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Clinical Surgery

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1. What are the main aetiologies in diffuse enlargement of the thryoid?
Refers to congenital disease or primary lymphatic failure. It is three times more common in women and the pathology originates from within the lymphatics. It is also known as Milroys disease.
Tenderness over the graft - Reduction in urine output - Rising creatinine
Multinodular goitre - Toxic - Simple colloid goitre - Thyroiditis - Neoplasia
Physical preparation - marking of side - explanation of procedure - anaesthetic work up - Pyschological preparation - Breast care nurse preoperatively and discussion of reasons for mastectomy - option of reconstructive surgery

2. What are the late side-effects of radiotherapy?
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery
Clinical examination - Fine-needle aspiration which would show an opalescent fluid containing cholesterol crystals or pus.
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
Skin : as above - Lungs : pneumonitis - pulmonary fibrosis - Heart : Ischemic heart disease - Arteries: radiation arteritis -Spinal cord : myelopathy - Gonadal damage : infertility - Thyroid : hypothyroidism due to depletion of follicular thyroid cel

3. What is the surgical treatment of benign parotid tumours?
Neuropathic - 45 to 60% of ulcers - Ischaemic due to peripheral occlusive arterial disaese - 10% of ulcers - Mixed neuroischaemic - 25-45% of ulcers
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
Ultrasound - first line - Which is used to define the liver architecture and give an idea of the size and may identify the pathology - Contrast-enhanced CT may also be useful - especially to further investigate solid lesions
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)

4. What is a secondary hydrocoele?
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair
Cirrhosis - Malignancy - Lymphatic rupture or damage
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
White lines and streaks inside the mouth

5. What are the signs in the mouth of acanthosis nigricans?
Dohlman's procedure - endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling with less risk of fistula formation and consequent mediastinitis
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
Black discolouration of the skin
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

6. What does minimally invasive surgery involve in the surgical treatment of a pharyngeal pouch?
Dohlman's procedure - endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling with less risk of fistula formation and consequent mediastinitis
Early - haematoma - Intermediate - Infection and nerve damage e.g saphenous in stripping - Late - Recurrence
Dissection of the hernial sac from surrounding tissues and definitioni of tissue bordering the defect on all sides to 2-3cm - Closing the defect(if small) and/or using mesh overlapping adequately( more than 5 to 8cm) over normal tissues to allows for
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La

7. What conditions increase the risk of developing pressure sores?
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
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
Any cause of deep venous insufficiency can lead to ulceration: Valvular disease - varicose veins - deep vein reflux - communicating vein reflux - Outflow tract obstruction - often post-DVT - Muscle pump failure - primary such as stroke and neuromuscu
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

8. What do you know about the epidemiology of hypertrophic scars?
Affect any age - Males = females - All races may be affected
Dohlman's procedure - endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling with less risk of fistula formation and consequent mediastinitis
Heamolysis - Hereditary e.g : gilbert's syndrome
Surgical excision with preoperative embolizatoin if the tumour is large - Ultrasonic surgical dissection may also be used - Radiotherapy is used for patients unfit for surgery or for large tumours

9. What are the stages of restorative proctocolectomy?
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
Unilateral total lobectomy and isthmusectomy
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
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

10. What is the pathophysiology of coarctation?
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
Venous gangrene is a rare complication of deep vein thrombosis in the iliofemoral segment and presents in three phases: 1 - Phlegmasia alba dolens - white leg 2 - Phlegmasia cerulea dolens - blue leg 3 - Gangrene - occurs as a consequence of acute is
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
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma

11. What is venous gangrene?
Nephrotic syndrome - Tuberculosis - Chylous ascites
Superior thyroid artery - Inferior thyroid artery - Thyroidea ima(in 3% of people)
Venous gangrene is a rare complication of deep vein thrombosis in the iliofemoral segment and presents in three phases: 1 - Phlegmasia alba dolens - white leg 2 - Phlegmasia cerulea dolens - blue leg 3 - Gangrene - occurs as a consequence of acute is
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise

12. What is the risk of rupture for an aneurysm more than 5.5cm?
10% per year
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's
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
Clinical examination - Fine-needle aspiration which would show an opalescent fluid containing cholesterol crystals or pus.

13. What are the features of nodular melanoma?
Second most common type - Occurs most often on the trunk - Polypoid in shape and is raised - Smooth surface - Irregular edge - Frequently ulcerated
Unilateral total lobectomy and isthmusectomy
Ultrasound would be the first investigation - Abdo wall masses and extent of disease better seen with CT Scan - IV contrast enhance CT scanning to clarify lower abdominal and pelvic vasculature
Rapid growth and pain(on history) - Hyperemic hot skin - Hard consistency - Fixed to skin and underlying muscle - Irregular surface or ill-defined edge - Facial nerve involvement

14. How would you treat solar keratoses?
Left spermatic vein is more vertical where it connects to the left renal vein - The left renal vein can be compressed by the colon - The left testicular vein is longer than the right - It frequently lack a terminal valve which serves to try to preven
Infection - acute and chronic otitis media - herpes zoster(ramsay hunt syndrome) - Idiopathic - Bell's Palsy - Trauma - surgical -accidental - e.g basal skull fracture - Tumour - paraganglioma - squamous cell carcinoma of external or middle ear - met
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin
Via the bloodstream(R is equal to red is equal to blood)

15. What do you know about thyroid cysts?
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
Pregnancy - Ascites - Ovarian cysts - Fibroids - Bowel distension
Mechanical obstruction - Coordination abnormalities
Wash Hands - Observe from end of bed - Start examination from right-hand side - Look for JACCOL which means jaundice -anaemia -cyanosis -clubbing -oedema and lymphadenopathy - Observation -Palpation -Percussion and Auscultation

16. Why do these neuropathic ulcers form?
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present
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.
Mneumonic : BEDD - Base - Edge - Describe structure visualized at the base of the ulcer - Discharge
Any cause of deep venous insufficiency can lead to ulceration: Valvular disease - varicose veins - deep vein reflux - communicating vein reflux - Outflow tract obstruction - often post-DVT - Muscle pump failure - primary such as stroke and neuromuscu

17. What is the treatment of choice in differentiated thyroid cancer?
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
Resection of a lobe including its bronchial origin with re-anastamosis of the proximal and distal bronchus
It is a collagen vascular disease - caused by infiltrate of plasma cells into the arterial wall - This leads to luminal thrombosis and affects small and medium-sized arteries of the lower limb - Eventually - collagen is deposited and forms a thick fi
Thyroidectomy

18. How may pleural effusions be classified?
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
Psychological and social implications - Haematoma and wound infection - including gas gangrene - Deep vein thrombosis and pulmonary embolus - Phantom limb pain - due to the sensory cortex 'believing' the limb is still present - Skin necrosis
Schirmer's test for xeropthalmia - Slit-lamp examination of the cornea - Lip biopsy for histological examination of the minor salivary glands
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

19. What is the differential diagnosis of a ganglion?
Idiopathic(50%) - Myeloproliferative disorders - Autoimmune hepatitis - More common in males than females
Discolouration - Discharge - Depression - Deviation - Displacement - Destruction - [Duplication - unlikely in the exam]
Bursae - Cystic protrusions from the synovial cavity of arthritic joints - Benign giant cell tumors of the flexor sheath - Rarely : Malignant swelling e.g synovial sarcoma
Benign skin lesions: Moles -freckles -lentigo -pigmented seborrhoeic keratoses - dermatofibromas and thrombosed haemangiomas - When it comes to malignant skin lesions - pigmented basal cell carcinomas

20. How would you rehabilitate a patient following the placement of a stoma?
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
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
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
Sturge-Weber syndrome is the association of a facial port-wine stain with a corresponding haemangioma in the brain - leading to contralateral focal fits.

21. What elements are ascertained in a thyroid history with regards to symptoms arising from the swelling?
Duration and change in size - Cosmetic symptoms - Discomfort during swallowing/dysphagia - Dyspnoea - Hoarseness - Pain
A cystic swelling related to a synovial lined caivity - either a joint or a tendon sheath
Recurrence of the cyst - Developement of a chronic -discharging sinus
1

22. How would you treat hidradenitis suppurativa?
Produces IgM - to capture and process foreign antigen - Filters especially encapsulated microorganisms e.g pneumococcus - Sequesters and removes old red blood cells and platelets - Recycles iron - Pools platelets(30% of total platelets within spleen)
Ultrasound - first line - Which is used to define the liver architecture and give an idea of the size and may identify the pathology - Contrast-enhanced CT may also be useful - especially to further investigate solid lesions
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
Psychological and social implications - Haematoma and wound infection - including gas gangrene - Deep vein thrombosis and pulmonary embolus - Phantom limb pain - due to the sensory cortex 'believing' the limb is still present - Skin necrosis

23. Where are pressure sores most commonly found?
Sacrum - Greater trochanter - Heel - Lateral Malleolus - Ischial Tuberosity - Occiput
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
Well-differentiated - Myxoid and round cell - Pleomorphic liposarcoma
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

24. What are the causes of gynaecomastia?
Surgical excision with preoperative embolizatoin if the tumour is large - Ultrasonic surgical dissection may also be used - Radiotherapy is used for patients unfit for surgery or for large tumours
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
Early - haematoma - Intermediate - Infection and nerve damage e.g saphenous in stripping - Late - Recurrence
Emergency procedures e.g following penetrating chest trauma - Cardiac surgery - Resection of lung cancer

25. Why are 98% of varicocoeles left-side?
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
Conservative - Medical - Surgical
Left spermatic vein is more vertical where it connects to the left renal vein - The left renal vein can be compressed by the colon - The left testicular vein is longer than the right - It frequently lack a terminal valve which serves to try to preven
Any cause of deep venous insufficiency can lead to ulceration: Valvular disease - varicose veins - deep vein reflux - communicating vein reflux - Outflow tract obstruction - often post-DVT - Muscle pump failure - primary such as stroke and neuromuscu

26. What is the order of skin changes seen in Raynaud's?
Mnemonic : No POMP - No opthalmic features are seen - Progression of simple diffuse goitre to nodular enlargement - Overactivity in parts of an MNG may lead to mild hyperthyroidism(Plummer's syndrome) - Middle-aged women - Positive family history
Mnemonic: WBC - White - blanching of digits - Blue - cyanosis of pain - Crimson - reactive hyperaemia - fingers turn red in colour
Superficial spreading at 70% of malignant melanomas
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

27. Which normal tissues are particularly affected by radiotherapy?
Definition - Incidence - Sex - Geography - Aetiology - Pathogenesis - Macroscopic Pathology - Microscopic Pathology - Prognosis - Symptoms - Signs - Investigations - Treatment
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)
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.
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

28. What other investigations can be done for Sjogren's syndrome?
Leave alone if asymptomatic and if patient does not want intervention - Intervene only when extensive or for cosmetic reasons with local radiotherapy and/or chemotherapy using interferon-alpha -doxorubicin and intralesional vinblastine.
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
Schirmer's test for xeropthalmia - Slit-lamp examination of the cornea - Lip biopsy for histological examination of the minor salivary glands
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

29. What will the Fine Needle Aspiration Cytology show you in the investigation of Cervical Lymphadenopathy?
It will show you if it is malignant or inflammatory
Mneumonic : LIST Lymphoma and Leukaemia - Infection(further subdivided into Bacterial - Viral - Protozoal and Toxoplasmosis) - Sarcoidosis - Tumours
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection
Trauma - Hypersplenism

30. What is the differential diagnosis of a midline neck swelling?
Pressure effects - Deafness with involvement of the 8th cranial nerve - Sarcomatous transformation - Intra-abdominal effects - Skeletal changes
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.
May affect people from puberty to 30 years - Females are more affected than males - Black and Hispanic Races are effected the most.

31. What is the non-surgical treatment of a multinodular goitre?
Remove goitrogens from diet(e.g cabbage) - Thyroxine 0.1/0.3 mg per day - If thyrotoxicosis treat as in Graves' disease - Aspiration of cysts with cytology to exclude malignancy - Radioiodine for elderly patients - particularly those unfit for surger
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
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
Simple colloid goitre - Graves' disease - Thyroiditis

32. What are the non-surgical treatment options for coarctation of aorta?
Investigation and treatment of concurrent abnormalities - Management of hypertension
Idiopathic Which is the most common - Gastrointestinal - Respiratory - Cardiac - Rare causes
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.
Solar keratosses are squamous cell carcinoma in situ

33. What are the arterial symptoms in thoracic outlet obstruction more commonly due to?
A blepharoplasty can be performed where excess skin and fat are removed.
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
Raynaud's phenomenon - Thrombangiitis obliterans - Takayasu's arteritis
Barium swallow Which is usually diagnostic - Rigid endoscopy if neoplasia suspected

34. What is the aim of the tourniquet test?
Wash Hands - Observe from end of bed - Start examination from right-hand side - Look for JACCOL which means jaundice -anaemia -cyanosis -clubbing -oedema and lymphadenopathy - Observation -Palpation -Percussion and Auscultation
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
The tourniquet test is designed to reveal the presence and site of incompetent veins - especially at the sites of connection between the superficial and deep venous systems.
Emergency procedures e.g following penetrating chest trauma - Cardiac surgery - Resection of lung cancer

35. What is the aetiology of enterocutaneous fistulae?
Inflammation : inflammatory bowel disease -especially Crohn's disease - Diverticular disease - tuberculosis - Malignancy : Often following spontaneous rupture and abscess formation by the tumour - Radiotherapy : Pelvic irradiation can damage the inte
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.
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
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

36. In patients with gynaecomastia - what would make you concerned the patient may have a breast cancer?
Left spermatic vein is more vertical where it connects to the left renal vein - The left renal vein can be compressed by the colon - The left testicular vein is longer than the right - It frequently lack a terminal valve which serves to try to preven
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 -
Males represent 1% of all breast cancers. Features that would be suspicious would be: Older age - Unilateral gynaecomastia - Firm or hard nodules within the breast tissue - Remember to examine the axillary and supraclavicular fossae for lymphadenopat
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s

37. What investigations would you perform in a suspected case of Inflammatory Bowel Disease?
Stool tests: Stool Culture - in new cases of IBD to exclude infection - Blood tests - Full blood count - may show anemia and leukocytosis - Electrolytes may show evidence of dehydration or hypokalemia - Liver function tests - CRP and ESR may be raise
Any cause of deep venous insufficiency can lead to ulceration: Valvular disease - varicose veins - deep vein reflux - communicating vein reflux - Outflow tract obstruction - often post-DVT - Muscle pump failure - primary such as stroke and neuromuscu
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair
Form of telangiectasias - Central arteriole with leg-like branches Which blanch on central pressure - Found over upper torso - head and neck in adults - Associated with chronic liver disease and pregnancy

38. What surgical treatments are available for ptosis?
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.
A blepharoplasty can be performed where excess skin and fat are removed.
Scar confined to wound margins - It is found across flexor surfaces and skin creases
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.

39. What is the aetiology of varicocoeles?
Excision of a single lobe of the lung
Varicocoeles are dilated tortuous 'varicose' veins in the pampiniform plexus - the network of veins that drains the testis - They usually occur in 15% of younger men - often around puberty - and are thought to have an anatomical basis - If they appea
A enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and the skin
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 :

40. What is the pathogenesis of umbilical herniae?
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
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
Defective gene on chromosome 17
These are due to a defect through the linea alba adjacent to the umbilicus and usually due to obesity stretching the fibres.

41. What important questions should you ask in a patient with jaundice?
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.
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists
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?
Klippel-Trenaunay-Weber Syndrome - Parkes-Weber syndrome

42. What side effect would you warn this patient about if considering cervical sympathectomy?
Coarctation may be associated with:Bicuspid aortic valcves - Aortic stenosis - Aneurysms in the circle of Wilis
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
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
Excessive dryness of skin - Compensatory sweating around trunk ( in up to 50% of patients) - Horner's syndrome( a consequence of damage to the stellate ganglion) - 0.1% - Pneumothorax/haemothorax - Important to warn of the risk of a general anaesthet

43. How would you treat a patient with a single neurofibroma?
Pre-hepatic - Hepatic - Post-hepatic
Non-Surgical : leave alone if asymptomatic and if patient does not want intervention - Surgical : Indicated only if malignant growth suspected; post-excision - local regrowth is common as neurofibromata cannot be surgically detached from underlying n
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
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

44. How would you prepare a patient who is going for surgery which will involve forming a stoma?
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer
Carcinoma of the stomach and oesophagus - lymphomas and with endocrine disorders such as acromegaly - Cushing's - diabetes complicated by severe insulin resistance
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
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

45. What is the pathogenesis of Raynaud's phenomenon?
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?
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
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological
Vascular - Cerebrovascular accident - Tumour - acoustic neuroma - Infection - Meningitis(rarely

46. What are the surgical options for managing ulcerative colitis?
Subtotal colectomy with ileostomy plus or minus mucous fistula formation in acute severe colitis - Proctocolectomy and permanent ileostomy when the patient chooses or if patient not suitable for a restorative procedure - Restorative proctocolectomy W
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
Cardiac and respiratory disease should be controlled first - Other risk-factors should be optimized - Preoperative weight loss should be encourage
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery

47. Which are the respiratory causes of digital clubbing?
Bronchial carcionoma - Chronic suppurative lung disease(abscess -bronchiectasis -cystic fibrosis -empyema) - Fibrosing alveolitis - Mesothelioma
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
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
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.

48. What are the indications for preoperative Duplex ultrasound scanning
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present
Physical preparation - marking of side - explanation of procedure - anaesthetic work up - Pyschological preparation - Breast care nurse preoperatively and discussion of reasons for mastectomy - option of reconstructive surgery
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
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

49. What are the extratemporal causes of facial nerve palsy?
Arising from the skin and soft tissues - sebaceous cysts -sarcoma -lipoma -epigastric hernia - Arising from the gastrointestinal tract - carcinoma of the stomach -hepatomegaly -pancreatic ca - pancreatic pseudocyst - Arising from the vascular system
Tumour - parotid gland malignancy - Trauma - surgical - accidental e.g facial lacerations
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
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

50. How do you treat these scars?
Reflux Trahere transplantation - Kistner's operation - Obstruction: Palma Operation - Warren Bypass
A papilloma is an over-growth of all layers of the skin with a central vascular core. They are increasingly common with age.
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
malignant change?

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502 Pages of Distilled Wisdom
250+ Easy-to-Follow Guides
5000+ Proven Tips
13 Types of Essential Skills
The World's First & Only Encyclopedia of
Self Help, Self Improvement & Career Advice
Just $3.99 | PDF / EPub, Kindle Ready