotor malformation - Secondary Raynauds occurs as a consequence of pathology affecting the vessel wall

32. What are the features of an indirect inguinal hernia?
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
A cystic swelling related to a synovial lined caivity - either a joint or a tendon sheath
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
Remnants of a patent processus vaginalis - Arise from the abdominal cavity lateral to the inferior epigastric vessels at operation - passing obliquely through the deep inguinal ring and travelling along the inguinal canal with the spermatic cord - Ma

33. What other non-surgical treatments are available for ischaemic ulcers?
Risk factor modification - stopping smoking - good diabetic and hypertensive control and optimized serum lipid levels - Symptom modification - avoidance of drugs which might worsen symptoms - commencement of low-dose aspirin daily -IV prostaglandins
White lines and streaks inside the mouth
Haemorrhage - Hoarseness - Hyperthyroidism
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

34. What is the classification used in the definition of severe exarcerbation of inflammatory bowel disease?
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 seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.
Truelove classification - Gastrointestinal symptoms : passage of bloody stools more than 6 times per day - Systemic signs : tachycardia and pyrexia - Laboratory findings : anaemia and CRP more than 30
Symptomatic carotid stenosis of more than 70% - Trials demonstrated that for patients with severe stenosis surgery reduce the relative risk of disabling stroke by 48%

35. What are the features of ulcers in patients with rheumatoid arthritis?
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
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
0.5 to 0.8
Necrotizing vasculitis - Purpuric -haemorrhagic bullae

36. What are the surgical options available for deep venous occlusion/reflux

37. What are the majore causes of hepatic jaundice?
Soft-tissues(lipoma -dental cyst) - Dental origin(infection) - Muscular origin(hypertrophy of masseter muscle) - Bony origin(winged mandible -transverse process of atlas/axis) - Neoplasia(infratemporal fossa and parapharyngeal tumours)
Hepatitis - Decompensated chronic liver disease - Drugs
General - Specific
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.

38. What is a cystic hygroma?
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
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.
Affect any age - Males = females - All races may be affected
If untreated - 25% progress to invasive squamous cell carcinoma

39. How are epididymal cysts caused?
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
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
Carcinoma of the stomach and oesophagus - lymphomas and with endocrine disorders such as acromegaly - Cushing's - diabetes complicated by severe insulin resistance
They are often multiple and most commonly arise in the head of the epididymis. Occassionally they occur as a complication of vasectomy - in which case they are full of sperm and are termed spermatocoeles.

40. What tissues do skin graft not take on?
Multinodular goitre - Toxic - Simple colloid goitre - Thyroiditis - Neoplasia
Hyperthyroidism - Recurrent - Hypothyroidism - Hypertrophic scarring
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer
Unhealthy -necrotic and infected tissue - Irradiated tissue - Exposed cortical bone without periosteum - Tendon without peritendon - Cartilage without perichondrium

41. What are the complications with regards to the surgical treatment of a ganglion?
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)
The advantages of having surgery are a six-fold reduction in the rate of stroke at 3 years - The operative risk of stroke is 2% and operative mortality 1-2% - Specific risks of haematoma -hypoglossal nerve injury and numbness of the ipsilateral earlo
Parafollicular C Cells
Wound complications - Recurrence - Damage to adjacent neurovascular structures

42. What about umbilical herniae in children?
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
Minor defects in neonates are common but usually repair spontaneously. In children - umbilical herniae are mor common; they tend to have a narrow neck and folds of peritoneum stuck within this neck - which can occassionally strangulate. Most cases re
It arises de novo
Arising inside the parotid gland - Arising outside the parotid gland

43. What should you keep in mind when assessing surgical scars?
Nephrotic syndrome - Tuberculosis - Chylous ascites
Mnemonic: SNAiL - Superficial spreading - Nodular melanoma - Acral lentiginous melanoma - Lentigo maligna melanoma
Is there evidence of a new or old stoma site? Is there evidence of a small incision to one side of the scar(from a drain - this may have been due to a bowel operation) - Are there also scars in the groins? - Are there striae gravidarum
Chronic Liver disease - Right Heart Failure - Intra-abdominal Malignancy - Hypoalbuminaemia

44. What are the indications for surgery in goitre?
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital
The five Ms - Mechanical - obstructive symptoms - Malignancy - Marred Beauty - cosmetic reasons - Medical treatment failure - thyrotoxicosis - Mediastinal(retrosternal) extension - unable to perform FNAC or monitor change clinically
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
Palomo operation

45. What are the surgical options for Raynauds?
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
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
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
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

46. What are the non-surgical treatment options for coarctation of aorta?
Trauma - Hypersplenism
Nephrotic syndrome - Tuberculosis - Chylous ascites
Investigation and treatment of concurrent abnormalities - Management of hypertension
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

47. What are the two main categories of causes of dysphagia?
Mechanical obstruction - Coordination abnormalities
Temperature - Capillary Refill - Peripheral Pulses
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
A dermatofibroma is a benign neoplasm of dermal fibroblasts.

48. How should one examine a lump or swelling?
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
Tumour - parotid gland malignancy - Trauma - surgical - accidental e.g facial lacerations
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.
Are you having difficulties swallowing liquids - or solids - or both? - Did the problem start suddenly or was the onset gradual? - Do you ever regurgitate food? - Can you eat a full meal? - How long have you had this problem for? - Where does the foo

49. What is seborrhoeic keratosis?
Diffuse enlargement - smooth or nodular - Solitary nodule
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
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.
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

50. What is the risk of rupture for an aneurysm more than 5.5cm?
10% per year
Skin and soft tissues such as a sebaceous cyst -lipoma or sarcoma - Bowel - ca caecum - crohns mass in terminal ileum - TB terminal ileum - appendicular mass or abscess - Gynaecological organs - ovarian tumours or fibroid uterus - Male Reproductive S
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision
Resection of a lobe including its bronchial origin with re-anastamosis of the proximal and distal bronchus