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Clinical Surgery

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1. What is the pathogenesis of Raynaud's phenomenon?
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
Recurrence of the cyst - Developement of a chronic -discharging sinus
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
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)

2. What is a papilloma?
Similar to those in the right iliac fossa except for the bowel where a mass in the Left iliac fossa could indicate: Diverticular mass Which is often tender - Carcinoma of the colon - Faecal mass
A carbuncle is an extensive infection of hair follicles by the same organism with involvement of adjacent follicles and development of draining sinuses. It is associated with diabetes and is treated with a combination of systemic antibiotics and surg
A papilloma is an over-growth of all layers of the skin with a central vascular core. They are increasingly common with age.
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.

3. How would you treat this condition?
Ulcer is distal to the fistula - Shallow indolent ulcers
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection
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.
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

4. What is a keratoacanthoma?
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
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
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
90% of lung resections in the Western world are performed for bronchial carcinoma. Other indications include traumatic injury - bronchiectasis - chronic infection including tuberculosis - benign tumours e.g carcinoid and metastatic tumour

5. What are the features of a femoral hernia?
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
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
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
Barium swallow Which is usually diagnostic - Rigid endoscopy if neoplasia suspected

6. Why is surgical treatment advised in the treatment of varicocoele?
Sunlight - Pre-existing skin lesions - Previous melanoma
Bilateral subtotal thyroidectomy leaving approximately 4g of thyroid tissue on each side of the trachea
It is often advised as the problem usually gets worse with age and there is risk of infertility.
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

7. In What age group does anaplastic carcinoma usually present in?
Liver - fatty change - chronic active hepatitis -cirrhosis and amyloid deposition - Gall bladder and bile ducts - gallstones - sclerosing cholangitis - and cholangiocarcinoma
It is important to exclude malignant tumours such as: Malignant melanoma - Basal cell carcinoma
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
Elderly(A for Aged)

8. Do you know of any infectious agents associated with AAA?
An abnormal sac containing gas -fluid or semisolid material - with an epithelial lining
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms
Raynaud's phenomenon - Thrombangiitis obliterans - Takayasu's arteritis
Barium swallow may be useful - If diagnosis is in doubt - endoscopy with biopsies and brushings should be performed to exclude a carcinoma - Physiological function could be tested using 24-hour oesophageal pH studies to exclude reflux and manometry

9. What are the three objectives to be taken note of in the palpation part of the arterial examination?
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
Temperature - Capillary Refill - Peripheral Pulses
Barium swallow may be useful - If diagnosis is in doubt - endoscopy with biopsies and brushings should be performed to exclude a carcinoma - Physiological function could be tested using 24-hour oesophageal pH studies to exclude reflux and manometry
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema

10. How would you treat a pharyngeal pouch?
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
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
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision

11. What are the acquired predisposing factors for basal cell carcinomas?
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
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion
Patient must be standing up as he or she must be able to see the stoma - The stoma must be within the rectus abdominis muscle - Away from scars or skin creases - Away from bony points or waistline of clothes - At a site that is easily accessible to t
Benign skin lesions: Moles -freckles -lentigo -pigmented seborrhoeic keratoses - dermatofibromas and thrombosed haemangiomas - When it comes to malignant skin lesions - pigmented basal cell carcinomas

12. What is a pyogenic granuloma?
A lipoma is a benign tumour consisting of mature fat cells.
This removes the possibility of recurrent disease appears to improves the outcome for patietns with significant eye disease and eliminates the need for annual TFT monitoring to assess remnant function. It does - of course - demand thyroxine replaceme
90% of lung resections in the Western world are performed for bronchial carcinoma. Other indications include traumatic injury - bronchiectasis - chronic infection including tuberculosis - benign tumours e.g carcinoid and metastatic tumour
A pyogenic granuloma is a rapidly growing capillary haemangioma whic usually measures less than 1cm in diameter

13. What are the treatment options available for Basal Cell Carcinoma?
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
Tumours raised above the skin : excision with 0.5cm margin(maximum) - Tumours not raised above the skin - Wider margin of excision - particularly if at inner canthus of eye -nasolabial fold and ear. A frozen section may be necessary to ensure adequat
The 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
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling

14. What is the treatment of a lipoma?

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15. What do you know about thyroid adenomas?
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
Lymphocyte-mediated destruction of the exocrine glands secondary to B-cell hyper-reactivity and associated loss of suppressor T-Cell activity
Mnemonic : PACT - Prominent nodule in a multinodular goitre - Adenoma - Cyst/Carcinoma/Lymphoma - Thyroiditis
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

16. What are the stages of restorative proctocolectomy?
Temperature - Capillary Refill - Peripheral Pulses
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.
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
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

17. What is the pathogenesis of peripheral neuropathy?
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
Emergency procedures e.g following penetrating chest trauma - Cardiac surgery - Resection of lung cancer
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
Superior thyroid artery - Inferior thyroid artery - Thyroidea ima(in 3% of people)

18. What about umbilical herniae in children?
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
The cyst may be surgically excised - whole if possible - although this may be difficult if there has been previous infection - Bonney's blue dye can be injected into the fistula/sinus allowing accurate surgical excision and therefore reduces recurren
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
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

19. What are the main aetiologies in diffuse enlargement of the thryoid?
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
High success - 50 to 70% will heal at 3 months - 80 to 90% at 12 months - The patient should be warned to avoid trauma to the affected area - Four-layer compression bandaging - Encourage rest and elevation of leg - Once healed - grade 2 compression s
Excision of a single lobe of the lung
Multinodular goitre - Toxic - Simple colloid goitre - Thyroiditis - Neoplasia

20. How would you prepare a patient prior to breast surgery?
Those related to anaesthesia
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
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
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present

21. What is the treatment of medullary carcinoma?
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
Mnemonic: SNAiL - Superficial spreading - Nodular melanoma - Acral lentiginous melanoma - Lentigo maligna melanoma
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
Treatment is radical surgery with follow-up using sequent calcitonin assays

22. How do carcinomas of the oesophagus present?
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
True aneurysms are uncommon and are generally caused by atherosclerosis - and occasionally by dissection -trauma -previous carotid surgery or infection - When a true aneurysm has been excluded - the patient can be reassured and discharged. - Dilated
The characteristic presentation is insidious with progressive weight-loss and dysphagia - The patient initally hass difficulty swallowing solids and often describes the food getting stuck in the lower part of the oesophagus - They may also describe o
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

23. Surgical way too treat Varicose veins
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
Solar keratosses are squamous cell carcinoma in situ
Ligation of the incompetent SFJ or SPJ with stripping of the involved vein and stab avulsion of varicosities - Ligation of incompetent perforating vessels - Subcutaneous endoscopic perforator surgery
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.

24. What is the risk of rupture for an aneurysm more than 5.5cm?
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
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
10% per year

25. What is the non-surgical treatment of a ganglion?

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26. 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
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
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair

27. What is neurofibromatosis?
Commonest in children and young adults(P for Paediatric)
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection
Presence of multiple neurofibromas in a patient - in combination with other dermatological manifestations(six cafe-au-lait psots) - It is an autosomal dominant condition with two types: 1 and 2.
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery

28. What are the features of spider naevi?
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 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.
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
Familial e.g 'hazel nails' - pachydermoperiostitis - Graves' disease - Unilaterally seen in axillary artery aneurysm and brachial arteriovenous malformation

29. How would you treat a keratoacanthoma?
Non-Surgical : Leave alone if asymptomatic(particularly in young patients) - Surgical : Complete excision of lesion with histology(.
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
VINTA MEDIC - Vascular - Iatrogenic - Neoplastic - Traumatic - Autoimmune - Metabolic - Endocrine - Degenerative - Inflammatory/Infective - Congenital
Grade 3 compression stockings to apply 40mmHg pressure at the ankles - Intermittent pneumatic compression device - Cellulitis should be treated - Advise patient to elevate their leg as much as possible and stress the importance of cleanliness and car

30. What are the surgical treatment principles of incisional hernia?
An aneurysm is an abnormal dilatation of a blood vessel - A true aneurysm involves all layers of the arterial wall - A false aneurysm follows a partial laceration of the vessel wall causing blood to leak out of the vessel into the surrounding tissues
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
Early mobilization is important - They should keep the area clean and wash carefully -especially after the clip/sutures have been removed - They are able to bathe immediately - They may need to be off work for 6 weeks if their job involves heavy lift
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)

31. What are the features of ulcers in tuberculosis?
Familial e.g 'hazel nails' - pachydermoperiostitis - Graves' disease - Unilaterally seen in axillary artery aneurysm and brachial arteriovenous malformation
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
Undermined edge - Shallow ulcer
May affect people from puberty to 30 years - Females are more affected than males - Black and Hispanic Races are effected the most.

32. Where are pressure sores most commonly found?
Sacrum - Greater trochanter - Heel - Lateral Malleolus - Ischial Tuberosity - Occiput
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms
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?
Small -punched out ulcers - Often over medial aspect of lower leg

33. What are the congenital predisposing factors for malignant melanomas?
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
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery
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

34. What is the shorter version of the surgical sieve?
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital
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
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives
Cardiac disease - hypertension -myocardial infarction -ischaemia -mitral valve disease - cardiomyopathy -endocarditis - Respiratory disease - Pneumonia - lung cancer - sarcoidosis - Other: Hypothyroidism and idiopathic ( lone AF)

35. Sleeve resection
Resection of a lobe including its bronchial origin with re-anastamosis of the proximal and distal bronchus
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
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review
Size - Tenderness - Mobility - Consistency

36. How would you perform an ascitic tap?
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
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s
The procedure should be performed under sterile condition and if the ascites is not clinically apparent or easy to locate - it should be done by a radiologist under ultrasound guidance to prevent inadvertent injuries to intra-abdominal structures.
Dohlman's procedure - endoscopic diathermy resection of the posterior pharyngeal wall or endoscopic stapling with less risk of fistula formation and consequent mediastinitis

37. What is a useful mneumonic to remember what you have to present when examining a lump or swelling?
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
Should The Children Ever Find Lumps Readily
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
Primary Raynauds is due to vasomotor malformation - Secondary Raynauds occurs as a consequence of pathology affecting the vessel wall

38. What are the benign diseases of the breast?
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
Unilateral total lobectomy and isthmusectomy
Stoma diarrhoea - related to water and electrolyte imbalances - hypokalemia being the commonest and most important consequence - Nutritional disorders - Stones - both gall stones and renal stones increase in frequency following an ileostomy - Psychos
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis

39. What is the aim of cardiopulmonary bypass?
The aim of bypass is to provide a systemic circulation while the heart is stopped and emptied of blood.
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
An aneurysm is an abnormal dilatation of a blood vessel - A true aneurysm involves all layers of the arterial wall - A false aneurysm follows a partial laceration of the vessel wall causing blood to leak out of the vessel into the surrounding tissues
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

40. What systems are tackled when taking into consideration a thyroid history?
Prolonged weight-bearing and mechanical shear forces act on areas of soft-tissues overlying bony prominences - leading to both occlusion and tearing of small blood vessels -reduced tissue perfusion and ischaemic necrosis.
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological
Small -punched out ulcers - Often over medial aspect of lower leg
Congenital ptosis - Myopathies - Syphillis

41. What is venous gangrene?
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
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
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
Often surgeons place two drains - one in the axilla and one at the site of surgery within the breast tissue - The drains are usually left for 3 to 5 days or until the drainage volume is less than 50mL in 1 day. - Patients can safely be sent home with

42. Why is total thyroidectomy preferred in the surgical treatment of Graves' disease?
The aim of bypass is to provide a systemic circulation while the heart is stopped and emptied of blood.
20%
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
This removes the possibility of recurrent disease appears to improves the outcome for patietns with significant eye disease and eliminates the need for annual TFT monitoring to assess remnant function. It does - of course - demand thyroxine replaceme

43. What other associations of pyoderma gangrenosum do you know of?
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
Idiopathic(50%) - Myeloproliferative disorders - Autoimmune hepatitis - More common in males than females
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
Non-surgical : risk factor modification such as establishment of good diabetic control and for recurrent infections eradication of nasal carriage of staphylococcus aureus with antiseptics and/or antibiotics such as chlorhexidine and mupirocin - Surgi

44. How would you treat a patient with a single neurofibroma?
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
Recurrence of the cyst - Developement of a chronic -discharging sinus
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
'Watch and wait' or aspiration followed by 3 weeks of immobilzation

45. What is the non-surgical treatment of a multinodular goitre?

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46. What are the late side-effects of radiotherapy?
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.
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
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
Multinodular goitre - Toxic - Simple colloid goitre - Thyroiditis - Neoplasia

47. What are the major causes of post-hepatic jaundice?
Plasma alpha feto-protein and beta-HCG - raised levels may indicate a testicular tumor - Testosterone and LH levels to demonstrate hypogonadism - Thyroid function tests
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
Gall stones - Carcinoma head of pancreas - Lymph nodes
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological

48. How would you treat a dermatofibroma?
Necrotizing vasculitis - Purpuric -haemorrhagic bullae
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)
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
Non-Surgical : leave alone if asymptomatic and if patient does not want intervention - Surgical : Simple excision followed by histology

49. What symptoms - a patient with an epigastric hernia might have complained of at presentation?
Simple colloid goitre - Graves' disease - Thyroiditis
Prolonged weight-bearing and mechanical shear forces act on areas of soft-tissues overlying bony prominences - leading to both occlusion and tearing of small blood vessels -reduced tissue perfusion and ischaemic necrosis.
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion
Epigastric pain - which may increase after meals - May be acutely painful after physical exercise - Nausea and early satiety - Reflux and non-ulcer dyspepsia

50. What investigations may help confirm the diagnosis of thoracic outlet obstruction?
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
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
The aneurysm is surgically repaired by either an excision bypass -where the popliteal artery is ligated above and below the diseased segment and a graft interposed - or a simple resection and anastamoses without the use of a graft - Acute ischemia ca
Cervical rib or prominent transverse process of the Chest X-ray or thoracic outlet views - Doppler examination may be useful in quantifying the postural changes and post-stenotic dilatation - Arteriograms of the subclavian artery may show a marked ki