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Clinical Surgery

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1. What are the elements of the reconstruction ladder?
The protein content of a sample of effusion fluid is measured and the classification depends on this value:Transudate is equal to a protein value of less than 30g/L - Exudate is equal to a protein value of more than 30g/L
Healing by secondary intention - Skin graft - Local flap - Distant flap - Composite flap - Island flaps vs pedicled flaps - Free tissue transfer - Composite neurovascular free tissue transfer
Mnemonic: WBC - White - blanching of digits - Blue - cyanosis of pain - Crimson - reactive hyperaemia - fingers turn red in colour
Results from persistence of part of the thyroglossal tract - which marks development descent of the thyroid gland

2. How would you treat pyoderma gangrenosum?
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
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 :
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
Diffuse enlargement - smooth or nodular - Solitary nodule

3. What are the secretomotor branches of the facial nerve?
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
Via greater superficial petrosal nerve to lacrimal - nasal and palatine glands
Collagen antibodies are present in 45% of patients - There is an association with HLA-B5 - Angiography has typical appearances of normal proximal vessels with distal occlusion and 'corkscrew' collaterals.
Sacrum - Greater trochanter - Heel - Lateral Malleolus - Ischial Tuberosity - Occiput

4. How are epididymal cysts caused?
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally
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.
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.
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

5. What is the treatment of choice in differentiated thyroid cancer?
According to site - contents and if it is random or axial. When it comes to site - you consider where it is local or distant(Which is also known as a free flap). You have to also consider the contents which can contain any tissue capable of transfer
Thyroidectomy
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
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

6. What is the normal ABPI?
Scar confined to wound margins - It is found across flexor surfaces and skin creases
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
1
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

7. What is Adiposis dolorosa or Dercum's disease associated with?
Peripheral Neuropathy
Notching on the underside of the ribs may be seen on a chest x-ray - this sign is caused by erosion by the intercostal collateral vessels - On the chest x-ray the aorta may be abnormal - it contains two bulges - the 'three sign' - A barium swallow sh
Mneumonic : BEDD - Base - Edge - Describe structure visualized at the base of the ulcer - Discharge
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm

8. What are possible useful investigations in gynaecomastia?
10% per year
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
Plasma alpha feto-protein and beta-HCG - raised levels may indicate a testicular tumor - Testosterone and LH levels to demonstrate hypogonadism - Thyroid function tests
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

9. What are the different histological subtypes of a sebaceous cyst?
Trauma - Hypersplenism
Epidermal Cyst - Trichilemmal Cyst
Cyanotic congenital heart disease - Infective endocarditis - Atrial myxoma (rare)
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.

10. How do you treat a thyroglossal cyst?

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11. What are the intratemporal causes of facial nerve palsy?

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12. Which normal tissues are particularly affected by radiotherapy?
Regular skin inspection - Frequent turning of immobile patients( 2 to 4 hourly) - Massage - Toileting - The use of special mattresses and cushion which redistribute the pressure on at-risk areas
A cystic swelling related to a synovial lined caivity - either a joint or a tendon sheath
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)
A blepharoplasty can be performed where excess skin and fat are removed.

13. What are the specific complications of inguinal hernia repair?
Intracranial - Intratemporal - Extratemporal
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
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
Angiolipomas - Hibernomas - Bannayan-Zonana Syndrome

14. What is the non-surgical treatment of venous ulcers?
A lipoma is a benign tumour consisting of mature fat cells.
Undermined edge - Shallow ulcer
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
Carcinoma of the stomach and oesophagus - lymphomas and with endocrine disorders such as acromegaly - Cushing's - diabetes complicated by severe insulin resistance

15. How would you treat a branchial cyst?

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16. What do patients with rest pain typically get more severe pain at night?
Hyperthyroidism - Late Hypothyroidism - Later Hyperparathyroidism
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
Usually occurs in the over 50s although it may affect younger patients. It is the most common causes of a renal mass in women of childbearing age - Beck's Triad of: Haematuria - Mass - Loin Pain
Lord's plication - Jaboulay's operation

17. What is the causes of the carotid artery aneurysms?
Iodine deficiency - Increased physiological demand - Goitrogens(less common) - Defects of thyroid hormone production
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
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
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.

18. What are the non-surgical treatment options for hydrocoele?
Characteristic cold-induced changes associated with vasospasm
Non-surgical : Watch and wait - a small hydrocoele may require no treatment other than reassurance - but an underlying malignancy should be excluded. Aspiration - the hydrocoele fluid can be aspirated to relieve symptoms; tends to reaccumulate
A furuncle results from infection of hair follicles with Staphylococcus aureus
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.

19. What are the treatment options of false aneurysms?
Xeroderma pigmentosum - Gorlin's syndrome
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
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 :
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review

20. How should one treat a sebaceous cyst?
Immediate : Facial nerve transection - Reactionary haemorrhage - Early : Wound infection - Temporary facial weakness -salivary fistula and division of the greater auricular nerve which means loss of sensation to the pinna - Late : Wound dimple - Frey
Halfway along inguinal ligament that is between pubic tubercle and ASIS Which is equal to the location of the deep inguinal ring
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.
Increase in size - Ulceration - Change in colour - Irritation - Bleeding - Halo of pigmentation - Satellite nodules - Enlarged local lymph nodes - Evidence of distant spread

21. What are the surgical options in Crohns disease?
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
Wound complications - Recurrence - Damage to adjacent neurovascular structures
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
Non-Surgical - Reassure and 'Watch and Wait' - Surgical - Reason : Pain/Cosmesis and this is done with suction lipolysis via a small - remote incision Which is performed under local anaesthetic as a day case.

22. What is the consequence of carotid stenosis?
Carcinoma of the stomach and oesophagus - lymphomas and with endocrine disorders such as acromegaly - Cushing's - diabetes complicated by severe insulin resistance
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.
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
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

23. What other part of the body can be affected by hyperhidrosis?

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24. What are the predisposing factors for Raynaud's phenomenon?
Primary Raynauds is due to vasomotor malformation - Secondary Raynauds occurs as a consequence of pathology affecting the vessel wall
Hyperkeratoses(thickening of the keratin layer) - Focal parakeratosis - Irregular acanthosis - Basal layer atypia only
Surgical treatment involves complete excision of the cyst.
Mayo's 'vest-over-pants' operation is the most widely accepted repair for these herniae

25. Which are the gastrointestinal causes of clubbing?
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection
Liver Cirrhosis - Inflammatory Bowel disease - Malabsorption - Gastrointestinal lymphoma
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.
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

26. What would you warn the patient of in consenting them for an endarterectomy?
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
Epidermal Cyst - Trichilemmal Cyst
Infection - acute and chronic otitis media - herpes zoster(ramsay hunt syndrome) - Idiopathic - Bell's Palsy - Trauma - surgical -accidental - e.g basal skull fracture - Tumour - paraganglioma - squamous cell carcinoma of external or middle ear - met
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

27. What is a fistula?
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)
Ultrasound would be the first investigation - Abdo wall masses and extent of disease better seen with CT Scan - IV contrast enhance CT scanning to clarify lower abdominal and pelvic vasculature
Superficial spreading at 70% of malignant melanomas
Definition - Incidence - Sex - Geography - Aetiology - Pathogenesis - Macroscopic Pathology - Microscopic Pathology - Prognosis - Symptoms - Signs - Investigations - Treatment

28. Large hernia
May require the placing of postoperative drains
May affect people from puberty to 30 years - Females are more affected than males - Black and Hispanic Races are effected the most.
Congenital Which is rare and Acquired Which is very common.
Multinodular goitre - Toxic - Simple colloid goitre - Thyroiditis - Neoplasia

29. How would you perform a hernia repair?
The main points to mention are: testicular damage should be mentioned as a specific risk factor - the operation can be performed under local or general anaesthetic and often as a day case - The Royal College of Surgeons has recommended the Lichtenste
Coarctation may be associated with:Bicuspid aortic valcves - Aortic stenosis - Aneurysms in the circle of Wilis
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
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

30. What are the two main systems which need to be examining thyroid status in a surgical patient?
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.
History and Clinical Examination - Investigate if prominent nodule or features suspicious of malignancy such as cervical lymphadenopathy or recurrent laryngeal nerve palsy
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
Hands and Eyes

31. What are the complications of a sebaceous cyst?
Mneumonic : I - CHUM - Infection(frequent) - Calcification - Ulceration - sebaceous Horn formation - Malignant change
The incompetent vein is at or above the level of the tourniquet
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.
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

32. 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
Ulcer is distal to the fistula - Shallow indolent ulcers
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
Less than 0.5

33. How would you investigate a patient with a breast lump?
Triple assessment which consists of: Clinical : history and physical examination - Radiological : ultrasound or mammography - Pathological : cytology(fine-needle aspiration) or histological(tru-cut biopsy)
Neuropathic - 45 to 60% of ulcers - Ischaemic due to peripheral occlusive arterial disaese - 10% of ulcers - Mixed neuroischaemic - 25-45% of ulcers
Wound complications - Recurrence - Damage to adjacent neurovascular structures
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

34. What other non-surgical treatments are available for ischaemic ulcers?
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
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
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
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

35. What are the main types of predisposing factors for basal cell carcinoma?
Congenital Which is rare and Acquired Which is very common.
Mechanical obstruction - Coordination abnormalities
Unilateral - Bilateral
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

36. What does a keloid scar look like?
Mnemonic : CHIASMA - Congestive : cardiac failure - Haematological : reticuloses - Infection : viral -bacterial -protozoal - Amyloid - Storage disorders : Wilson's disease - haemochromatosis - Masses: primary/secondary neoplasia - Autoimmune/alcohol
The incompetent vein is at or above the level of the tourniquet
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation
Scar extends beyond wound margins - It is found mostly on earlobes - chin -neck -shoulder and chest.

37. What are the main features of splenomegaly in the clinical examination?
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.
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
Loss of hair on outer-third of eyebrows - Lid retraction - Lid lag - Ophthalmoplegia - Exophthalmos - Chemosis - Proptosis
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

38. What systems are tackled when taking into consideration a thyroid history?
They are known as adiposis dolorosa or Dercum's disease.
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
Via the lymphatic route(Y for yellow = lymph)
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological

39. What do you know about thyroid adenomas?
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
Solar keratosses are squamous cell carcinoma in situ
It helps to give an indication as to What the exact aetiology is.
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological

40. What is the origin of lymphangiomas?
Mnemonic : CHIASMA - Congestive : cardiac failure - Haematological : reticuloses - Infection : viral -bacterial -protozoal - Amyloid - Storage disorders : Wilson's disease - haemochromatosis - Masses: primary/secondary neoplasia - Autoimmune/alcohol
At two levels:ABO Compatibility - HLA Compatibility
Triple assessment which consists of: Clinical : history and physical examination - Radiological : ultrasound or mammography - Pathological : cytology(fine-needle aspiration) or histological(tru-cut biopsy)
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

41. What are the features of adult polycystic kidney disease?
Undermined edge - Violaceous - Necrotic ulcer with hypertrophic margins
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s
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)

42. What is a dermatofibroma?
The tumour arises from epidermal cells that normally migrate to the skin surface to form the superficial keratinizing squamous layer. Full-thickness epidermal atypia is seen and tumour cells are seen to extend in all directions into the deep dermis a
The 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.
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation
A dermatofibroma is a benign neoplasm of dermal fibroblasts.

43. What are the main points that doctors are looking for during the Surgical OSCEs?
Size - Tenderness - Mobility - Consistency
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
Congenital ptosis - Myopathies - Syphillis
A caring and competent approach - A good examination technique - An ability to elicit and draw conclusions from physical signs

44. What is the ABPI of patients with intermittent claudication?
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
Motor - Secretomotor - Taste - Sensory
A hypervascular mas displacing the bifurcation of the carotid arteries
0.5 to 0.8

45. How might you be aware the transplant rejection is occurring?
Tenderness over the graft - Reduction in urine output - Rising creatinine
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.
Infections within the oesophagus especially candidiasis and herpes simplex - Pharyngitis - Occasionally ulceration over the lower third of the oesophagus
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.

46. What are the features of infantile polycystic kidney disease?
The commonest presentation is a painless lump or a dull ache in one testis in a young man - Occasionally there is a history of trauma accompanying the discovery of the mass - 10% present with an acutely painful testis - If para-aortic nodes have beco
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
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
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally

47. What features of the lump would make you suspicious that it is breast cancer?
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 :
Via chorda tympani to anterior two-thirds of the tongue
Non-Surgical - Reassure and 'Watch and Wait' - Surgical - Reason : Pain/Cosmesis and this is done with suction lipolysis via a small - remote incision Which is performed under local anaesthetic as a day case.
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

48. How do you classify the severity of thyroid eye disease?
Essentially to treat complications not amenable to medical therapy such as:Intra-abdominal abscesses that cannot be drained radiologically - Enterocutaneous fistulae - Stenosis causing obstructive symptoms - Control of acute/chronic bleeding
If untreated - 25% progress to invasive squamous cell carcinoma
Size - Tenderness - Mobility - Consistency
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

49. What are the signs in the mouth of acanthosis nigricans?
90% of lung resections in the Western world are performed for bronchial carcinoma. Other indications include traumatic injury - bronchiectasis - chronic infection including tuberculosis - benign tumours e.g carcinoid and metastatic tumour
Black discolouration of the skin
A furuncle results from infection of hair follicles with Staphylococcus aureus
Excision of an entire lung

50. What are the complications of a cystic hygroma?
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
Notching on the underside of the ribs may be seen on a chest x-ray - this sign is caused by erosion by the intercostal collateral vessels - On the chest x-ray the aorta may be abnormal - it contains two bulges - the 'three sign' - A barium swallow sh
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
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.