Clinical Surgery

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1. How would you investigate a patient with hepatomegaly?
Hands and Eyes
The insensitive - mechanically abnormal - dry foot is at risk from unperceived external trauma e.g from shoes and from repetitive painless injury e.g foreign body in shoe. Progressive skin loss and ulceration may occur.
Blood Tests:FBC - to look for raised white cell count in infection - Liver function - to look out for hypoalbuminaemia or evidence of hepatic dysfunction - Clotting - functional hepatic impairment - CRP/ESR - increased in infection/inflammation and i
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout


2. What is the treatment of choice in differentiated thyroid cancer?
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's
Thyroidectomy
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
State of the skin/subcutanaeous tissues - Sites of fascia defects - Site of incompetence(including the Trendelenburg and Tourniquet Tests)


3. What are the congenital predisposing factors for basal cell carcinoma?

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4. What surgical options are available in the management of cervical lymphadenopathy?
The elective mortality from open AAA repair is 5% but this figure may be lower in specialist centres - If the patient suffers a ruptured aneurysm and reaches the hospital - their operative mortality rises to 50% - but only 50% of patients reach hospi
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
Cardiac disease - hypertension -myocardial infarction -ischaemia -mitral valve disease - cardiomyopathy -endocarditis - Respiratory disease - Pneumonia - lung cancer - sarcoidosis - Other: Hypothyroidism and idiopathic ( lone AF)


5. What is the aim of the tourniquet test?
Sunlight - Pre-existing skin lesions - Previous melanoma
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
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland
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.


6. What is the pathophysiology of coarctation?
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
Xeroderma pigmentosum - Gorlin's syndrome
The aorta is narrowed below the origin of the left subclavian artery and therefore blood flow to the abdomen and legs is reduced - The prominent vessels over the back are large collateral that have developed to bypass the obstruction and supply the l


7. 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
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
The aim of bypass is to provide a systemic circulation while the heart is stopped and emptied of blood.
More worrying features for a tumour would include: Thick or irregular wall - Extensive calcification within the cavity or wall of the cyst - Multilocular cysts


8. What is the differential diagnosis of a testicular tumour?
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation
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
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
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.


9. What are the early side-effects of radiotherapy?
There are two pathological systems in use: Clark's level of invasion based mostly on the depth/extent of tumour and Breslow's thickness Which is based mostly on the thickness of malignant melanoma. Breslow's thickness is a better prognostic indicator
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents
General : malaise -fatigue - loss of appetite - nausea and vomiting - Skin : as above - Bone marrow suppression : particular if irradiation to the pelvis and long bones - Gastrointestinal : diarrhoea
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.


10. What are the features of ulcers in patients with rheumatoid arthritis?
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
Necrotizing vasculitis - Purpuric -haemorrhagic bullae
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
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation


11. How would you investigate and treat a solitary thyroid nodule?
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
All patients should undergo triple assessment that is Clinical Examination - Radiological assessment usually ultrasonographic - Pathological - most commonly cytological following FNAC
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
It is important to exclude malignant tumours such as: Malignant melanoma - Basal cell carcinoma


12. What is the consequence of carotid stenosis?
Sunlight - Pre-existing skin lesions - Previous melanoma
Duplex Ultrasound - Angiography - CT/MRI
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
Stroke is the third leading cause of death in the west and 85% of strokes are thromboembolic - caused by atherosclerosis at the carotid bifurcation or proximal (2-3cm) internal carotid artery.


13. What are the surgical options for managing ulcerative colitis?
Subtotal colectomy with ileostomy plus or minus mucous fistula formation in acute severe colitis - Proctocolectomy and permanent ileostomy when the patient chooses or if patient not suitable for a restorative procedure - Restorative proctocolectomy W
Hyperkeratoses(thickening of the keratin layer) - Focal parakeratosis - Irregular acanthosis - Basal layer atypia only
Simple mastectomy - Modified radical mastectomy(patey) - Radical mastectomy(Halsted mastectomy) - Extended radical mastectomy
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


14. How would you treat a pharyngeal pouch?
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision
Defective gene on chromosome 22 with variable penetrance - Cutaneous signs are less often seen in this type.
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
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland


15. What is the mainstay of treatment in ascites?
Multiple telangiectasia around the mouth and on the tongue and lips
1
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.
Indications for amputation can be remembered as the 4Ds: Dead - ischemic - peripheral vascular disease - thromboangiitis obliterans - AV fistulae - Damaged - trauma - unsalvageable limbs - burns - frostbite - Dangerous - Malignancy - bone and soft ti


16. How do patients with a pharyngeal pouch usually present?
Patients are usually symptom-free for a long period of time followed by dysphagia and hoarseness - associated with regurgitation of undigested foods - and associated weight-loss
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
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
Gumma of tertiary syphillis has a typical punched-out ulcer - over the anterior surface of the lower leg and has a yellow coloured 'wash leather' base. - Scalloped border


17. Radiological investigations for hepatomegaly
The elective mortality from open AAA repair is 5% but this figure may be lower in specialist centres - If the patient suffers a ruptured aneurysm and reaches the hospital - their operative mortality rises to 50% - but only 50% of patients reach hospi
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema
Pre-hepatic - Hepatic - Post-hepatic
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


18. Why are diabetics particularly prone to foot pathology?
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 -
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
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
Uncommon sensory component of facial nerve carrying cutaneous impulses from the anterior wall of the external auditory meatus known as nervus intermedius or pars intermedia of Wrisberg


19. What are the seven signs in the hands that one should look for when assessing the thyroid status?
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
Increased sweating - Palmar erythema - Thyroid acropachy - Onycholysis - Areas of vitiligo - Pulse - Fine Tremor
Schirmer's test for xeropthalmia - Slit-lamp examination of the cornea - Lip biopsy for histological examination of the minor salivary glands
40 X increased risk of developing lymphoma - usually B-Cell non-Hodgkin's type


20. What is the classic presentation of renal cell carcinoma?

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21. How do you treat these scars?
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
The major risk is embolic stroke(4% per year) which results from thrombus accumulating in an inefficiently contracting left atrium - Emboli can also lodge in the mesenteric vessel - causing intestinal ischaemia - Patients are also at risk from acute
Urinary retention - Bruising - Pain - often very severe and patients should be discharged with adequate analgesia; chronic groin pain persists in 5% of patients - Haematoma - 10% - Ischaemic orchitis - 0.5%(prev. vasectomy predisposing cause and diss
Non-Surgical - mechanical pressure therapy(day and night for up to 1 year) and topical silicone gel sheets - Surgical : Revision of scar with closure by direct suturing - local Z-plasty or skin grafting to avoid excessive tension - Intralesional ster


22. How is a testicular tumour removed?
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
Through an inguinal approach - with early clamping of the testicular artery and vein within the spermatic cord before the testis is mobilized out of the scrotum - this prevents intraoperative seeding of tumour up the testicular vein
Dilatation of normal capillaries - Can be secondary to skin irradiation - Can be part of hereditary haemorrhagic telangiectasia
An absolute pressure of less than 50mmHg


23. What is the risk of rupture for an aneurysm more than 5.5cm?
The major risk is embolic stroke(4% per year) which results from thrombus accumulating in an inefficiently contracting left atrium - Emboli can also lodge in the mesenteric vessel - causing intestinal ischaemia - Patients are also at risk from acute
10% per year
Idiopathic Which is the most common - Gastrointestinal - Respiratory - Cardiac - Rare causes
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


24. 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
Painless - Associated with normal appearance of the surrounding skin - Associated with local sensory loss
Sunlight - Pre-existing skin lesions - Previous melanoma
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)


25. What are the two main systems which need to be examining thyroid status in a surgical patient?
Hands and Eyes
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.
Gall stones - Carcinoma head of pancreas - Lymph nodes
Anaesthesia is more complicated because of the increased risk of stroke - In addition - patients with AF may be anticoagulated and if on warfarin - this medication needs to be discontinued prior to elective surgery - Patients with controlled AF may d


26. What are the seven signs in the eyes that one should look out for when assessing the thyroid status?
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
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
Gangrene is the result of irreversible tissue necrosis and has a number of causes: Diabetes - Embolus and thrombosis - Raynaud's syndrome - Thrombangiitis obliterans - Ergot poisoning - Vessel injury secondary to extreme cold -heat -trauma or pressur
Loss of hair on outer-third of eyebrows - Lid retraction - Lid lag - Ophthalmoplegia - Exophthalmos - Chemosis - Proptosis


27. What are the causes of facial nerve palsy?
Almost all are follicular adenomas - Usually 2 to 4 cm and encapsulated at presentation - Indistinguishable from carcinomas on FNAC - as the presence of a capsule cannot be demonstrated - Surgical excision is needed to confirm diagnosis
Painless - Associated with normal appearance of the surrounding skin - Associated with local sensory loss
Anaesthesia is more complicated because of the increased risk of stroke - In addition - patients with AF may be anticoagulated and if on warfarin - this medication needs to be discontinued prior to elective surgery - Patients with controlled AF may d
Intracranial - Intratemporal - Extratemporal


28. What are the features of superficial spreading melanoma?
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
Epidermal Cyst - Trichilemmal Cyst
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
May require the placing of postoperative drains


29. What are the features of a femoral hernia?
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema
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
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.
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


30. What do you know about the epidemiology of hypertrophic scars?
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
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.
They are known as adiposis dolorosa or Dercum's disease.
Affect any age - Males = females - All races may be affected


31. What are the signs of chronic venous insufficiency?
It arises de novo
Uncommon sensory component of facial nerve carrying cutaneous impulses from the anterior wall of the external auditory meatus known as nervus intermedius or pars intermedia of Wrisberg
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
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema


32. How would you prepare a patient prior to breast surgery?
A blepharoplasty can be performed where excess skin and fat are removed.
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
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
General : malaise -fatigue - loss of appetite - nausea and vomiting - Skin : as above - Bone marrow suppression : particular if irradiation to the pelvis and long bones - Gastrointestinal : diarrhoea


33. How does follicular carcinoma spread?
Those related to anaesthesia
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.
Via the bloodstream(R is equal to red is equal to blood)
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)


34. What are the features of ulcers in pyoderma gangrenosum?
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
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
Defective gene on chromosome 17
Undermined edge - Violaceous - Necrotic ulcer with hypertrophic margins


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

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36. What features of the lump would make you suspicious that it is breast cancer?
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
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives
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 :
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


37. How should you organize information when talking about a disease?
Definition - Incidence - Sex - Geography - Aetiology - Pathogenesis - Macroscopic Pathology - Microscopic Pathology - Prognosis - Symptoms - Signs - Investigations - Treatment
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
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.
A caring and competent approach - A good examination technique - An ability to elicit and draw conclusions from physical signs


38. When are spider naevi considered to be pathological?
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
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.
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
More than five is considered as pathological in chronic liver disease


39. What are the stages of restorative proctocolectomy?
Multiple telangiectasia around the mouth and on the tongue and lips
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis
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
Small red capillary naevus - Develops on the trunk in middle-age - No clinical significance


40. What are the mechanical obstruction causes of dysphagia?

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41. What should you keep in mind when assessing surgical scars?
Hands and Eyes
20%
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
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


42. What are the features of a multinodular goitre?

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43. What are the neurological symptoms in thoracic outlet obstruction more commonly due to?

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44. What do you know about thyroid adenomas?
A neurofibroma is a benign tumour derived from peripheral nerve elements.
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
Almost all are follicular adenomas - Usually 2 to 4 cm and encapsulated at presentation - Indistinguishable from carcinomas on FNAC - as the presence of a capsule cannot be demonstrated - Surgical excision is needed to confirm diagnosis
Blood Tests:FBC - to look for raised white cell count in infection - Liver function - to look out for hypoalbuminaemia or evidence of hepatic dysfunction - Clotting - functional hepatic impairment - CRP/ESR - increased in infection/inflammation and i


45. How would you treat pyoderma gangrenosum?
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.
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
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.
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)


46. How should epididymal cysts be managed?
Popliteal aneurysms represent 80% of all peripheral (non-aortic) aneurysms - The patient may have presented with a lump behind the knee if the aneurysm has grown to such a size that it has expanded beyond the popliteal fossa - 50% present with distal
A neurofibroma is a benign tumour derived from peripheral nerve elements.
Non-Surgical - mechanical pressure therapy(day and night for up to 1 year) and topical silicone gel sheets - Surgical : Revision of scar with closure by direct suturing - local Z-plasty or skin grafting to avoid excessive tension - Intralesional ster
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


47. What is a lipoma?
Mnemonic : PACT - Prominent nodule in a multinodular goitre - Adenoma - Cyst/Carcinoma/Lymphoma - Thyroiditis
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
Investigation and treatment of concurrent abnormalities - Management of hypertension
A lipoma is a benign tumour consisting of mature fat cells.


48. What is the purpose of limb elevation in the non-surgical treatment of lymphoedema?
Vaginal Hydrocoele - fluid accumulates in the tunica vaginalis - Hydrocoele of the cord - fluid accumulates around the spermatic cord - Congenital Hydrocoele - Infantile Hydrocoele
Non-surgical - same as in incisional hernia with possible investigations : LFTs - H.pylori serology and Upper GI endoscopy
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.
Unilateral - Bilateral


49. What are the signs in the mouth of Peutz-Jegher disease?
Excision of an entire lung
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
Characteristic cold-induced changes associated with vasospasm
Pigmented freckles around the lips and inside the mouth - associated with intestinal intussusception and gastrointestinal bleeding from colonic polyps


50. Do you know of any infectious agents associated with AAA?
History and Clinical Examination - they usually present incidentally but occasionally with a renal mass or haematuria
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms
Carcinoma of the stomach and oesophagus - lymphomas and with endocrine disorders such as acromegaly - Cushing's - diabetes complicated by severe insulin resistance
Intracranial - Intratemporal - Extratemporal