Clinical Surgery

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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. What are the three objectives to be taken note of in the palpation part of the arterial examination?
A cystic swelling related to a synovial lined caivity - either a joint or a tendon sheath
Temperature - Capillary Refill - Peripheral Pulses
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
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


2. What are the signs of chronic venous insufficiency?
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
Motor - Secretomotor - Taste - Sensory
Trauma - Hypersplenism
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema


3. Obstructive Jaundice - With regards to radiological investigations
Elderly(A for Aged)
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
Intra-abdominal abscesses should be drained - Colonic defunctioning using a loop ileostomy may be needed for patients who have failed medical therapy - Occasionally a subtotal colectomy and permanent ileostomy may be needed - Pouch surgery is general
Ultrasound will show: Presence of underlying liver disease - Degree of dilatation of the common bile duct(>8mm is abnormal) - Presence of gall stones - Presence of lymphadenopathy or a pancreatic mass - CT Scan - ERCP - MRCP


4. What surgical options are available in the management of cervical lymphadenopathy?
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.
Treatment is radical surgery with follow-up using sequent calcitonin assays
1
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection


5. What are the features of ulcers in patients with sickle-cell disease?
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
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.
Small -punched out ulcers - Often over medial aspect of lower leg
As the perfusion of the leg begins to decrease in a patient with peripheral vascular disease; the ratio begins to fall.


6. How would you treat a pyogenic granuloma?
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
Hands and Eyes
Fine-needle aspiration cytology for diagnosis - MRI to exclude deep-lobe involvement
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


7. What would you warn the patient of in consenting them for an endarterectomy?
Thyroid function tests - hyperthyroid - Ultrasound - dimensions of goitre and nodules looking for dominant nodules or cysts for FNAC - Chest X-ray as a retrosternal goitre may compress the trachea
Triple assessment which consists of: Clinical : history and physical examination - Radiological : ultrasound or mammography - Pathological : cytology(fine-needle aspiration) or histological(tru-cut biopsy)
malignant change?
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


8. What are the different types of mastectomy that can be performed?
Mneumonic : I - CHUM - Infection(frequent) - Calcification - Ulceration - sebaceous Horn formation - Malignant change
Urine cytology -blood tests would be expected to be normal and a renal ultrasound scan which shows a cyst with a smooth outline -sharply defined thin wall and no internal echoes(which imply solid components)
Via chorda tympani to anterior two-thirds of the tongue
Simple mastectomy - Modified radical mastectomy(patey) - Radical mastectomy(Halsted mastectomy) - Extended radical mastectomy


9. What are the 'exudate' causes of a pleural effusion?

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10. What is the significance of the ankle brachial pressure index?
As the perfusion of the leg begins to decrease in a patient with peripheral vascular disease; the ratio begins to fall.
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
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%
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


11. What other conditions cause odynophagia?
Infections within the oesophagus especially candidiasis and herpes simplex - Pharyngitis - Occasionally ulceration over the lower third of the oesophagus
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
Excess accumulation of fluid in the processus vaginalis.
Affect any age - Males = females - All races may be affected


12. What are the vital points to be taken into consideration when examining the neck?
Inspect - Protrusion of the tongue - Swallowing - Palpate(from the back) - Continue Accordingly(Neck Decision Circle)
A lipoma is a benign tumour consisting of mature fat cells.
Mneumonic : BEDD - Base - Edge - Describe structure visualized at the base of the ulcer - Discharge
Epidermal Cyst - Trichilemmal Cyst


13. What are the histological appearances of solar keratoses?
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation
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
Hyperkeratoses(thickening of the keratin layer) - Focal parakeratosis - Irregular acanthosis - Basal layer atypia only
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


14. What are the indications for preoperative Duplex ultrasound scanning
Discolouration - Discharge - Depression - Deviation - Displacement - Destruction - [Duplication - unlikely in the exam]
malignant change?
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
The insensitive - mechanically abnormal - dry foot is at risk from unperceived external trauma e.g from shoes and from repetitive painless injury e.g foreign body in shoe. Progressive skin loss and ulceration may occur.


15. How would you investigate a patient who was referred with a carotid bruit?
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
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
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
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


16. How do you treat this condition?
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin
Unilateral - Bilateral
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
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


17. Simple cyst Treatment
Sunlight - Pre-existing skin lesions - Previous melanoma
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
The major differential diagnoses would be with a renal tumour and adult polcystic kidney disease and if there is any doubt of a tumour - then the cyst fluid may be sent for cytological analysis
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


18. What are the major causes of post-hepatic jaundice?
Gall stones - Carcinoma head of pancreas - Lymph nodes
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)
Acute severe ulcerative colitis - MPS - toxic Megacolon - Perforation - rare in absence of toxic dilatation and raises possibility of Crohn's disease. The mortality is 40% - Severe gastrointestinal bleeding - Chronic ulcerative colitis - 3 Ms - Medic
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


19. What are the causes of facial nerve palsy?
Congenital : Cystic disease - horseshoe kidney - hypertrophic single kidney - Acquired : Diseases specific to the kidney such as solitary cysts - tumours - hydronephrosis - pyonephrosis - perinephric abscess and renal vein thrombosis and diseases as
Intracranial - Intratemporal - Extratemporal
Mnemonic: WBC - White - blanching of digits - Blue - cyanosis of pain - Crimson - reactive hyperaemia - fingers turn red in colour
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


20. What are the surgical options in Crohns disease?
Familial e.g 'hazel nails' - pachydermoperiostitis - Graves' disease - Unilaterally seen in axillary artery aneurysm and brachial arteriovenous malformation
Intra-abdominal abscesses should be drained - Colonic defunctioning using a loop ileostomy may be needed for patients who have failed medical therapy - Occasionally a subtotal colectomy and permanent ileostomy may be needed - Pouch surgery is general
Thrombosis during or just after haemodialysis - which may be due to relative hypotension and damage to the intima of the vein - Venous hypertension in the hand causes swelling and ischemia of the fingertips. This should be avoided by the ligation of
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


21. What are the main aetiologies in diffuse enlargement of the thryoid?
Via greater superficial petrosal nerve to lacrimal - nasal and palatine glands
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 :
80% of salivary gland tumours occurs in the parotid gland - 80% of these parotid tumours being benign - with 80% of these benign tumours being pleomorphic adenomas
Multinodular goitre - Toxic - Simple colloid goitre - Thyroiditis - Neoplasia


22. What is lid lag secondary to ?
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
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
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
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


23. How does papillary carcinoma spread?
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
A furuncle results from infection of hair follicles with Staphylococcus aureus
Via the lymphatic route(Y for yellow = lymph)
Small -punched out ulcers - Often over medial aspect of lower leg


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


25. What are the cause of cervical lymphadenopathy that you know of?
Mneumonic : LIST Lymphoma and Leukaemia - Infection(further subdivided into Bacterial - Viral - Protozoal and Toxoplasmosis) - Sarcoidosis - Tumours
Angiolipomas - Hibernomas - Bannayan-Zonana Syndrome
A dermatofibroma is a benign neoplasm of dermal fibroblasts.
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


26. What are the signs in the mouth of Lichen Planus?
White lines and streaks inside the mouth
Endovascular repair - Laparoscopic repaire of abdominal aneurysms is the subject of current clinical trials
Wounds associated with - Infection - Trauma - Burns - Tension especially over the sternum such as after CABG - Wounds on certain areas of the body
Palomo operation


27. What is acanthosis nigricans associated with?

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28. What is exopthalmos secondary to?
Least common - Occurs on hairless skin - Irregular area of brown or black pigmentation
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
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents


29. How would you treat an acquired dermoid cyst?
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
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.
Surgical treatment involves complete excision of the cyst.
Onset and Continuous Symptoms - When did you first notice it? - What made you notice it? - Predisposing events? - How does it bother you? - What symptoms does it cause? - Has it changed since you first noticed it ? - Have you noticed any other lumps?


30. What are the motor branches of the facial nerve?
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally
Idiopathic(50%) - Myeloproliferative disorders - Autoimmune hepatitis - More common in males than females
The face can be affected in patients with: Syringomyelia - Frey's syndrome
Nerve to stapedius - Nerve to posterior belly of digastric - Five divisions within the parotid gland - temporal - zygomatic - buccal - mandibular and cervical


31. What are the other types of arteriovenous fistula?
Complete excision to include the neck of the ganglion at its site of origin
Congenital - Multiple arteriovenous fistulae - Traumatic
Site and size of varicosities - including the presence of saphena varix - Skin for changes and scars - Swelling of the ankle
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


32. What is the classification used in the definition of severe exarcerbation of inflammatory bowel disease?
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
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
Hands and Eyes
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair


33. What surgical treatments are available for ptosis?
A blepharoplasty can be performed where excess skin and fat are removed.
Mainly teratoma or seminomas - other types are: Embryonal carcinoma - Choriocarcinoma - Yolk sac tumour - Leydig cell tumours - Sertoli cell tumours - Lymphoma
Pressure effects - Deafness with involvement of the 8th cranial nerve - Sarcomatous transformation - Intra-abdominal effects - Skeletal changes
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


34. What are the features of a multinodular goitre?

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35. What level does the serum bilirubin need to rise to before jaundice can be detected on clinical examination?
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.
Via the lymphatic route(Y for yellow = lymph)
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
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?


36. How do you classify the severity of thyroid eye disease?
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
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
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.
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


37. What is the non-surgical treatment of pressure sores?
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
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
Classic Kaposi's sarcoma - AIDS-associated Kaposi's sarcoma - Endemic(central African) variety - Transplantation-associated Kaposi's sarcoma
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological


38. What is a neurofibroma?
A neurofibroma is a benign tumour derived from peripheral nerve elements.
Raynaud's phenomenon - Thrombangiitis obliterans - Takayasu's arteritis
Below Knee - Above Knee
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin


39. What are the indications for surgery in goitre?
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 major risk is embolic stroke(4% per year) which results from thrombus accumulating in an inefficiently contracting left atrium - Emboli can also lodge in the mesenteric vessel - causing intestinal ischaemia - Patients are also at risk from acute
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.
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


40. What side effect would you warn this patient about if considering cervical sympathectomy?

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41. In What age group does anaplastic carcinoma usually present in?
Motor - Secretomotor - Taste - Sensory
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
Low approach - Lockwood - Transinguinal repair - Lotheissen - High approach - McEvedy
Elderly(A for Aged)


42. What is the pathophysiology of coarctation?
Some 50% are present at birth and they are thought to represent a congenital abnormality during the evolution of embryonic lymph nodes into the adult type
It will show you if it is malignant or inflammatory
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
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


43. What are the indications for surgery in ulcerative colitis?

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44. Where is the midinguinal point?
Situations where skin grafts will not take - When the aim is to reconstruct the tissue that is 'like-for-like'(bone -joint -tendon -nerve -epithelial lining -etc) to promote optimal structure - function and cosmesis - When blood supply has to be impo
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
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery
Non-Surgical : leave alone if asymptomatic and if patient does not want intervention - Surgical : Simple excision followed by histology


45. What are the causes of gynaecomastia?
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
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.
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
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


46. What will you observe on angiography of a chemodectoma?
For patients who refuse radiation therapy or relapse after an adequate course - pregnant patients or those wishing to become pregnant within 4 years - patients under the age of 40 years and those with nodular or large goitres
Medical : treat underlying condition - saline cleansing - high-dose oral or intralesional steroids plus/minus cyclosporin - Surgical : serial allograft followed by autologous skin graft or muscle flap coverage when necessary
Reduction of the contents of the sac - Excision of the sac - Repair of the defect - taking care not to narrow the femoral vein while tightening up the femoral canal
A hypervascular mas displacing the bifurcation of the carotid arteries


47. How do you stage malignant melanomas?

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48. What are the complications of incisional hernia?
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation
Primary Raynauds is due to vasomotor malformation - Secondary Raynauds occurs as a consequence of pathology affecting the vessel wall
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.
malignant change?


49. What questions should one ask to someone with dysphagia?
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)
Chest x-ray to map the caudal extent of the cystic hygroma - CT/MRI scanning especially if it is complex
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
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


50. How should one examine a lump or swelling?
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms
Non-surgical - same as in incisional hernia with possible investigations : LFTs - H.pylori serology and Upper GI endoscopy
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
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.