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Clinical Surgery

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1. How would a patient with carotid aneurysm be investigated?
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland
Lord's plication - Jaboulay's operation
Idiopathic(50%) - Myeloproliferative disorders - Autoimmune hepatitis - More common in males than females
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

2. What are the taste branches of the facial nerve?
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.
Symptomatic carotid stenosis of more than 70% - Trials demonstrated that for patients with severe stenosis surgery reduce the relative risk of disabling stroke by 48%
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
Via chorda tympani to anterior two-thirds of the tongue

3. What are the signs in the mouth of acanthosis nigricans?
Vascular symptoms - Risk factors for arterial disease - Fitness for surgery
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
Black discolouration of the skin
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

4. What is the medical treatment of Graves disease?
Plasma alpha feto-protein and beta-HCG - raised levels may indicate a testicular tumor - Testosterone and LH levels to demonstrate hypogonadism - Thyroid function tests
The Branham-Nicoladoni sign indicates the degree of shunting and cardiac impairment resulting from a large AV fistula - The carotid pulse is palpated and then a tourniquet placed around the proximal affected limb and inflated above systolic pressure
For patients who refuse radiation therapy or relapse after an adequate course - pregnant patients or those wishing to become pregnant within 4 years - patients under the age of 40 years and those with nodular or large goitres
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

5. How are the side-effects of radiotherapy minimized?
Lead shields to protect the eyes and gonads - Dose-fractionation - Prior chemotherapy - Regional hypothermia - Radiolabelled antibodies
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
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
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

6. 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
Wound complications - Recurrence - Damage to adjacent neurovascular structures
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
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.

7. Which are the most benign parotid tumours?

8. What are the acquired predisposing factors for basal cell carcinomas?
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair
Within the lumen: Foreign body - oesophageal web - Plummer-Vinson syndrome - In the wall : Carcinoma of the oesophagus -oesophagitis -barrett's oesophagus - benign oesophageal stricture and post-radiation or chemical strictures - Outside the wall: re
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion

9. What is the surgical treatment of coarctation of aorta?
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
End-to-end anastamosis - patching and the use of the left subclavian artery as a flap are all surgical options
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
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

10. What are the main points to be elicited during a clerking of the surgical patient?
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
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
The advantages of having surgery are a six-fold reduction in the rate of stroke at 3 years - The operative risk of stroke is 2% and operative mortality 1-2% - Specific risks of haematoma -hypoglossal nerve injury and numbness of the ipsilateral earlo
Demographics - Presenting Complaint - History of Presenting Complaint - Medical and Surgical History - Drugs and any other allergies - Family History - Social History - Systemic Enquiry

11. What is venous gangrene?
An intravenous injection of contrast into the veins in the arm can illustrate the degree of obstruction - A CT Scan of the thorax may demonstrate the cause of the obstruction and the length of the SVC affected
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 pain is caused by a reduced blood supply to the distal aspects of the limb. The pain gets worse at night because the perfusion of the limb is further reduced when the patient is lying down - This is due to: Decreased cardiac output at night - Red
The incompetent vein is below the level of the tourniquest

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

13. What are the indications for lung resection?
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
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
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
Paraumbilical herniae occur around the umbilical scar. They are uncommon before the age of 40 years and can become large. Peristalsis can be observed through the skin when the defect is large. The neck of the sac is often tight and held with a fibrou

14. What are the features of spider naevi?
Idiopathic(50%) - Myeloproliferative disorders - Autoimmune hepatitis - More common in males than females
Congenital - Usually due to a cervical rib(arising from the seventh cervical vertebra) and the subclavian artery is compressed between the rib and either the scalenus anterior muscle or the clavicle - Acquired - The obstruction may also follow a frac
Injection sclerotherapy with 1% sodium tetradecyl sulphate - this has a high recurrence rate and indicated for postoperative recurrence of veins - below knee varicosities if the long saphenous vein and short saphenous vein are not involved.
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

15. What is the origin of lymphangiomas?
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
Weight loss - Change in bowel habit - Loss of appetite - Back pain
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
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris

16. What investigations would you perform in a suspected case of Inflammatory Bowel Disease?
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
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
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
A chemodectoma is a tumour of the paraganglion cells of the carotid body located at the bifurcation of the common carotid artery. They are usually benign(but locally invasive) - but occassionally - they are malignant with potential to metastasize to

17. What surgical options are available in the management of cervical lymphadenopathy?
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally
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
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection

18. 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
The patient should have a full workup for atherosclerosis - General investigations : Urinalysis for proteinuria - marker of atherosclerotic renal disease - Blood tests: FBC for anemia - which might precipitate symptoms - Renal function for possible u
Congenital - Multiple arteriovenous fistulae - Traumatic
It is the result of a weak posterior wall to the inguinal canal - Arise medial to the inferior epigastric vessels at operation - This weakness causes the abdominal contents to bulge through the wall into the inguinal canal but the hernia is not withi

19. What are the non-surgical treatment options for coarctation of aorta?
Investigation and treatment of concurrent abnormalities - Management of hypertension
Non-Surgical : leave alone if asymptomatic and if patient does not want intervention - Surgical : Simple excision followed by histology
1
Size - Tenderness - Mobility - Consistency

20. What do you know about Kaposi's Sarcoma?
Weight loss - Change in bowel habit - Loss of appetite - Back pain
Derived from capillary endothelial cells or from fibrous tissue - It is linked to human herpes virus 8
VINTA MEDIC - Vascular - Iatrogenic - Neoplastic - Traumatic - Autoimmune - Metabolic - Endocrine - Degenerative - Inflammatory/Infective - Congenital
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review

21. Simple cyst Treatment
Thyroidectomy
It is the result of a weak posterior wall to the inguinal canal - Arise medial to the inferior epigastric vessels at operation - This weakness causes the abdominal contents to bulge through the wall into the inguinal canal but the hernia is not withi
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
Mayo's 'vest-over-pants' operation is the most widely accepted repair for these herniae

22. What features of the lump would make you suspicious that it is breast cancer?
Familial e.g 'hazel nails' - pachydermoperiostitis - Graves' disease - Unilaterally seen in axillary artery aneurysm and brachial arteriovenous malformation
A dermoid cyst is a skin-lined cyst deep to the skin. They may be congenital or acquired.
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
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 :

23. How would you treat a patient with a single neurofibroma?
Mechanical obstruction - Coordination abnormalities
Transfemoral radiological embolization of the testicular vein - using either a spring coil or sclerosant
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
Peripheral Neuropathy

24. What do you know about thyroid malignancy?
Some surgeons would advocate that all patients should undergo Duplex scanning of the leg veins before any surgery is undertaken. Others would consider indications to be: Previous history of deep vein thrombosis - Any signs of chronic venous insuffici
The 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)
Malignancy - Primary lung tumour - Cardiovascular : Pulmonary embolus/infarct or Dressler's syndrome - Infections such as Pneumonia - Tuberculosis or Subphrenic abscess - Systemic diseases such as rheumatoid arthritis and SLE
Mneumonic : LIST Lymphoma and Leukaemia - Infection(further subdivided into Bacterial - Viral - Protozoal and Toxoplasmosis) - Sarcoidosis - Tumours

25. What are the histological features of seborrhoeic keratosis?
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
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery
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
Hyperkeratosis - Acanthosis - Hyperplasia of variably pigmented basaloid cells

26. What are the pathological features of thyroglossal cyst?
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives
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.
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
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

27. What will you observe on angiography of a chemodectoma?
A hypervascular mas displacing the bifurcation of the carotid arteries
Commonest form of thyroid abnormality - Secondary to hyperplasia of the gland to meet physiological demand for thyroxine - Secondary to defective production of thyroid hormone
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)
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

28. How would you treat a pyogenic granuloma?
Non-surgical : regression is uncommon - except those arising in pregnancy and so they are best treated surgically - though occassionally a silver nitrate stick can be attempted - Surgical : curettage with diathermy of the base or complete excision b
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
Idiopathic Which is the most common - Gastrointestinal - Respiratory - Cardiac - Rare causes
Via the lymphatic route(Y for yellow = lymph)

29. What are the common causes of ascites?
Tenderness over the graft - Reduction in urine output - Rising creatinine
Chronic Liver disease - Right Heart Failure - Intra-abdominal Malignancy - Hypoalbuminaemia
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
Triple assessment which consists of: Clinical : history and physical examination - Radiological : ultrasound or mammography - Pathological : cytology(fine-needle aspiration) or histological(tru-cut biopsy)

30. What is the surgical treatment of a ganglion?
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological
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
Complete excision to include the neck of the ganglion at its site of origin
Inspect - Protrusion of the tongue - Swallowing - Palpate(from the back) - Continue Accordingly(Neck Decision Circle)

31. What is the pathogenesis of thromboangiitis obliterans?
50%
Mnemonic : SPRUE - Site of enlargement : from the right costal margin towards the right iliac fossa - Percussion Note : dull - Respiration Movement: it descends - Unable to get above it - Edge : may be smooth or irregular
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
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

32. What are the two main systems which need to be examining thyroid status in a surgical patient?
A caring and competent approach - A good examination technique - An ability to elicit and draw conclusions from physical signs
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
Sturge-Weber syndrome is the association of a facial port-wine stain with a corresponding haemangioma in the brain - leading to contralateral focal fits.
Hands and Eyes

33. What does surgical excision involved in the surgical treatment of a pharyngeal pouch?
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
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
A caring and competent approach - A good examination technique - An ability to elicit and draw conclusions from physical signs
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.

34. How would you treat a cystic hygroma?
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
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
Early - haematoma - Intermediate - Infection and nerve damage e.g saphenous in stripping - Late - Recurrence
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.

35. What are the specific late complications of amputations?
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
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision
The Branham-Nicoladoni sign indicates the degree of shunting and cardiac impairment resulting from a large AV fistula - The carotid pulse is palpated and then a tourniquet placed around the proximal affected limb and inflated above systolic pressure
Plasma alpha feto-protein and beta-HCG - raised levels may indicate a testicular tumor - Testosterone and LH levels to demonstrate hypogonadism - Thyroid function tests

36. What is the prophylactic treatment of pressure sores?
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
Hyperkeratosis - Acanthosis - Hyperplasia of variably pigmented basaloid cells
Regular skin inspection - Frequent turning of immobile patients( 2 to 4 hourly) - Massage - Toileting - The use of special mattresses and cushion which redistribute the pressure on at-risk areas
A dermatofibroma is a benign neoplasm of dermal fibroblasts.

37. How might you be aware the transplant rejection is occurring?
Immediate : Facial nerve transection - Reactionary haemorrhage - Early : Wound infection - Temporary facial weakness -salivary fistula and division of the greater auricular nerve which means loss of sensation to the pinna - Late : Wound dimple - Frey
Tenderness over the graft - Reduction in urine output - Rising creatinine
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's
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.

38. What do you know about solitary thyroid nodules?
Increase in size - Ulceration - Change in colour - Irritation - Bleeding - Halo of pigmentation - Satellite nodules - Enlarged local lymph nodes - Evidence of distant spread
Non-surgical - if the cyst is not troublesome - it should not be removed - especially in younger men - because there is risk of operative damage and postoperative fibrosis causing subfertility - Surgical - very large or painful cysts can be removed a
Healing by secondary intention - Skin graft - Local flap - Distant flap - Composite flap - Island flaps vs pedicled flaps - Free tissue transfer - Composite neurovascular free tissue transfer
More common in females - Occur most commonly in the fourth or fifth decade - 10% in middle-aged are malignant but 50% are malignat in the young and the elderly - FNAC is the most important investigation

39. What is the treatment of Sjogren's syndrome?
Scar confined to wound margins - It is found across flexor surfaces and skin creases
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
Treatment involves the use of artificial tears and saliva - use of systemic steroids and careful follow-up due to increased risk of lymphoma development
0.5 to 0.8

40. If the patient has noticed pale stools and dark urine - what other questions would you ask?
Weight loss - Change in bowel habit - Loss of appetite - Back pain
Reflux Trahere transplantation - Kistner's operation - Obstruction: Palma Operation - Warren Bypass
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
Testicular tumours can be mimicked by chronic or old infection leading to scarring such as in orchitis or tuberculosis - Occasionally a long-standing hydrocoele may develop calcification and become harder - clinically similar to a tumour - Tumours oc

41. What is the treatment of medullary carcinoma?
'Watch and wait' or aspiration followed by 3 weeks of immobilzation
Treatment is radical surgery with follow-up using sequent calcitonin assays
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
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists

42. What are single lumps in the breast more likely to be ?
Excision of an entire lung
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
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer
Endovascular repair - Laparoscopic repaire of abdominal aneurysms is the subject of current clinical trials

43. What are the venous symptoms in thoracic outlet obstruction more commonly due to?
Surgical treatment involves complete excision of the cyst.
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)
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision

44. What are the specific and late complications of thyroidectomy?
A pyogenic granuloma is a rapidly growing capillary haemangioma whic usually measures less than 1cm in diameter
Treatment with radiotherapy and doxorubicin gives best survival of 1 year
Bilateral subtotal thyroidectomy leaving approximately 4g of thyroid tissue on each side of the trachea
Hyperthyroidism - Recurrent - Hypothyroidism - Hypertrophic scarring

45. What are the malignant diseases of the breast?
A enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and the skin
Superior thyroid artery - Inferior thyroid artery - Thyroidea ima(in 3% of people)
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
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

46. What other conditions cause odynophagia?
Mnemonic: WBC - White - blanching of digits - Blue - cyanosis of pain - Crimson - reactive hyperaemia - fingers turn red in colour
Infections within the oesophagus especially candidiasis and herpes simplex - Pharyngitis - Occasionally ulceration over the lower third of the oesophagus
The primary lesion could be treated with excision with 1cm margin and Moh's staged chemosurgery with histological assessment of margins and electrodessication - for lesions of the eyelids -ears and nasolabial folds. Radiotherapy is applied for unrese
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review

47. What is the surgical treatment of a patient with an epigastric hernia?
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
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
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
Barrett's oesophagus - Stricture especially chemical - Achalasia - Plummer-Vinson Syndrome

48. In the tourniquet test - What do rapid filling of the collapsed veins below the tourniquet indicate?
Autoimmune condition - Intermittent or constant swelling of one or all of the salivary glands
Undermined edge - Violaceous - Necrotic ulcer with hypertrophic margins
The incompetent vein is below the level of the tourniquest
A blepharoplasty can be performed where excess skin and fat are removed.

49. What is a cystic hygroma?
The incompetent vein is below the level of the tourniquest
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.
Look - Feel - Press - Move - Listen - Transilluminate and Examine Surrounding Areas.
Haemorrhage - Hoarseness - Hyperthyroidism

50. What does a keloid scar look like?
History - Examination - Special Investigations - Treatment
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
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.
If untreated - 25% progress to invasive squamous cell carcinoma