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Clinical Surgery

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. How would you manage a multinodular goitre?
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
History and Clinical Examination - Investigate if prominent nodule or features suspicious of malignancy such as cervical lymphadenopathy or recurrent laryngeal nerve palsy
Cardiac disease - hypertension -myocardial infarction -ischaemia -mitral valve disease - cardiomyopathy -endocarditis - Respiratory disease - Pneumonia - lung cancer - sarcoidosis - Other: Hypothyroidism and idiopathic ( lone AF)
In the presence of jaundice if a mass(the gall bladder) is palpable in the right upper quadrant - the cause is unlikely to be due to gallstones.

2. What is a secondary hydrocoele?
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.
Mayo's 'vest-over-pants' operation is the most widely accepted repair for these herniae
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair
Simple colloid goitre - Graves' disease - Thyroiditis

3. What are the motor branches of the facial nerve?
Autosomal recessive - 1 in 5000 to 40000 - Chromosome 6 is affected - It presents perinatally
Cardiac failure - Tricuspid regurgitation - Constrictive pericarditis
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
Nerve to stapedius - Nerve to posterior belly of digastric - Five divisions within the parotid gland - temporal - zygomatic - buccal - mandibular and cervical

4. What is a pyogenic granuloma?
A pyogenic granuloma is a rapidly growing capillary haemangioma whic usually measures less than 1cm in diameter
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.
Treatment is radical surgery with follow-up using sequent calcitonin assays
The incompetent vein is at or above the level of the tourniquet

5. What is the differential diagnosis of a malignant melanoma?
Small -punched out ulcers - Often over medial aspect of lower leg
Mnemonic : CHIASMA - Congestive : cardiac failure - Haematological : reticuloses - Infection : viral -bacterial -protozoal - Amyloid - Storage disorders : Wilson's disease - haemochromatosis - Masses: primary/secondary neoplasia - Autoimmune/alcohol
Treatment involves the use of artificial tears and saliva - use of systemic steroids and careful follow-up due to increased risk of lymphoma development
Benign skin lesions: Moles -freckles -lentigo -pigmented seborrhoeic keratoses - dermatofibromas and thrombosed haemangiomas - When it comes to malignant skin lesions - pigmented basal cell carcinomas

6. How do true umbilical herniae occur?
Hypertrophic scars tend to appear soon after injury and usually regress spontaneously - while keloid scars appear months after injury and continue to grow
In the presence of jaundice if a mass(the gall bladder) is palpable in the right upper quadrant - the cause is unlikely to be due to gallstones.
Cardiac disease - hypertension -myocardial infarction -ischaemia -mitral valve disease - cardiomyopathy -endocarditis - Respiratory disease - Pneumonia - lung cancer - sarcoidosis - Other: Hypothyroidism and idiopathic ( lone AF)
True umbilical herniae occur through the umbilical scar and are usually congenital in origin and particulary common in patients of Afro-Caribbean origin

7. What is the differential diagnosis for a skin lesion?
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
Defective gene on chromosome 22 with variable penetrance - Cutaneous signs are less often seen in this type.
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
Increased platelet count and large platelets - Increased neutrophils - Nucleated red cells with Howell-Jolly bodies and target cell - Tend to mount more of a leukocytosis in response to infection

8. What questions should one ask to someone with dysphagia?
Unhealthy -necrotic and infected tissue - Irradiated tissue - Exposed cortical bone without periosteum - Tendon without peritendon - Cartilage without perichondrium
Anti-salivary antibodies - rheumatoid factor - but two specific antibodies present are anti-SSA-Ro and anti-SSA-La
Neo-rectum is created in a pelvic reservoir - Stage 1 : resection of colon and/or rectum - Stage 2 : Construction of an ileal reservoir - Which is anastamosed to the anus - this is usually covered with a diverting loop ileostomy proximal to the pouch
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 principles of management of enterocutaneous fistulae?
Mnemonic : SNAPP - Sepsis elimination : open or percutaneous drainage of collections; administration of appropriate antimicrobials - Nutritional resuscitation/optimization : patients may be fluid and electrolyte depleted and malnourished. Resuscitati
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
Wash Hands - Observe from end of bed - Start examination from right-hand side - Look for JACCOL which means jaundice -anaemia -cyanosis -clubbing -oedema and lymphadenopathy - Observation -Palpation -Percussion and Auscultation
Myelofibrosis - Chronic Myeloid Leukaemia - Malaria - Tropical splenomegaly - Kala-azar(visceral leishmaniasis)

10. What are the indications for lung resection?
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.
Mechanical obstruction - Coordination abnormalities
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
Those related to anaesthesia

11. What are the surgical problems associated with AF?
Anaesthesia is more complicated because of the increased risk of stroke - In addition - patients with AF may be anticoagulated and if on warfarin - this medication needs to be discontinued prior to elective surgery - Patients with controlled AF may d
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
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 :
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair

12. What are the uncommon causes of ascites?
Skin and soft tissues such as a sebaceous cyst -lipoma or sarcoma - Bowel - ca caecum - crohns mass in terminal ileum - TB terminal ileum - appendicular mass or abscess - Gynaecological organs - ovarian tumours or fibroid uterus - Male Reproductive S
Nephrotic syndrome - Tuberculosis - Chylous ascites
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
Physical preparation - marking of side - explanation of procedure - anaesthetic work up - Pyschological preparation - Breast care nurse preoperatively and discussion of reasons for mastectomy - option of reconstructive surgery

13. What is the definition of an enterocutaneous fistula?
Excision of a single lobe of the lung
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 ptosis - Myopathies - Syphillis
A enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and the skin

14. What are the surgical options for managing ulcerative colitis?
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
White lines and streaks inside the mouth
Less than 0.5
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

15. Where is the midinguinal point?
It is a point halfway along a line joining the ASIS and the midline Which is equal to the location of femoral artery
Sympathetic overstimulation and restrictive myopathy of levator palpebrae superioris
Non-surgical : Leave alone if small and asymptomatic - Surgical : minimally invasive surgery or surgical excision
Chest x-ray to map the caudal extent of the cystic hygroma - CT/MRI scanning especially if it is complex

16. What are the early side-effects of radiotherapy?
This is the array of plastic surgeon techniques of increasing complexity that is available to the surgeon and Which is used according to their suitability for individual patients
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
Third cranial nerve palsy - complete ptosis - Horner's syndrome - partial ptosis - Syphillis
'Watch and wait' or aspiration followed by 3 weeks of immobilzation

17. What is jaundice?
Stoma diarrhoea - related to water and electrolyte imbalances - hypokalemia being the commonest and most important consequence - Nutritional disorders - Stones - both gall stones and renal stones increase in frequency following an ileostomy - Psychos
0.5 to 0.8
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
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

18. How is 'matching' of transplanted kidneys performed?
1
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
Hyperkeratoses(thickening of the keratin layer) - Focal parakeratosis - Irregular acanthosis - Basal layer atypia only
At two levels:ABO Compatibility - HLA Compatibility

19. What is the differential diagnosis in basal cell carcinoma?
Vascular symptoms - Risk factors for arterial disease - Fitness for surgery
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%
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
Intracranial - Intratemporal - Extratemporal

20. What does surgical excision involved in the surgical treatment of a pharyngeal pouch?
Mneumonic : I - CHUM - Infection(frequent) - Calcification - Ulceration - sebaceous Horn formation - Malignant change
Simple inversion and oversewing(diverticulopexy) - as pouch is left in situ - risk of missing a possible diverticular carcinoma - or diverticulectomy.
Fine-needle aspiration cytology for diagnosis - MRI to exclude deep-lobe involvement
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

21. What investigations would you perform to help you in your diagnosis?
Halfway along inguinal ligament that is between pubic tubercle and ASIS Which is equal to the location of the deep inguinal ring
Barium swallow Which is usually diagnostic - Rigid endoscopy if neoplasia suspected
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
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

22. What is venous gangrene?
Bilateral subtotal thyroidectomy leaving approximately 4g of thyroid tissue on each side of the trachea
Duration and change in size - Cosmetic symptoms - Discomfort during swallowing/dysphagia - Dyspnoea - Hoarseness - Pain
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.
Venous gangrene is a rare complication of deep vein thrombosis in the iliofemoral segment and presents in three phases: 1 - Phlegmasia alba dolens - white leg 2 - Phlegmasia cerulea dolens - blue leg 3 - Gangrene - occurs as a consequence of acute is

23. What syndrome is associated with a port-wine stain?
Sturge-Weber syndrome is the association of a facial port-wine stain with a corresponding haemangioma in the brain - leading to contralateral focal fits.
A pyogenic granuloma is a rapidly growing capillary haemangioma whic usually measures less than 1cm in diameter
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
Third cranial nerve palsy - complete ptosis - Horner's syndrome - partial ptosis - Syphillis

24. How would you investigate a patient with a breast lump?
Commonest form of thyroid abnormality - Secondary to hyperplasia of the gland to meet physiological demand for thyroxine - Secondary to defective production of thyroid hormone
Auscultation - Percussion of the thyroid gland and downwards for retrosternal extension
Ultrasound compression of the false aneurysm - Thrombin injection - Surgical repair - Observation and review
Triple assessment which consists of: Clinical : history and physical examination - Radiological : ultrasound or mammography - Pathological : cytology(fine-needle aspiration) or histological(tru-cut biopsy)

25. Obstructive Jaundice - With regards to radiological investigations
Axillary vein thrombosis - Damage to axillary drainage following surgery such as axillary dissection in breast surgery
Ultrasound will show: Presence of underlying liver disease - Degree of dilatation of the common bile duct(>8mm is abnormal) - Presence of gall stones - Presence of lymphadenopathy or a pancreatic mass - CT Scan - ERCP - MRCP
A lipoma is a benign tumour consisting of mature fat cells.
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

26. What are the aetiologies arising outside the parotid gland in a unilateral swelling of the parotid gland?
A furuncle results from infection of hair follicles with Staphylococcus aureus
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.
Congenital - Usually due to a cervical rib(arising from the seventh cervical vertebra) and the subclavian artery is compressed between the rib and either the scalenus anterior muscle or the clavicle - Acquired - The obstruction may also follow a frac
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)

27. What are the causes of a false aneurysm?
Traumatic - Iatrogenic(following angiography and bypass)
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
Thyroidectomy
Barium swallow Which is usually diagnostic - Rigid endoscopy if neoplasia suspected

28. What surgical options are available in the management of cervical lymphadenopathy?
Open lymph node excision biopsy - Block dissection of the neck - Radical Neck Dissection
Vascular - Cerebrovascular accident - Tumour - acoustic neuroma - Infection - Meningitis(rarely
Undermined edge - Violaceous - Necrotic ulcer with hypertrophic margins
malignant change?

29. What about umbilical herniae in children?
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.
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)
Found above the inguinal ligament - Usually reducible - Commoner in males - 6:1 - Risk of strangulation is low - Cough impulse present
Minor defects in neonates are common but usually repair spontaneously. In children - umbilical herniae are mor common; they tend to have a narrow neck and folds of peritoneum stuck within this neck - which can occassionally strangulate. Most cases re

30. What are the signs of chronic venous insufficiency?
Duplex Ultrasound - Angiography - CT/MRI
A enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and the skin
An absolute pressure of less than 50mmHg
Mnemonic : LEGS - Lipodermatosclerosis - Eczema - Gaps in the skin i.e ulceration - active and healed - Swelling - pedal oedema

31. What is a hydrocoele?
A seborrhoeic keratosis is a benign overgrowth of the basal cell layer of the epidermis.
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%
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
Excess accumulation of fluid in the processus vaginalis.

32. What radiological features would make you suspicious of an occult renal cell carcinoma?
More worrying features for a tumour would include: Thick or irregular wall - Extensive calcification within the cavity or wall of the cyst - Multilocular cysts
Mnemonic : HIS PRIPS - Ischaemia/gangrene - Haemorrhage - Retraction - Prolapse/intussusception - Parastomal Hernia - Stenosis - Skin excoriation
A pyogenic granuloma is a rapidly growing capillary haemangioma whic usually measures less than 1cm in diameter
History and Clinical Examination - Investigate if prominent nodule or features suspicious of malignancy such as cervical lymphadenopathy or recurrent laryngeal nerve palsy

33. What are the features of a multinodular goitre?

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34. What are the seven signs in the eyes that one should look out for when assessing the thyroid status?
Increased platelet count and large platelets - Increased neutrophils - Nucleated red cells with Howell-Jolly bodies and target cell - Tend to mount more of a leukocytosis in response to infection
Necrotizing vasculitis - Purpuric -haemorrhagic bullae
Loss of hair on outer-third of eyebrows - Lid retraction - Lid lag - Ophthalmoplegia - Exophthalmos - Chemosis - Proptosis
Mneumonic : LIST Lymphoma and Leukaemia - Infection(further subdivided into Bacterial - Viral - Protozoal and Toxoplasmosis) - Sarcoidosis - Tumours

35. Raynaud's disease
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.
General - Thermoregulatory - Dermatological - Musculoskeletal - Gastrointestinal - Cardiovascular - Gynaecological - Psychiatric - Neurological
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
Primary disease occurring in isolation

36. What are the rare causes of digital clubbing?

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37. What are the acquired predisposing factors for basal cell carcinomas?
Sunlight - Carcinogens - Previous radiotherapy - Malignant transformation in pre-existing skin lesion
Sunlight - Pre-existing skin lesions - Previous melanoma
Lobectomy - Pneumonectomy - Non-anatomical resection are often performed for traumatic injury - Sleeve resection
The incompetent vein is below the level of the tourniquest

38. What features of the lump would make you suspicious that it is breast cancer?
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
Painless - Associated with normal appearance of the surrounding skin - Associated with local sensory loss
Size - Tenderness - Mobility - Consistency
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 :

39. What is the ABPI of patients with intermittent claudication?
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
0.5 to 0.8
An abnormal sac containing gas -fluid or semisolid material - with an epithelial lining
A papilloma is an over-growth of all layers of the skin with a central vascular core. They are increasingly common with age.

40. How would you treat a dermatofibroma?
Autosomal dominant - 1 in 500 - Chromosomes 4 and 16 are affected - Age of Presentation is between 30s and 50s
Painless - Associated with normal appearance of the surrounding skin - Associated with local sensory loss
Non-Surgical : leave alone if asymptomatic and if patient does not want intervention - Surgical : Simple excision followed by histology
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

41. What is the non-surgical treatment of pressure sores?
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
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)
Non-surgical - if the cyst is not troublesome - it should not be removed - especially in younger men - because there is risk of operative damage and postoperative fibrosis causing subfertility - Surgical - very large or painful cysts can be removed a
It is important to exclude malignant tumours such as: Malignant melanoma - Basal cell carcinoma

42. What do you know about the pathology of Squamous Cell Carcinoma of the skin?
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
malignant change?
Classic Kaposi's sarcoma - AIDS-associated Kaposi's sarcoma - Endemic(central African) variety - Transplantation-associated Kaposi's sarcoma
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.

43. What are the hepatobiliary complications of IBD?
Liver - fatty change - chronic active hepatitis -cirrhosis and amyloid deposition - Gall bladder and bile ducts - gallstones - sclerosing cholangitis - and cholangiocarcinoma
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
Characteristic cold-induced changes associated with vasospasm
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

44. Lipomas do not undergo...
Secondary Raynaud's phenomenon associated with other diseases
malignant change?
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.
The vaginal type of hydrocoele may be secondary to a number of local pathologies: Testicular tumours - Torsion - Orchitis - Trauma - Following inguinal hernia repair

45. What would you tell patients about their recovery from inguinal hernia repair?
Jaundice is yellow discolouration of the skin and mucous membranes caused by the accumulation of bile pigments.
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
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
Lead shields to protect the eyes and gonads - Dose-fractionation - Prior chemotherapy - Regional hypothermia - Radiolabelled antibodies

46. What are the causes of a mass in the left iliac fossa?
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
A caring and competent approach - A good examination technique - An ability to elicit and draw conclusions from physical signs
At two levels:ABO Compatibility - HLA Compatibility
It helps to give an indication as to What the exact aetiology is.

47. What is the treatment of choice in differentiated thyroid cancer?
10% per year
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.
Thyroidectomy
An abnormal communication between two epithelial surfaces(or endothelial surfaces such as in arteriovenous fistula)

48. What are the categorical causes of digital clubbing?
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 -
Use of truss or corset - Weight loss and management of other risk factors
Gumma of tertiary syphillis has a typical punched-out ulcer - over the anterior surface of the lower leg and has a yellow coloured 'wash leather' base. - Scalloped border
Idiopathic Which is the most common - Gastrointestinal - Respiratory - Cardiac - Rare causes

49. What are the causes of ischaemic ulcers?
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
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
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
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

50. What are the malignant diseases of the breast?
Congenital abnormalities - Aberrations of normal development and involution( fibroadenomas -breast cysts -sclerotic or fibrotic lesions) - Non-ANDI conditions such as infections -lipomas -fat necrosis
Hands and Eyes
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
Recurrence of the cyst - Developement of a chronic -discharging sinus