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Clinical Surgery

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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 should you keep in mind when assessing surgical scars?
Is there evidence of a new or old stoma site? Is there evidence of a small incision to one side of the scar(from a drain - this may have been due to a bowel operation) - Are there also scars in the groins? - Are there striae gravidarum
Excision for the main lesion with varying margins depending on the size of the lesion. - If there is nodal spread - Fine Needle Aspiration Cytology or Lymph node biopsy - Therapeutic Block Dissection(if palpable lymph nodes) - Palliation adjuvant th
Barrett's oesophagus - Stricture especially chemical - Achalasia - Plummer-Vinson Syndrome
Hyperthyroidism - Recurrent - Hypothyroidism - Hypertrophic scarring

2. What are the functions of the spleen?
History and Clinical Examination - Investigate if prominent nodule or features suspicious of malignancy such as cervical lymphadenopathy or recurrent laryngeal nerve palsy
Infections within the oesophagus especially candidiasis and herpes simplex - Pharyngitis - Occasionally ulceration over the lower third of the oesophagus
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)
Use of gloves and discontinuing any predisposing drugs e.g beta blockers - Using warm pads in gloves and socks in the winter - Encourage patients to stop smoking

3. What is the pathogenesis of an acquired dermoid cyst?
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 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.
Recurrence of the cyst - Developement of a chronic -discharging sinus
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

4. What is the aetiology of diabetic foot ulcers?
Neuropathic - 45 to 60% of ulcers - Ischaemic due to peripheral occlusive arterial disaese - 10% of ulcers - Mixed neuroischaemic - 25-45% of ulcers
Demographics - Presenting Complaint - History of Presenting Complaint - Medical and Surgical History - Drugs and any other allergies - Family History - Social History - Systemic Enquiry
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
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

5. How should you organize information when talking about a disease?
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.
A blepharoplasty can be performed where excess skin and fat are removed.
Definition - Incidence - Sex - Geography - Aetiology - Pathogenesis - Macroscopic Pathology - Microscopic Pathology - Prognosis - Symptoms - Signs - Investigations - Treatment
Excision of an entire lung

6. What are the major indications for renal transplantation?
Renal transplantation is indicated in end stage renal failure - the commonest reasons in the UK are:Diabetes mellitus - Hypertensive renal disease - Glomerulonephritis - Polycystic kidney disease
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
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
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland

7. What kinds of analgesia would be appropriate for this patient?
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
Mnemonic: SNAiL - Superficial spreading - Nodular melanoma - Acral lentiginous melanoma - Lentigo maligna melanoma
Peripheral Neuropathy
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

8. What is neurofibromatosis?
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.
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.
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.
Surgical treatment involves complete excision of the cyst.

9. How should one treat a sebaceous cyst?
Use of truss or corset - Weight loss and management of other risk factors
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
Non-Surgical : May be left alone if small and asymptomatic - Surgical : To prevent recurrence - complete excision of the cyst and its contents is required and this is done through the removal of an elliptical portion of skin containing the punctum.
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

10. What are the signs of chronic venous insufficiency?
Cardiac failure - Metabolic disorders leading to hypoalbuminaemia such as Cirrhosis and Nephrotic syndrome
Pressure effects - Deafness with involvement of the 8th cranial nerve - Sarcomatous transformation - Intra-abdominal effects - Skeletal changes
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema
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

11. What are the indications for surgery in goitre?
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)
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
Recurrence of the cyst - Developement of a chronic -discharging sinus
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

12. How would you investigate a patient with cervical lymphadenopathy?

13. How are epididymal cysts caused?
Reflux Trahere transplantation - Kistner's operation - Obstruction: Palma Operation - Warren Bypass
Mean age is 50 years at presentation(F for fifty)
SRSN -OPD -RAT - Site - Radiation - Severity - Nature - Onset - Periodicity - Duration - Relieved by - Accentuated by - Timing
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.

14. What are the features of superficial spreading melanoma?
Hyperthyroidism - Late Hypothyroidism - Later Hyperparathyroidism
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
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
Demographics - Presenting Complaint - History of Presenting Complaint - Medical and Surgical History - Drugs and any other allergies - Family History - Social History - Systemic Enquiry

15. What is the differential diagnosis of a malignant melanoma?
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents
May affect people from puberty to 30 years - Females are more affected than males - Black and Hispanic Races are effected the most.
Benign skin lesions: Moles -freckles -lentigo -pigmented seborrhoeic keratoses - dermatofibromas and thrombosed haemangiomas - When it comes to malignant skin lesions - pigmented basal cell carcinomas
Lined by stratified squamous or ciliated pseudostratified columnar epithelium - May also contain thyroid or lymphoid tissue - which can undergo malignant change - If malignancy occurs - usually of thyroid papillary type.

16. Where is the midpoint of the inguinal ligament?
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present
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
Halfway along inguinal ligament that is between pubic tubercle and ASIS Which is equal to the location of the deep inguinal ring

17. How would you treat an acquired dermoid cyst?
Surgical treatment involves complete excision of the cyst.
Increased platelet count and large platelets - Increased neutrophils - Nucleated red cells with Howell-Jolly bodies and target cell - Tend to mount more of a leukocytosis in response to infection
Mnemonic : CHIASMA - Congestive : cardiac failure - Haematological : reticuloses - Infection : viral -bacterial -protozoal - Amyloid - Storage disorders : Wilson's disease - haemochromatosis - Masses: primary/secondary neoplasia - Autoimmune/alcohol
Non-surgical : Watch and wait - a small hydrocoele may require no treatment other than reassurance - but an underlying malignancy should be excluded. Aspiration - the hydrocoele fluid can be aspirated to relieve symptoms; tends to reaccumulate

18. How would you perform an ascitic tap?
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
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.
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
Non-surgical : Watch and wait - a small hydrocoele may require no treatment other than reassurance - but an underlying malignancy should be excluded. Aspiration - the hydrocoele fluid can be aspirated to relieve symptoms; tends to reaccumulate

19. What is a cyst?
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
A cystic swelling related to a synovial lined caivity - either a joint or a tendon sheath
Early - haematoma - Intermediate - Infection and nerve damage e.g saphenous in stripping - Late - Recurrence
An abnormal sac containing gas -fluid or semisolid material - with an epithelial lining

20. What is the differential diagnosis of a lump in the groin?
Mnemonic : L-SHAPE - Lymph node/Lipoma of the cord - Sapheno-varix/Skin lesions(sebaceous cyst/lipoma -etc) - Hernia - inguinal or femoral - Aneurysmal dilatation of the femoral artery - Psoas abscess or bursa - Ectopic/undescended testes
Cardiac and respiratory disease should be controlled first - Other risk-factors should be optimized - Preoperative weight loss should be encourage
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision
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

21. What are the indications of mastectomy?
Increased sweating - Palmar erythema - Thyroid acropachy - Onycholysis - Areas of vitiligo - Pulse - Fine Tremor
Surgical treatment involved complete excision but the full extent of the cyst should be established with suitable radiographic views such as x-ray or CT scan.
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 -
50%

22. Large hernia
May require the placing of postoperative drains
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis
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.
Aneurysms are most common in: Men - Aged more than 60 years - Smokers - Hypertensive patients - Often strong family history

23. What are the cardiac causes of digital clubbing?
Investigation and treatment of concurrent abnormalities - Management of hypertension
Cyanotic congenital heart disease - Infective endocarditis - Atrial myxoma (rare)
Peripheral Neuropathy
Resection of a lobe including its bronchial origin with re-anastamosis of the proximal and distal bronchus

24. What are the main features of neuropathic ulcers?
Tenderness over the graft - Reduction in urine output - Rising creatinine
Painless - Associated with normal appearance of the surrounding skin - Associated with local sensory loss
An absolute pressure of less than 50mmHg
Clinical examination - Fine-needle aspiration which would show an opalescent fluid containing cholesterol crystals or pus.

25. What are the aetiologies arising outside the parotid gland in a unilateral swelling of the parotid gland?
Hyperkeratoses(thickening of the keratin layer) - Focal parakeratosis - Irregular acanthosis - Basal layer atypia only
Undermined edge - Violaceous - Necrotic ulcer with hypertrophic margins
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)
May require the placing of postoperative drains

26. What are the main features of splenomegaly in the clinical examination?
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
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
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
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

27. What factors predispose to incisional hernia?
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
Treatment involves the use of artificial tears and saliva - use of systemic steroids and careful follow-up due to increased risk of lymphoma development
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
Sunlight - Pre-existing skin lesions - Previous melanoma

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

29. How are the side-effects of radiotherapy minimized?
Haemorrhage - Hoarseness - Hyperthyroidism
Small -punched out ulcers - Often over medial aspect of lower leg
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
Lead shields to protect the eyes and gonads - Dose-fractionation - Prior chemotherapy - Regional hypothermia - Radiolabelled antibodies

30. What are the complications of a pharyngeal pouch?
10% per year
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
Chest infection due to pulmonary aspiration - Diverticular neoplasia in less than 1% of cases
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

31. What are the different histological subtypes of a sebaceous cyst?
Normal bilirubin is less than 17 mmol/L and it usually has to reach at least three times this before the sclera is discoloured(i.e >50mmol/L). Very high levels of bilirubin are usually associated with hepatic jaundice
The 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
Schirmer's test for xeropthalmia - Slit-lamp examination of the cornea - Lip biopsy for histological examination of the minor salivary glands
Epidermal Cyst - Trichilemmal Cyst

32. What is the Courvoisier's law?
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
CHIASMA - Congestive : portal hypertension - hepatic vein obstruction - Haematological : reticuloses - Infection : Viral - bacterial - protozoal - Amyloid - Storage disorders : Gaucher's disease - Masses : primary/secondary neoplasia - Autoimmune : F
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.
Via chorda tympani to anterior two-thirds of the tongue

33. What are the hepatobiliary complications of IBD?
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
It will show you if it is malignant or inflammatory
'Watch and wait' or aspiration followed by 3 weeks of immobilzation
Liver - fatty change - chronic active hepatitis -cirrhosis and amyloid deposition - Gall bladder and bile ducts - gallstones - sclerosing cholangitis - and cholangiocarcinoma

34. How would you diagnose a branchial cyst?
Clinical examination - Fine-needle aspiration which would show an opalescent fluid containing cholesterol crystals or pus.
The commonest presentation is a painless lump or a dull ache in one testis in a young man - Occasionally there is a history of trauma accompanying the discovery of the mass - 10% present with an acutely painful testis - If para-aortic nodes have beco
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital
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

35. What is the mainstay of treatment in ascites?
Osteomyelitis - infection transmitted to the bone through the stump - Stump ulceration - can be caused by pressure from the prosthesis - Stump neuroma - Swelling of the distal nerve as it tries to regrow following division; during the initial procedu
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
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.
The mainstay of treatment of ascites is to treat the underlying condition and to place the patient on a weight reduction program - with the help of diuretic - and a low-sodium diet.

36. Why are diabetics particularly prone to foot pathology?
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
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
Notching on the underside of the ribs may be seen on a chest x-ray - this sign is caused by erosion by the intercostal collateral vessels - On the chest x-ray the aorta may be abnormal - it contains two bulges - the 'three sign' - A barium swallow sh
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.

37. What tissues do skin graft not take on?
A blepharoplasty can be performed where excess skin and fat are removed.
Superior thyroid artery - Inferior thyroid artery - Thyroidea ima(in 3% of people)
Unhealthy -necrotic and infected tissue - Irradiated tissue - Exposed cortical bone without periosteum - Tendon without peritendon - Cartilage without perichondrium
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion

38. What do you know about the pathology of Squamous Cell Carcinoma of the skin?
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 : CHIASMA - Congestive : cardiac failure - Haematological : reticuloses - Infection : viral -bacterial -protozoal - Amyloid - Storage disorders : Wilson's disease - haemochromatosis - Masses: primary/secondary neoplasia - Autoimmune/alcohol
Hyperthyroidism - Recurrent - Hypothyroidism - Hypertrophic scarring
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin

39. With which conditions would an ascitic exudate be expected?
Endovascular repair - Laparoscopic repaire of abdominal aneurysms is the subject of current clinical trials
Cirrhosis - Malignancy - Lymphatic rupture or damage
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
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital

40. How would you demonstrate a patient's ankle brachial pressure index?
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
Xeroderma pigmentosum - Gorlin's syndrome
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
The pressure cuff is inflated over the upper arm and the systolic pressure measured at the brachial artery using a Doppler probe - The cuff is then placed over the calf. - When the dorsalis pedis pulse has been located with the Doppler - the cuff is

41. How does papillary carcinoma spread?
Via the lymphatic route(Y for yellow = lymph)
Essentially to treat complications not amenable to medical therapy such as:Intra-abdominal abscesses that cannot be drained radiologically - Enterocutaneous fistulae - Stenosis causing obstructive symptoms - Control of acute/chronic bleeding
The two main differential diagnoses to consider are; Benign - keratoacanthoma - especially if it is sloughing at its centre - Malignant -Squamous cell carcinoma - particularly the nodulo-ulcerative type with a rolled edge
Pre-hepatic - Hepatic - Post-hepatic

42. What are the two main classifications for thyroid enlargement?
At two levels:ABO Compatibility - HLA Compatibility
Diffuse enlargement - smooth or nodular - Solitary nodule
Cardiac failure - Tricuspid regurgitation - Constrictive pericarditis
Simple mastectomy - Modified radical mastectomy(patey) - Radical mastectomy(Halsted mastectomy) - Extended radical mastectomy

43. What are the two types of ptosis?
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
20%
Unilateral - Bilateral
They are known as adiposis dolorosa or Dercum's disease.

44. What do you know about the pathophysiology of varicose veins?
Fibrous tissue invades the tunica intima and media of the vein and breaks up the smooth muscle - preventing the maintenance of adequate vascular tone. These changes are patchy and may not affect adjacent segments of vein.
Gall stones - Carcinoma head of pancreas - Lymph nodes
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
Calcification of the walls of the vessel preserves the pulses until late in the natural history of disease - and prevent the sphygmomanometer from compressing the vessels. This tends to lead to an abnormally(and reassuringly) high ankle brachial pres

45. What are the causes of atrial fibrillation?
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
Renal transplantation is indicated in end stage renal failure - the commonest reasons in the UK are:Diabetes mellitus - Hypertensive renal disease - Glomerulonephritis - Polycystic kidney disease
Cardiac disease - hypertension -myocardial infarction -ischaemia -mitral valve disease - cardiomyopathy -endocarditis - Respiratory disease - Pneumonia - lung cancer - sarcoidosis - Other: Hypothyroidism and idiopathic ( lone AF)
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

46. How should one examine a lump or swelling?
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.
Parafollicular C Cells
A pyogenic granuloma is a rapidly growing capillary haemangioma whic usually measures less than 1cm in diameter
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

47. Where is the midinguinal point?
20%
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
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 :
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery

48. What about umbilical herniae in children?
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
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
Cardiac disease - hypertension -myocardial infarction -ischaemia -mitral valve disease - cardiomyopathy -endocarditis - Respiratory disease - Pneumonia - lung cancer - sarcoidosis - Other: Hypothyroidism and idiopathic ( lone AF)
Non-Surgical : May be left alone if small and asymptomatic - Surgical : To prevent recurrence - complete excision of the cyst and its contents is required and this is done through the removal of an elliptical portion of skin containing the punctum.

49. What is the surgical treatment of coarctation of aorta?
End-to-end anastamosis - patching and the use of the left subclavian artery as a flap are all surgical options
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
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
Notching on the underside of the ribs may be seen on a chest x-ray - this sign is caused by erosion by the intercostal collateral vessels - On the chest x-ray the aorta may be abnormal - it contains two bulges - the 'three sign' - A barium swallow sh

50. Why is surgical treatment advised in the treatment of varicocoele?
'Watch and wait' or aspiration followed by 3 weeks of immobilzation
Peripheral Neuropathy
It is often advised as the problem usually gets worse with age and there is risk of infertility.
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