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Clinical Surgery

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1. What are the two main types of aetiologies in the differential diagnosis of a unilateral swelling of the parotid gland?
Arising inside the parotid gland - Arising outside the parotid gland
Pleomorphic adenoma(commonest) and Warthin's tumour
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
Chronic Liver disease - Right Heart Failure - Intra-abdominal Malignancy - Hypoalbuminaemia

2. What would you tell patients about their recovery from inguinal hernia repair?
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
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.
Duration and change in size - Cosmetic symptoms - Discomfort during swallowing/dysphagia - Dyspnoea - Hoarseness - Pain
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

3. What are the main features of neuropathic ulcers?
Painless - Associated with normal appearance of the surrounding skin - Associated with local sensory loss
Diffuse enlargement - smooth or nodular - Solitary nodule
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
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

4. What are the other types of arteriovenous fistula?
Congenital - Multiple arteriovenous fistulae - Traumatic
Motor - Secretomotor - Taste - Sensory
Via chorda tympani to anterior two-thirds of the tongue
Surgical treatment involves complete excision of the cyst.

5. How are epididymal cysts caused?
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
Arises in a lentigo maligna - Occurs most often on the face or dorsum of the hands and forearms - Underlying lesion is flat and brown-to-black in colour with an irregular outline - Malignant area in the lesion is usually thicker - and darker in colou
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.
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

6. What are the complications with regards to the surgical treatment of a ganglion?
Wound complications - Recurrence - Damage to adjacent neurovascular structures
Debulking or bypass procedures - Direct lymphovenous anastamosis - Stripping a piece of intestinal mucosa - exposing the rich submucosal plexus - this can then be used to replace a leg lymph node which then forms new connections with distal lymphatic
Blood Tests:Haematological - FBC - ESR - Biochemical : TFT - ACE Levels(raised in sarcoidosis) - Serological : 'monospot' or Paul-Bunnell test looking for atypical mononuclear cells in infectious mononucleosis - Radiological : Ultrasound - CT Scan an
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La

7. What are the acquired predisposing factors for basal cell carcinomas?
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?
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion
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
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)

8. How does follicular carcinoma spread?
Via greater superficial petrosal nerve to lacrimal - nasal and palatine glands
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
Via the bloodstream(R is equal to red is equal to blood)
Excess accumulation of fluid in the processus vaginalis.

9. What is the signifcance of an arterial bruit or venous hum over the liver?
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's
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.
A horizontal ellipse of stretched supra or infra-umbilical skin is excised - deeping the incision to the rectus sheath and identifying the fibrous band Which is the neck of the sac - The sac is dissected free from the surrounding tissues - which may
An arterial bruit may indicate alcoholic hepatits and carcinoma. A venous hum is associated with portal hypertension and if this is secondary to cirrhosis with a patent umbilical vein(or varices in the falciform ligament) - this is known as the Cruve

10. How would you treat a branchial cyst?

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11. What are the functions of the spleen?
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)
Thyroid function tests - hyperthyroid - Ultrasound - dimensions of goitre and nodules looking for dominant nodules or cysts for FNAC - Chest X-ray as a retrosternal goitre may compress the trachea
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.
Cardiac failure - Tricuspid regurgitation - Constrictive pericarditis

12. What are the causes of a mass in the right iliac fossa?
Secondary Raynaud's phenomenon associated with other diseases
Congenital Which is rare and Acquired Which is very common.
Skin and soft tissues such as a sebaceous cyst -lipoma or sarcoma - Bowel - ca caecum - crohns mass in terminal ileum - TB terminal ileum - appendicular mass or abscess - Gynaecological organs - ovarian tumours or fibroid uterus - Male Reproductive S
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection

13. What is venous gangrene?
More than five is considered as pathological in chronic liver disease
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
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)
Emergency procedures e.g following penetrating chest trauma - Cardiac surgery - Resection of lung cancer

14. Radiological investigations for hepatomegaly
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
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
Extrahepatic : caused by increased resistance to flow e.g : portal or splenic vein thrombosis - Intrahepatic : due to cirrhosis - right heart failure - sarcoidosis and schistosomiasis(the latter is the most important cause worldwide - ova of the para
Ultrasound - first line - Which is used to define the liver architecture and give an idea of the size and may identify the pathology - Contrast-enhanced CT may also be useful - especially to further investigate solid lesions

15. What needs to be taken into consideration when marking the stoma site?
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
A skin flap consists of tissue - or tissues - transferred from one site of the body to another - while maintaining a continuous blood supply through a vascular pedicle.
Myelofibrosis - Chronic Myeloid Leukaemia - Malaria - Tropical splenomegaly - Kala-azar(visceral leishmaniasis)
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally

16. With which conditions would an ascitic transudate be expected?
More worrying features for a tumour would include: Thick or irregular wall - Extensive calcification within the cavity or wall of the cyst - Multilocular cysts
Cardiac failure - Tricuspid regurgitation - Constrictive pericarditis
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
Cirrhosis - Malignancy - Lymphatic rupture or damage

17. What do you know about the pathophysiology of pressure necrosis?
At two levels:ABO Compatibility - HLA Compatibility
Weight loss - Change in bowel habit - Loss of appetite - Back pain
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.
Chest infection due to pulmonary aspiration - Diverticular neoplasia in less than 1% of cases

18. What investigations would be helpful in confirming the diagnosis of coarctation of aorta?

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19. What is the pathogenesis of peripheral neuropathy?
Risk factor modification - stopping smoking - good diabetic and hypertensive control and optimized serum lipid levels - Symptom modification - avoidance of drugs which might worsen symptoms - commencement of low-dose aspirin daily -IV prostaglandins
Duplex Ultrasound - Angiography - CT/MRI
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
Depends on local guidelines but essentially: Pneumococcal vaccine - Haemophilus influenzae type B vaccine - Meningococcal vaccine - Annual 'flu' vaccine - Consideration for lifelong penicillin or penicillin as required when infection present - Warn a

20. What is the surgical treatment of benign parotid tumours?
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
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
Surgical treatment is superficial parotidectomy(if superfical lobe of gland only involved) or total parotidectomy with preservation of the facial nerve(if deep lobe of gland or both lobes involved)

21. How do carcinomas of the oesophagus present?
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
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
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise
A blepharoplasty can be performed where excess skin and fat are removed.

22. Obstructive Jaundice - With regards to radiological investigations
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
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
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
Traditionally -Bilateral subtotal thyroidectomy without need for postoperative replacement of thyroxine was recommended but more recently total thyroidectomy is the preferred procedure due to the risk of pathological change in the thyroid remnant nec

23. Conservative way to treat varicose veins?
Site and size of varicosities - including the presence of saphena varix - Skin for changes and scars - Swelling of the ankle
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise
Vaginal Hydrocoele - fluid accumulates in the tunica vaginalis - Hydrocoele of the cord - fluid accumulates around the spermatic cord - Congenital Hydrocoele - Infantile Hydrocoele
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

24. How can the extent of the obstruction be determined?
Via the lymphatic route(Y for yellow = lymph)
Wound complications - Recurrence - Damage to adjacent neurovascular structures
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
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.

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

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26. What are the features of ulcers in patients with arteriovenous fistulae?
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
Ulcer is distal to the fistula - Shallow indolent ulcers
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
Recurrence of the cyst - Developement of a chronic -discharging sinus

27. What are the extratemporal causes of facial nerve palsy?
Tumour - parotid gland malignancy - Trauma - surgical - accidental e.g facial lacerations
Congenital Which is rare and Acquired Which is very common.
A caring and competent approach - A good examination technique - An ability to elicit and draw conclusions from physical signs
Classic Kaposi's sarcoma - AIDS-associated Kaposi's sarcoma - Endemic(central African) variety - Transplantation-associated Kaposi's sarcoma

28. What will you observe on angiography of a chemodectoma?
Dilatation of normal capillaries - Can be secondary to skin irradiation - Can be part of hereditary haemorrhagic telangiectasia
Onset and Continuous Symptoms - When did you first notice it? - What made you notice it? - Predisposing events? - How does it bother you? - What symptoms does it cause? - Has it changed since you first noticed it ? - Have you noticed any other lumps?
Superior thyroid artery - Inferior thyroid artery - Thyroidea ima(in 3% of people)
A hypervascular mas displacing the bifurcation of the carotid arteries

29. What are the causes of superior vena cava obstruction?
Second most common type - Occurs most often on the trunk - Polypoid in shape and is raised - Smooth surface - Irregular edge - Frequently ulcerated
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
Primary Raynauds is due to vasomotor malformation - Secondary Raynauds occurs as a consequence of pathology affecting the vessel wall
Causes can be divided into pathology within and outside the SVC. Within the SVC obstruction tends to be as a consequence of thrombosis within intravenous jugular or subclavian lines(CPV Lines) - especially when hyperosmolar solutions are infused for

30. Large hernia
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
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
May require the placing of postoperative drains
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

31. How would you demonstrate to an examiner that a mass in the right upper quadrant is indeed an enlarged liver(hepatomegaly)?
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
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
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema
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

32. What are the constituents of the surgical sieve?
VINTA MEDIC - Vascular - Iatrogenic - Neoplastic - Traumatic - Autoimmune - Metabolic - Endocrine - Degenerative - Inflammatory/Infective - Congenital
Complications should be divided into specific to the amputation and general for any operation - and also immediate within 24 hours - early up to 1 month and late beyond 1 month
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
Wounds associated with - Infection - Trauma - Burns - Tension especially over the sternum such as after CABG - Wounds on certain areas of the body

33. How is Sjogren's clinically diagnosed?
Clinical diagnosis if at least two or the following triad is present: Keratoconjunctivitis sicca(dry eyes) - Xerostomia(dry mouth) - Associated connective tissue disorders such as rheumatoid arthritis(50% of cases) - scleroderma -SLE -Polymyositis or
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
General - Specific
'Watch and wait' or aspiration followed by 3 weeks of immobilzation

34. What are port-wine stains?
Rolled or raised edge - Often on sun-damaged skin
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
Purple-blue naevus found on face -lips and mucous membrane of the mouth - Present from birth and does not change in size thereafter - Found on limbs in association with Klippel-Trenaunay syndrome.
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

35. What is hidradenitis suppurativa?
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
Situations where skin grafts will not take - When the aim is to reconstruct the tissue that is 'like-for-like'(bone -joint -tendon -nerve -epithelial lining -etc) to promote optimal structure - function and cosmesis - When blood supply has to be impo
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
Hidradenitis suppurative - also known as acne inversa - is now considered a disease of follicular occlusion rather than an inflammatory or infectious process of the apocrine glands. Abscesses form recurrently and this causes the characteristic perman

36. What do you know about the pathology of Squamous Cell Carcinoma of the skin?
Neoplasia(benign -malignant -lymphoma and leukaemia) - Stone(sialolithiasis) - Infection/inflammation(mumps -acute sialadenitis -chronic recurrent sialadenitis -HIV - salivary gland disease) - Autoimmune(sjogren's syndrome) - Infiltration(sarcoidosis
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
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision

37. 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
Complete excision to include the neck of the ganglion at its site of origin
Low approach - Lockwood - Transinguinal repair - Lotheissen - High approach - McEvedy

38. What is a fistula?
Mean age is 50 years at presentation(F for fifty)
Excision of an entire lung
Epidermal Cyst - Trichilemmal Cyst
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)

39. What do you know about the pathophysiology of varicose veins?
Arises in a lentigo maligna - Occurs most often on the face or dorsum of the hands and forearms - Underlying lesion is flat and brown-to-black in colour with an irregular outline - Malignant area in the lesion is usually thicker - and darker in colou
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.
Bright-red raised strawberry-like lesion - Present from birth - but 60% undergo spontaneous resolution by the age of 3 years - Only treated if obscuring a visual field or spontaneous resolution not occurring.
Commonest in children and young adults(P for Paediatric)

40. What is the differential diagnosis of a ganglion?
An abnormal protrusion of abdominal contents through a defect in the linea alba - usually halfway between the xiphoid process and umbilicus
Motility disorders - diffuse oesophageal spasm and achalasia - Neurological disease such as myaesthenia gravis - bulbar palsy including MND and cerebrovascular accident with involvement of the 9th -10th and 12th cranial nerves.
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
Superficial spreading at 70% of malignant melanomas

41. What are the signs in the mouth of acanthosis nigricans?
Site and size of varicosities - including the presence of saphena varix - Skin for changes and scars - Swelling of the ankle
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms
They can be caused by any disease that leads to a peripheral sensory neuropathy - or by causes of spinal cord disease. Causes of peripheral neuropathy include: Systemic disease - diabetes -vasculitis -hypothyroidism and Vitamin B12 deficiency - Drugs
Black discolouration of the skin

42. What is jaundice?
Nephrotic syndrome - Tuberculosis - Chylous ascites
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)
Cardiac and respiratory disease should be controlled first - Other risk-factors should be optimized - Preoperative weight loss should be encourage
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.

43. What are the causes of acquired umbilical herniae in adults?
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.
Wounds associated with - Infection - Trauma - Burns - Tension especially over the sternum such as after CABG - Wounds on certain areas of the body
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
Pregnancy - Ascites - Ovarian cysts - Fibroids - Bowel distension

44. What are the causes of venous ulcers?
Any cause of deep venous insufficiency can lead to ulceration: Valvular disease - varicose veins - deep vein reflux - communicating vein reflux - Outflow tract obstruction - often post-DVT - Muscle pump failure - primary such as stroke and neuromuscu
The incompetent vein is below the level of the tourniquest
Excision of an entire lung
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma

45. What tissues do skin graft not take on?
A lipoma is a benign tumour consisting of mature fat cells.
Hypertrophic scars tend to appear soon after injury and usually regress spontaneously - while keloid scars appear months after injury and continue to grow
Unhealthy -necrotic and infected tissue - Irradiated tissue - Exposed cortical bone without periosteum - Tendon without peritendon - Cartilage without perichondrium
Mnemonic: BADCaT - Blood disorders e.g polycythemia - Arterial e.g atherosclerosis - thrombangiitis obliterans - Drugs e.g beta blockers - oral contraceptive pill - Connective tissue disorders e.g rheumatoid arthritis - systemic lupus erythematosus -

46. What are the motor branches of the facial nerve?
Nerve to stapedius - Nerve to posterior belly of digastric - Five divisions within the parotid gland - temporal - zygomatic - buccal - mandibular and cervical
A dermatofibroma is a benign neoplasm of dermal fibroblasts.
Undermined edge - Violaceous - Necrotic ulcer with hypertrophic margins
Discolouration - Discharge - Depression - Deviation - Displacement - Destruction - [Duplication - unlikely in the exam]

47. What are the taste branches of the facial nerve?
Via chorda tympani to anterior two-thirds of the tongue
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
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
Characteristic cold-induced changes associated with vasospasm

48. Which normal tissues are particularly affected by radiotherapy?
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)
Venous disease
Non-Surgical : Leave alone if asymptomatic(particularly in young patients) - Surgical : Complete excision of lesion with histology(.
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.

49. What is the differential diagnosis of a testicular tumour?
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
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
Sacrum - Greater trochanter - Heel - Lateral Malleolus - Ischial Tuberosity - Occiput
Investigation and treatment of concurrent abnormalities - Management of hypertension

50. What investigations would you do when investigating parotid tumours?
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
Increased sweating - Palmar erythema - Thyroid acropachy - Onycholysis - Areas of vitiligo - Pulse - Fine Tremor
A skin flap consists of tissue - or tissues - transferred from one site of the body to another - while maintaining a continuous blood supply through a vascular pedicle.
Fine-needle aspiration cytology for diagnosis - MRI to exclude deep-lobe involvement