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Clinical Surgery

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1. What is the pathogenesis of umbilical herniae?
Optimize tissue perfusion and oxygenation - Treat infection as it arises - Use topical dressings as required and provide nutritional support specifically vitamin C - zinc and multivitamins. - Other techniques include hyperbaric oxygen -hydrotherapy a
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
1
These are due to a defect through the linea alba adjacent to the umbilicus and usually due to obesity stretching the fibres.

2. What is portal hypertension?
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
General - Specific
Calcium channel blockers e.g nifedipine - Prostacyclin analogues - Alpha blockers - 5-HT antagonists
Retro-orbital inflammation and lymphocytic infiltration leading to oedema and an increase in retrobulbar orbital contents

3. What are telangiectasias?
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
CHIASMA - Congestive : portal hypertension - hepatic vein obstruction - Haematological : reticuloses - Infection : Viral - bacterial - protozoal - Amyloid - Storage disorders : Gaucher's disease - Masses : primary/secondary neoplasia - Autoimmune : F
Dilatation of normal capillaries - Can be secondary to skin irradiation - Can be part of hereditary haemorrhagic telangiectasia
Solar keratosses are squamous cell carcinoma in situ

4. What is the differential diagnosis for a skin lesion?
Benign skin lesion: Keratoacanthoma - Infected seborrhoeic wart - Solar keratoses - Pyogenic Granuloma - Malignant skin lesion - Basal cell carcinoma - Malingnant melanoma - Congenital: Xeroderma pigmentosum - Acquired - Environmental agents - Pre-ex
Hands and Eyes
Excision of an entire lung
Urine should be tested for raised bilirubin - Full Blood Count - Evidence of anemia in GI malignancies or associated infection - Renal function - any evidence for hepatorenal syndrome - Liver Function Tests -Clotting - functional assessment of hepati

5. What are the specific complications of a stoma?
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.
Second most common type - Occurs most often on the trunk - Polypoid in shape and is raised - Smooth surface - Irregular edge - Frequently ulcerated
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation
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

6. What is a pyogenic granuloma?
Calcification of the walls of the vessel preserves the pulses until late in the natural history of disease - and prevent the sphygmomanometer from compressing the vessels. This tends to lead to an abnormally(and reassuringly) high ankle brachial pres
A pyogenic granuloma is a rapidly growing capillary haemangioma whic usually measures less than 1cm in diameter
Cardiac failure - Metabolic disorders leading to hypoalbuminaemia such as Cirrhosis and Nephrotic syndrome
Superior thyroid artery - Inferior thyroid artery - Thyroidea ima(in 3% of people)

7. Why do these neuropathic ulcers form?
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
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.
Less than 0.5
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection

8. Under what circumstances would patients (with popliteal aneurysms) they be treated?
Motor - Secretomotor - Taste - Sensory
Well-localized abscesses are treated by incision and drainage under antibiotic cover - Larger lesions are treated by radical excision and full-thickness skin grafting usually harvested from the groins or abdomen
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
Are you having difficulties swallowing liquids - or solids - or both? - Did the problem start suddenly or was the onset gradual? - Do you ever regurgitate food? - Can you eat a full meal? - How long have you had this problem for? - Where does the foo

9. What are the surgical options in Crohns disease?
It is often advised as the problem usually gets worse with age and there is risk of infertility.
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema
Patient preference - Clinical evidence of multifocal/multicentric disease - Large lump is small breast tissue - this depends of the size of the breast but often defined as a lump more than 4cm - Large area ( more than 4cm) ductal carcinoma in situ -
Intra-abdominal abscesses should be drained - Colonic defunctioning using a loop ileostomy may be needed for patients who have failed medical therapy - Occasionally a subtotal colectomy and permanent ileostomy may be needed - Pouch surgery is general

10. What are multiple -painful lipomas known as?

11. What are the main features of splenomegaly in the clinical examination?
Mneumonic : LIST Lymphoma and Leukaemia - Infection(further subdivided into Bacterial - Viral - Protozoal and Toxoplasmosis) - Sarcoidosis - Tumours
Peripheral Neuropathy
SPRUE - Site of enlargement - from the left costal margin towards the umbilicus - Percussion note - dull - Respiration movement - it descends - Unable to get above it or ballot it(differentiating it from the kidney) - Edge - a notch may be palpable o
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery

12. What are the functions of the spleen?
Via the bloodstream(R is equal to red is equal to blood)
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
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
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)

13. What are the signs in the mouth of Addison's disease?
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.
A neurofibroma is a benign tumour derived from peripheral nerve elements.
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
Mouth and lips are hyperpigmented

14. What is the differential diagnosis of a midline neck swelling?
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
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
Calcification of the walls of the vessel preserves the pulses until late in the natural history of disease - and prevent the sphygmomanometer from compressing the vessels. This tends to lead to an abnormally(and reassuringly) high ankle brachial pres
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

15. What are the secondary causes of Raynauds?
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
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma
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
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 -

16. What is the non-surgical treatment of venous ulcers?
20%
Hands and Eyes
High success - 50 to 70% will heal at 3 months - 80 to 90% at 12 months - The patient should be warned to avoid trauma to the affected area - Four-layer compression bandaging - Encourage rest and elevation of leg - Once healed - grade 2 compression s
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.

17. What are the specific complications of varicose veins surgery?
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
High success - 50 to 70% will heal at 3 months - 80 to 90% at 12 months - The patient should be warned to avoid trauma to the affected area - Four-layer compression bandaging - Encourage rest and elevation of leg - Once healed - grade 2 compression s
Small -punched out ulcers - Often over medial aspect of lower leg
Early - haematoma - Intermediate - Infection and nerve damage e.g saphenous in stripping - Late - Recurrence

18. What are the histological features of seborrhoeic keratosis?
Hyperkeratosis - Acanthosis - Hyperplasia of variably pigmented basaloid cells
Lead shields to protect the eyes and gonads - Dose-fractionation - Prior chemotherapy - Regional hypothermia - Radiolabelled antibodies
Excessive dryness of skin - Compensatory sweating around trunk ( in up to 50% of patients) - Horner's syndrome( a consequence of damage to the stellate ganglion) - 0.1% - Pneumothorax/haemothorax - Important to warn of the risk of a general anaesthet
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

19. What does surgical excision involved in the surgical treatment of a pharyngeal pouch?
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
Definition - Incidence - Sex - Geography - Aetiology - Pathogenesis - Macroscopic Pathology - Microscopic Pathology - Prognosis - Symptoms - Signs - Investigations - Treatment
Cirrhosis - Malignancy - Lymphatic rupture or damage
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.

20. Which investigations would you use in a patient whom you thought might be suffering from a dysmotility problem?
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise
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
The reason for repairing abdominal aortic aneurysm is to avoid complications - The following aneurysms should be repaired: Symptomatic aneurysms(back pain - tenderness over the aneurysm on palpation -distal embolic events - ruptured/leaked aneurysms)
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

21. What is seborrhoeic keratosis?
40 X increased risk of developing lymphoma - usually B-Cell non-Hodgkin's type
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.
Plasma alpha feto-protein and beta-HCG - raised levels may indicate a testicular tumor - Testosterone and LH levels to demonstrate hypogonadism - Thyroid function tests
Characteristic cold-induced changes associated with vasospasm

22. What are the histological appearances of solar keratoses?
malignant change?
Hyperkeratoses(thickening of the keratin layer) - Focal parakeratosis - Irregular acanthosis - Basal layer atypia only
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.
Cardiac failure - Metabolic disorders leading to hypoalbuminaemia such as Cirrhosis and Nephrotic syndrome

23. What is the aetiology of diabetic foot ulcers?
Neuropathic - 45 to 60% of ulcers - Ischaemic due to peripheral occlusive arterial disaese - 10% of ulcers - Mixed neuroischaemic - 25-45% of ulcers
A enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and the skin
Three arteries - artery to vas deferens -testicular artery -cremasteric artery - Three nerves - ilioinguinal nerve on the front of the cord - nerve to cremaster and autonomic nerves - Three other structures - vas deferens - pampiniform plexus of vein
Congenital : Cystic disease - horseshoe kidney - hypertrophic single kidney - Acquired : Diseases specific to the kidney such as solitary cysts - tumours - hydronephrosis - pyonephrosis - perinephric abscess and renal vein thrombosis and diseases as

24. What are the general complications of thyroidectomy?
Those related to anaesthesia
These can be divided into large and small vessel arterial disease: Large vessel - atherosclerosis and thrombangiitis obliterans - Small vessel - Diabetes Mellitus - Polyarteritis nodosa and rheumatoid arthritis
Trauma - Hypersplenism
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

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

26. What symptoms - a patient with an epigastric hernia might have complained of at presentation?
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
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)
Epigastric pain - which may increase after meals - May be acutely painful after physical exercise - Nausea and early satiety - Reflux and non-ulcer dyspepsia
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%

27. How would you determine clinically the degree of shunt by a large fistula?
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)
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
An absolute pressure of less than 50mmHg
Haemorrhage - Hoarseness - Hyperthyroidism

28. What are the main features of neuropathic ulcers?
Painless - Associated with normal appearance of the surrounding skin - Associated with local sensory loss
Excision of an entire lung
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.
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.

29. What are the causes of a false aneurysm?
Venous disease
Surgical treatment involves complete excision of the cyst.
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.
Traumatic - Iatrogenic(following angiography and bypass)

30. How might a patient with a popliteal aneurysms present?
0.5 to 0.8
Mnemonic: WBC - White - blanching of digits - Blue - cyanosis of pain - Crimson - reactive hyperaemia - fingers turn red in colour
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
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

31. How do paraumbilical herniae occur?
Immobility and prolonged bed-rest are the most important factors - particulary secondary to conditions such as: Cardiopulmonary disease - Trauma - Neurological disease such as paraplegia - Bone and joint disease - Prolonged operative procedures - And
Commonest in children and young adults(P for Paediatric)
Thyroidectomy
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

32. What are the specific and early complications of thyroidectomy?
Dilatation of normal capillaries - Can be secondary to skin irradiation - Can be part of hereditary haemorrhagic telangiectasia
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
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
(H)infection - Hypoparathyroidism which leads to hypocalcemia

33. What are patients with Sjogren's syndrome at risk of?

34. What are the causes of ischaemic ulcers?
These can be divided into large and small vessel arterial disease: Large vessel - atherosclerosis and thrombangiitis obliterans - Small vessel - Diabetes Mellitus - Polyarteritis nodosa and rheumatoid arthritis
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.
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
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

35. What is an epigastric hernia?
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
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
Mneumonic : I - CHUM - Infection(frequent) - Calcification - Ulceration - sebaceous Horn formation - Malignant change
An abnormal protrusion of abdominal contents through a defect in the linea alba - usually halfway between the xiphoid process and umbilicus

36. How would you treat this condition?

37. What is the aim of cardiopulmonary bypass?
The aim of bypass is to provide a systemic circulation while the heart is stopped and emptied of blood.
Traumatic - Iatrogenic(following angiography and bypass)
Parafollicular C Cells
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.

38. What are the two main types of aetiologies in the differential diagnosis of a unilateral swelling of the parotid gland?
A skin graft involves the transfer of skin from a donor site to a recipient site independent of a blood supply. The graft 'takes' by acquiring a blood supply from a healthy donor bed. Skin grafts may either be full thickness or partial thickness - bu
Calcification of the walls of the vessel preserves the pulses until late in the natural history of disease - and prevent the sphygmomanometer from compressing the vessels. This tends to lead to an abnormally(and reassuringly) high ankle brachial pres
Defective gene on chromosome 17
Arising inside the parotid gland - Arising outside the parotid gland

39. What are the features of ulcers in tuberculosis?
Undermined edge - Shallow ulcer
CHIASMA - Congestive : portal hypertension - hepatic vein obstruction - Haematological : reticuloses - Infection : Viral - bacterial - protozoal - Amyloid - Storage disorders : Gaucher's disease - Masses : primary/secondary neoplasia - Autoimmune : F
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery
Intracranial - Intratemporal - Extratemporal

40. What do you know about the pathophysiology of varicose veins?
Fibrous tissue invades the tunica intima and media of the vein and breaks up the smooth muscle - preventing the maintenance of adequate vascular tone. These changes are patchy and may not affect adjacent segments of vein.
Via the bloodstream(R is equal to red is equal to blood)
Immobility and prolonged bed-rest are the most important factors - particulary secondary to conditions such as: Cardiopulmonary disease - Trauma - Neurological disease such as paraplegia - Bone and joint disease - Prolonged operative procedures - And
Barium swallow Which is usually diagnostic - Rigid endoscopy if neoplasia suspected

41. How might the liver function tests help in distinguishing the types of jaundice?
Treatment is essentially surgical - Operation of choice is Sistrunk's operation - Inject patent track with dye at the start of the operation - Excise cyst and the patent or fibrous track which runs through the central portion of the hyoid bone(Which
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
It helps to give an indication as to What the exact aetiology is.
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review

42. How would you manage a multinodular goitre?
History and Clinical Examination - Investigate if prominent nodule or features suspicious of malignancy such as cervical lymphadenopathy or recurrent laryngeal nerve palsy
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
It is due to forced implantation of skin into subcutaneous tissues following an injury. Normally found in areas of the body prone to injury such as fingers. Suspect if you see an adult in exam.
SRSN -OPD -RAT - Site - Radiation - Severity - Nature - Onset - Periodicity - Duration - Relieved by - Accentuated by - Timing

43. What is the classification used in the definition of severe exarcerbation of inflammatory bowel disease?
A blind-ending track -typically lined by epithelial or granulation tissue - which opens onto an epithelial surface
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
Endovascular repair - Laparoscopic repaire of abdominal aneurysms is the subject of current clinical trials
Secondary Raynaud's phenomenon associated with other diseases

44. What are the coordination abnormalities causes of dysphagia?
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation
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.
A dermoid cyst is a skin-lined cyst deep to the skin. They may be congenital or acquired.
Schirmer's test for xeropthalmia - Slit-lamp examination of the cornea - Lip biopsy for histological examination of the minor salivary glands

45. What immunizations would you need to organize in the event of performing a splenectomy?

46. What is the main statistic with regards to salivary gland tumours?
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)
80% of salivary gland tumours occurs in the parotid gland - 80% of these parotid tumours being benign - with 80% of these benign tumours being pleomorphic adenomas
Diffuse enlargement - smooth or nodular - Solitary nodule
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 :

47. How do you harvest a skin graft?
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
Non-Surgical : May be left alone if small and asymptomatic - Surgical : To prevent recurrence - complete excision of the cyst and its contents is required and this is done through the removal of an elliptical portion of skin containing the punctum.
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
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

48. What is the causes of the carotid artery aneurysms?
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.
Extrusion of peritoneum and abdominal contents through a weak scar of accidental wound on the abdominal wall - Represents a partial wound dehiscence where the skin remains intact
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
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

49. In patients with gynaecomastia - what would make you concerned the patient may have a breast cancer?
Parafollicular C Cells
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
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
Mneumonic : BEDD - Base - Edge - Describe structure visualized at the base of the ulcer - Discharge

50. What is the medical treatment of Graves disease?
The incompetent vein is at or above the level of the tourniquet
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
Congenital : Cystic disease - horseshoe kidney - hypertrophic single kidney - Acquired : Diseases specific to the kidney such as solitary cysts - tumours - hydronephrosis - pyonephrosis - perinephric abscess and renal vein thrombosis and diseases as
The two main differential diagnoses to consider are; Benign - keratoacanthoma - especially if it is sloughing at its centre - Malignant -Squamous cell carcinoma - particularly the nodulo-ulcerative type with a rolled edge