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Clinical Surgery

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1. What investigations are appropriate for deep venous disease?
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
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
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
Autoimmune thrombocytopaenia/haemolytic anemia - Hereditary spherocytosis - Thrombotic thrombocytopenia - Sickle cell/thalessemia - Myelofibrosis - occasionally in CML - Hodgkin's

2. What are the features of a multinodular goitre?

3. What is a fistula?
A furuncle results from infection of hair follicles with Staphylococcus aureus
It is due to development inclusion of epidermis along lines of fusion of skin dermatomes and are therefore commonly at: The medial and lateral ends of the eyebrows - The midline of the nose - The midline of the neck and trunk - Suspect if you see a c
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)
Intracranial - Intratemporal - Extratemporal

4. What is the origin of lymphangiomas?
Pigmented freckles around the lips and inside the mouth - associated with intestinal intussusception and gastrointestinal bleeding from colonic polyps
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
Gradual elastic compression stocking - grade 2 compression - Encourage weight loss and regular exercise
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

5. What are the early side-effects of radiotherapy?
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
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
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
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)

6. What is secondary lymphoedema?
Diet should be normal - Bag should be changed once or twice a day(needs to be emptied more frequently than this if it is urine or fluid faeces) - Ileostomies should have the base plate under the bag changed every 5 days and the bag changed daily - Ps
It can be classified according to cause: Malignancy - Infections - e.g filiaris - tuberculosis - Post Surgery or Radiotherapy - axillary dissection in breast surgery and inguinal irradiation
Infections within the oesophagus especially candidiasis and herpes simplex - Pharyngitis - Occasionally ulceration over the lower third of the oesophagus
A skin flap consists of tissue - or tissues - transferred from one site of the body to another - while maintaining a continuous blood supply through a vascular pedicle.

7. What is the pathogenesis of an acquired dermoid cyst?
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.
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
'Watch and wait' or aspiration followed by 3 weeks of immobilzation
A papilloma is an over-growth of all layers of the skin with a central vascular core. They are increasingly common with age.

8. What are the features of an indirect inguinal hernia?
An aneurysm is an abnormal dilatation of a blood vessel - A true aneurysm involves all layers of the arterial wall - A false aneurysm follows a partial laceration of the vessel wall causing blood to leak out of the vessel into the surrounding tissues
Neoplasia(benign -malignant -lymphoma and leukaemia) - Stone(sialolithiasis) - Infection/inflammation(mumps -acute sialadenitis -chronic recurrent sialadenitis -HIV - salivary gland disease) - Autoimmune(sjogren's syndrome) - Infiltration(sarcoidosis
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
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

9. What do you know about the epidemiology of hypertrophic scars?
Loss of hair on outer-third of eyebrows - Lid retraction - Lid lag - Ophthalmoplegia - Exophthalmos - Chemosis - Proptosis
Excision for the main lesion with varying margins depending on the size of the lesion. - If there is nodal spread - Fine Needle Aspiration Cytology or Lymph node biopsy - Therapeutic Block Dissection(if palpable lymph nodes) - Palliation adjuvant th
Affect any age - Males = females - All races may be affected
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

10. What are the non-surgical treatment options for hydrocoele?
True umbilical herniae occur through the umbilical scar and are usually congenital in origin and particulary common in patients of Afro-Caribbean origin
Transfemoral radiological embolization of the testicular vein - using either a spring coil or sclerosant
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
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

11. What are the features of ulcers in pyoderma gangrenosum?
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
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital
Undermined edge - Violaceous - Necrotic ulcer with hypertrophic margins
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

12. Radiological investigations for hepatomegaly
The face can be affected in patients with: Syringomyelia - Frey's syndrome
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
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
Fibroadenomas - Breast cysts - Fat necrosis - Breast cancer

13. What are the causes of postoperative jaundice?
Prehepatic jaundice can occur due to haemolysis - especially following a transfusion - Hepatic jaundice can result from the use of halogenated anaesthetics - sepsis or intra- or postoperative hypotension - Post-hepatic jaundice can occur due to bilia
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.
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision
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

14. Why is surgical treatment advised in the treatment of varicocoele?
Duplex Ultrasound - Angiography - CT/MRI
It is often advised as the problem usually gets worse with age and there is risk of infertility.
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
A cystic hygroma is a congenital cystic lymphatic malformation found in the posterior triangle of the neck.

15. What is the prophylactic treatment of pressure sores?
Non-surgical : cryotherapy - topical application of 5-fluorouracil - retinoic acid - Surgical : Shaving of affected skin
Extrahepatic : caused by increased resistance to flow e.g : portal or splenic vein thrombosis - Intrahepatic : due to cirrhosis - right heart failure - sarcoidosis and schistosomiasis(the latter is the most important cause worldwide - ova of the para
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)
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

16. What is the non-surgical treatment of a ganglion?

17. What are the treatment options of false aneurysms?
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review
Wounds associated with - Infection - Trauma - Burns - Tension especially over the sternum such as after CABG - Wounds on certain areas of the body
Benign skin lesions: Moles -freckles -lentigo -pigmented seborrhoeic keratoses - dermatofibromas and thrombosed haemangiomas - When it comes to malignant skin lesions - pigmented basal cell carcinomas
It reduces intravascular hydrostatic pressure and the stockings increase extracellular hydrostatic pressure - together reducing the level of tissue oedema.

18. What are the complications of incisional hernia?
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation
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
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
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

19. What does a hypertrophic scar look like?
Scar confined to wound margins - It is found across flexor surfaces and skin creases
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
Extrahepatic : caused by increased resistance to flow e.g : portal or splenic vein thrombosis - Intrahepatic : due to cirrhosis - right heart failure - sarcoidosis and schistosomiasis(the latter is the most important cause worldwide - ova of the para
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis

20. What are the indications for preoperative Duplex ultrasound scanning
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
Some surgeons would advocate that all patients should undergo Duplex scanning of the leg veins before any surgery is undertaken. Others would consider indications to be: Previous history of deep vein thrombosis - Any signs of chronic venous insuffici
Cervical sympathectomy and amputation of the affected phalanges - Cervical sympathectomy may not be a permanent solution and may only relieve symptoms for 2 years or less - Amputate only if digits are threatened with gangrene
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

21. What are the contents of the spermatic cord?
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
White lines and streaks inside the mouth
Derived from capillary endothelial cells or from fibrous tissue - It is linked to human herpes virus 8
Resection of a lobe including its bronchial origin with re-anastamosis of the proximal and distal bronchus

22. Where does a liposarcoma arise from?
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
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.
It arises de novo
Central causes - RHF - hypoalbuminaemia -nephrotic syndrome and hypothyroidism - Peripheral - venous disease such as DVT - Klippel-Trenaunay syndrome - chronic venous insufficiency or post-phlebitic limb - Rare - angio-oedema - arteriovenous malforma

23. How would you treat a cystic hygroma?
Rapid growth and pain(on history) - Hyperemic hot skin - Hard consistency - Fixed to skin and underlying muscle - Irregular surface or ill-defined edge - Facial nerve involvement
Arising inside the parotid gland - Arising outside the parotid gland
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
Non-surgically via aspiration and injection of sclerosant surgically via excision which may be partial ( to relieve symptoms) or complete as a one-stage procedure.

24. What are the congenital predisposing factors for malignant melanomas?
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
An absolute pressure of less than 50mmHg
Loss of hair on outer-third of eyebrows - Lid retraction - Lid lag - Ophthalmoplegia - Exophthalmos - Chemosis - Proptosis
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives

25. How would you treat a papilloma?
All patients should undergo triple assessment that is Clinical Examination - Radiological assessment usually ultrasonographic - Pathological - most commonly cytological following FNAC
Transfemoral radiological embolization of the testicular vein - using either a spring coil or sclerosant
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
The simplest surgical technique is to excise the papilloma with a sharp pair of scissors - controlling bleeding from the central vascular component with a single suture. Alternatively - diathermy can be used to control the bleeding at the same time a

26. What are the risk factors for arterial disease
Smoking - Diabetes - Hypertension - Cholesterol - Previous history especially heart disease or stroke - Family history - Possibly renal failure -hypothyroidism and gout
Traumatic - Iatrogenic(following angiography and bypass)
Demographics - Presenting Complaint - History of Presenting Complaint - Medical and Surgical History - Drugs and any other allergies - Family History - Social History - Systemic Enquiry
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

27. What are the features of lentigo maligna melanoma?
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.
Sacrum - Greater trochanter - Heel - Lateral Malleolus - Ischial Tuberosity - Occiput
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
Defective gene on chromosome 22 with variable penetrance - Cutaneous signs are less often seen in this type.

28. What is Sjogren's syndrome?
Salmonella typhi - Mycotic aneurysms as a result of staphylococcal infection - Syphilitic aneurysms
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
Autoimmune condition - Intermittent or constant swelling of one or all of the salivary glands
Diffuse enlargement - smooth or nodular - Solitary nodule

29. Raynaud's phenomenon
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
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery
Characteristic cold-induced changes associated with vasospasm
Haemorrhage - Hoarseness - Hyperthyroidism

30. What are the main points that doctors are looking for during the Surgical OSCEs?
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
Urine cytology -blood tests would be expected to be normal and a renal ultrasound scan which shows a cyst with a smooth outline -sharply defined thin wall and no internal echoes(which imply solid components)
A caring and competent approach - A good examination technique - An ability to elicit and draw conclusions from physical signs
Carcinoma of the stomach and oesophagus - lymphomas and with endocrine disorders such as acromegaly - Cushing's - diabetes complicated by severe insulin resistance

31. What other associations of pyoderma gangrenosum do you know of?
Cervical rib or prominent transverse process of the Chest X-ray or thoracic outlet views - Doppler examination may be useful in quantifying the postural changes and post-stenotic dilatation - Arteriograms of the subclavian artery may show a marked ki
Idiopathic(50%) - Myeloproliferative disorders - Autoimmune hepatitis - More common in males than females
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 -
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

32. How would you investigate a patient who was referred with a carotid bruit?
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
Classic Kaposi's sarcoma - AIDS-associated Kaposi's sarcoma - Endemic(central African) variety - Transplantation-associated Kaposi's sarcoma
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally
Hands and Eyes

33. What are the causes of gynaecomastia?
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
As the perfusion of the leg begins to decrease in a patient with peripheral vascular disease; the ratio begins to fall.
Anxiety - Hyperthyroidism - Hyperhidrosis erythematosus traumatica - Phaeochromocytoma
Causes may be classified as the 3 Ps: Physiological - Pathological - decreased androgens - androgen resistance - increased secretion -increased peripheral aromatization - Potions that is drugs such as recreational drugs - GI drugs - cardiovascular dr

34. How does follicular carcinoma spread?
Via the bloodstream(R is equal to red is equal to blood)
Preoperative - Age -Immunocompromised state -obesity -malignancy -abdominal distension from obstruction or ascites - Operate - Poor technical closure of the wound -placing drains through wounds - Postoperative - wound infection or haematoma - early m
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
Clinical examination - Fine-needle aspiration which would show an opalescent fluid containing cholesterol crystals or pus.

35. Lipomas do not undergo...
Sunlight - Pre-existing skin lesions - Previous melanoma
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
malignant change?
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

36. What is the surgical treatment of varicocoele?
A branchial cyst is thought to develop because of a failure of fusion of the embryonic second and third branchial arches. An alternative - and currently - popular - hypothesis is that it is an acquired condition due to cystic degeneration in cervical
Palomo operation
Auscultation - Percussion of the thyroid gland and downwards for retrosternal extension
Chest x-ray to map the caudal extent of the cystic hygroma - CT/MRI scanning especially if it is complex

37. What do you know about solitary thyroid nodules?
More common in females - Occur most commonly in the fourth or fifth decade - 10% in middle-aged are malignant but 50% are malignat in the young and the elderly - FNAC is the most important investigation
Tenderness over the graft - Reduction in urine output - Rising creatinine
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
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis

38. What are the specific complications of varicose veins surgery?
Mnemonic : PS : PLS C TiT - Pharyngeal pouch - Sublingual dermoid cyst - Plunging ranula - Lymph nodes - Subhyoid bursa - Ca - larynx/trachea/oesophagus - Thyroglossal cyst - Thyroid swelling
Intracranial - Intratemporal - Extratemporal
Early - haematoma - Intermediate - Infection and nerve damage e.g saphenous in stripping - Late - Recurrence
If the vessels are normal in calibre - the clinical features may be caused by relatively overactive alpha receptors in the wall - leading to abnormal smooth muscle contraction or changes in elasticity

39. What is a skin graft?

40. How would you perform an ascitic tap?
Mnemonic : PISS - Persistent Pain - Incarceration/Intestinal Obstruction(often intermittent) - Strangulation - Skin Excoriation
Third cranial nerve palsy - complete ptosis - Horner's syndrome - partial ptosis - Syphillis
The procedure should be performed under sterile condition and if the ascites is not clinically apparent or easy to locate - it should be done by a radiologist under ultrasound guidance to prevent inadvertent injuries to intra-abdominal structures.
These are due to a defect through the linea alba adjacent to the umbilicus and usually due to obesity stretching the fibres.

41. What needs to be taken into consideration when marking the stoma site?
Mneumonic : BEDD - Base - Edge - Describe structure visualized at the base of the ulcer - Discharge
Motor - Secretomotor - Taste - Sensory
Iodine deficiency - Increased physiological demand - Goitrogens(less common) - Defects of thyroid hormone production
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

42. In patients with gynaecomastia - what would make you concerned the patient may have a breast cancer?
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
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
Idiopathic Which is the most common - Gastrointestinal - Respiratory - Cardiac - Rare causes
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

43. What is a useful mneumonic to remember what you have to present when examining a lump or swelling?
All patients should undergo triple assessment that is Clinical Examination - Radiological assessment usually ultrasonographic - Pathological - most commonly cytological following FNAC
Depends on local guidelines but essentially: Pneumococcal vaccine - Haemophilus influenzae type B vaccine - Meningococcal vaccine - Annual 'flu' vaccine - Consideration for lifelong penicillin or penicillin as required when infection present - Warn a
Should The Children Ever Find Lumps Readily
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

44. Where is the midpoint of the inguinal ligament?
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
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
Halfway along inguinal ligament that is between pubic tubercle and ASIS Which is equal to the location of the deep inguinal ring
Xeroderma pigmentosum - Dysplastic naevus syndrome - Large congenital naevi - Family history in first-degree relatives

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

46. What is a chemodectoma?
Vaginal Hydrocoele - fluid accumulates in the tunica vaginalis - Hydrocoele of the cord - fluid accumulates around the spermatic cord - Congenital Hydrocoele - Infantile Hydrocoele
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
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
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

47. What are the surgical treatment principles of incisional hernia?
For patients who refuse radiation therapy or relapse after an adequate course - pregnant patients or those wishing to become pregnant within 4 years - patients under the age of 40 years and those with nodular or large goitres
Dissection of the hernial sac from surrounding tissues and definitioni of tissue bordering the defect on all sides to 2-3cm - Closing the defect(if small) and/or using mesh overlapping adequately( more than 5 to 8cm) over normal tissues to allows for
Early mobilization is important - They should keep the area clean and wash carefully -especially after the clip/sutures have been removed - They are able to bathe immediately - They may need to be off work for 6 weeks if their job involves heavy lift
Urine cytology -blood tests would be expected to be normal and a renal ultrasound scan which shows a cyst with a smooth outline -sharply defined thin wall and no internal echoes(which imply solid components)

48. What are the signs in the mouth of Lichen Planus?
Endovascular repair - Laparoscopic repaire of abdominal aneurysms is the subject of current clinical trials
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
White lines and streaks inside the mouth
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

49. What are the late side-effects of radiotherapy?
Mnemonic: DELFT(D) Feeding e.g feeding gastrostomy/jejunostomy - Lavage e.g appendicostomy - Decompression - bypass of an obstructing bowel lesion distal to the stom - Diversion - protection of a distal bowel anastamosis and urinary diversion followi
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
Central causes - RHF - hypoalbuminaemia -nephrotic syndrome and hypothyroidism - Peripheral - venous disease such as DVT - Klippel-Trenaunay syndrome - chronic venous insufficiency or post-phlebitic limb - Rare - angio-oedema - arteriovenous malforma
Undermined edge - Shallow ulcer

50. What are the non-surgical treatment options for coarctation of aorta?
Surgery is indicated for: Symptomatic aneurysms - Those containing thrombus - Those greater than 2cm
TIMEC - Trauma/Tumor - Infection/Inflammation/Ischemia - Metabolic -Mechanical - Endocrine - Congenital
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.
Investigation and treatment of concurrent abnormalities - Management of hypertension