MBChB SIC - Home
Surgery spots 2011:
1. Ulcer on sole of foot with pigment around it: MELANOMA
- [pic]
- [pic]
Types: LLNS
1. Lentigo maligna melanoma
- [pic]
- Black or brown spot on sun-exposed areas e.g. face
- >60 years
2. Superficial spreading melanoma
[pic]
3. Nodular malignant melanoma
- [pic]
- Most malignant
- Dark blue/black
4. Lentigo maligna acrale NB!!
- [pic]
- Non-sun exposed areas: feet, palms, perineum
- Found on soles and feet of black people
- Large: +/- 3cm at dx
- Aggressive
- Variation in colour
- Ulceration common
- Poor prognosis
Diff.dx for melanoma:
• Moles
• Basal cell papilloma (seborrhoeic keratosis)
• Pigmented BCC
• Histiocytoma
• SCC
• Café Au lait spots
• BCC
Special investigations for melanoma:
• Removal by excisional biopsy
• Full thickness biopsy – occasional, with large lesions on face or hands that cannot easily be excised
S&S of malignant change in mole:
A- Asymmetry – shape, size, colour, contour
B- Borders – irregular, ill-defined
C- Colour – black ,brown, blue, red, gray, white
D- Diameter - >5mm
Staging:
1. Clarke’s levels (histology)
2. Clinical staging (I-III)
3. Breslow’s infiltration depths:
- 50% mortality in 5 years
- Deeper than 3mm >75% mortality in 5 years
2. Female: anal/vaginal growth
[pic]
[pic]
Diff.dx:
- Anal carcinoma (squamous cell carcinoma)
- Vaginal ca
- Sarcoma
- Rectal ca
- TB
Confirm:
Biopsy
3. Flat breast: Mastectomy
- [pic]
- Recurrent breast cancer : cancer nodules
Risk factors:
- Fam Hx
- Nulliparous female
- Early menarche with late menopause
- Ca of opposite breast
- Older age
- Endometrial ca
- Long-term HRT (hormone therapy treatment)
Haemotoginous spread:
- Lung
- Thyroid
- Adrenals
- Bone
- Liver
- Brain
4. Tourniquet around leg: varicose veins
- [pic]
Trendellenburg test:
- Pt lies down
- Lift leg to empty veins
- Tourniquet around thigh
- Pt to stand
- Normal: veins fill slowly from below
- Abnormal: greater saphenous vein fills RAPIDLY from ABOVE
- = positive Trendellenburg test
Perthe’s test:
- Pt lies down
- Lift leg to empty veins
- 3 tourniquets: thigh, above knee, below knee
- If veins between tourniquets fill: incompetent veins
- Now pt must move around
- Competent vein: no vein enlargement (returns to heart)
- Incompetent veins: veins enlarge further, dilate, PAINFUL
Components of lower limb venous system:
- Superficial veins
- Deep veins
- Perforators (communicating veins)
Causes: (unknown)
- Incompetent valves
- Pregnancy
- Obesity
- Congenital abnormality of valves
- Occupation where one stands for long periods
5. Rectal prolapse:
- [pic]
Types:
- 1. Incomplete mucosal prolapse (young children)
- 2. Complete full thickness bowel prolapsed (elderly female)
Complaints:
- large tissue at anus after increased abd pressure e.g. defecation/coughing
- manually reducible
- pain
- tenesmus (straining)
- incontinence
- rectal bleeding
- constipation
- can ulcerate
- mucus discharge
Diff.Dx:
- Prolapsing haemorrhoids
- Complete rectal prolapse
- Large Polyps
- Malignant Mass – rectal adenoma
Special investigation:
- Rectal exam – sphincter tone
- Reduction and sigmoidoscopy
- Biopsy
- Barium enema
Rx:
- Incomplete mucosal prolapse: haemorrhoidectomy
- Complete prolapsed: Wells operation or Ripstein operation
6. Mass: ant of neck
[pic] [pic] [pic]
- Diff Dx:
- Thyroid mass (moves when swallowing)
- Bruit (aneurysm)
- Ca (lymph nodes)
- Nodular thyroid
- Thyroid carcinoma - thyroid/Parathyroid adenoma, carsinoma
- Carotid aneurysm (bifurcation)
- Dermoid cyst
- [pic]Thyroiditis,
- [pic]Thyroid cyst (moves when tongue protrudes)
[pic]Thyroid cyst/hemorrhage
- [pic]Laryngocele, ventricular
- [pic]Goiter
Special investigation:
- Sonar
- Bloods: TF
Causes of thyroid gland enlargement:
Physiological:
• Puberty
• Pregnancy
• Non-toxic nodular goiter/colloid goiter (common: iodine deficiency)
Thyrotoxic goiter
• Grave’s disease
• Plummer
Thyroiditis
• de Quervain’s (subacute)
• Hashimoto’s (autoimmune)
Solitary thyroid nodules
• Adenomas
• Cysts
• ca
Other neoplasias
• Lymphoma
• Anaplastic tumours
Female: Neck tumour, proptosis: Grave’s disease
[pic]
Clinical features:
• Young female
• Thyroid moderately to diffusely enlarged and soft
Vascular:
• Bruit may be audible
Increased metabolic rate:
• Pt feels hot, intolerant to heat
• Skin: moist, warm due to vasodilation & excessive sweating
• Weightloss despite increased appetite
• Increased CO2
Sympathetic effects:
• Tachycardia
• Palpitations
• Heart irregularities and arrhythmias esp AF
Hands:
• Fine tremor
Eyes:
• Upper eyelids retracted
• Lid lag
• Exophthalmos
• Ophthalmoplegia – diplopia
• Increased GIT motility
• General hyperkinesias, anxiety, psychiatric disturbance
Other features:
• Pretibial myxoedema
• Proximal myopathy
• Finger clubbing
Special investigations:
• Increased circulating T3 & T4
• Decreased TSH
• Increased I131 uptake with diffuse pattern
• Presence of Thyroid-stimulating Immunoglobulins (TSI)
Neck mass:
[pic]
Multiple lumps:
- LN
Single lump in Ant triangle that does NOT move on swallowing:
- Solid: LN, carotid body tumour
- Cystic: cold abscess (TB), brachial cyst
Post triangle mass that does NOT move on swallowing:
- Solid: LN
- Cystic: cystic hygroma, pharyngeal pouch
- Pulsate: subclavian aneurysm
Ant triangle mass that MOVES on swallowing:
- Solid: thyroid gland, thyroid isthmus, LN
- Cystic: thyroglossal cyst
Diff.dx on neck mass:
• Cervical lymphadenopathy:
- Infection: TB, syphilis, glandular fever
- Metastases: Head, neck ,chast, abd
- Primary reticulosis: lymphoma, lymphosarcoma, reticulosarcoma
- Sarcoidosis
• Brachial cyst
• Brachial fistulaCarotid body tumour
• Cystic hygroma (lymph cyst, lymph angiomata)
• Pharyngeal pouch
• Sternomastoid tumour
• Cervical rib
• Thyroglossal cyst
7. barium swallow: T4 Oesophageal Ca
[pic] [pic]
Symptoms:
• Dysphagia
• Haematemesis
• Regurgitation
• Weight loss
• Haemoptysis
• Hoarseness (aspiration)
• Recurrent pneumonia (aspiration)
• Cough after meal (aspiration)
Confirm:
• Gastroscopy
• Biopsy
8. Jaundice
[pic] [pic]
Diff.Dx:
Pre-hepatic jaundice
• malaria
• genetic diseases, such as sickle cell anemia,spherocytosis, thalassemia and glucose 6-phosphate dehydrogenase deficiency
Hepatic
• acute hepatitis
• hepatotoxicity
• Gilbert's syndrome (a genetic disorder of bilirubin metabolism)
• Crigler-Najjar syndrome
• alcoholic liver disease
Post-hepatic: Obstructive jaundice
• gallstones
• pancreatic cancer in the head of the pancreas
• strictures of the common bile duct
• biliary atresia
• ductal carcinoma
• pancreatitis
• pancreatic pseudocysts
Investigations:
• Bloods: FBC, UCE, CRP, LFT< amylase, lipase
• Sonar
• ERCP
• CT scan
Pt with distended abd + enlarged liver + dark urine sample
[pic]
9. Parotid mass
[pic]
Diff Dx:
Pleomorphic adenoma
Risk factors:
• Smoking
• Stones
• Sunlight
• Stasis
• Spices
Parotid gland enlargement:
Dif.Dx:
• Viral infection: Mumps
• Bacterial infection: bacterial parotitis (elderly: post-op)
• Recurrent parotitis of childhood
• Parotid duct obstruction e.g. stone
• Sialectasis
• Trauma
• Parotid cyst
• Tumor
• Sjogren syndrome (multiple masses in salivary glands)
• Sarcoidosis
• Drugs (iodide-containing compounds)
• Sialadenosis
Swelling that is not the parotid gland:
- Pre-auricular LN
- LN enlargement caused by Ca of tongue
Tumours of parotid gland:
Benign:
Characteristics:
- Slow growing
- Painless
- Normal temp
- Normal colour of skin
- Non-tender
- No enlarged LN
- Pleomorphic adenoma
- Adenolymphoma
Malignant:
Characteristics:
- Fast growing
- Painful
- Increased temp
- Abnormal colour of skin
- Tender
- Enlarged LN
- SCC
- Adenocarcinoma
- Muco-epidermoid tumour
Special investigations:
• Culture from ducts MCS
• X-ray – stones, infiltrating malignancy
• Sialogram
• CT (tumour)
• Biopsy (careful!!)
Complications:
• Facial nerve palsy (carcinoma)
• Malignancy
• Predispose to stones
Rx
Superficial parotidectomy
10. Skin: Squamous cell Carcinoma (SCC)
[pic][pic]
• 30% of skin ca
• Sun exposed areas: ears, cheeks, hands, lips
• Preceded by solar keratosis (epithelia hyperplasia)
Clinical picture:
• Starts as hard, erathematous nodule, then proliferates to malignancy
• Small, raised plaque
• Gradually enlarges and ulcerates
• Raised edges, necrotizing base
Special investigations:
Biopsy (excisional)
Diff.Dx:
• BCC
• Melanoma
• Keloid
• Keratosis
• Keratocanthoma
• Pyogenic granuloma
• Kaposi’s sarcoma
• Glomous tumour
11. Albino pt: SCC of ear
[pic][pic][pic]
12. Breast lump: Deformed breast: Breast ca
[pic][pic]
Site:
• most common: upper outer quadrant
Colour:
• Reddish purple in beginning
• When skin becomes infiltrated: less vascular, yellow-white
• Non-tender, only mild discomfort
Shape:
• Spherical
Surface:
Relation to surrounding tissue:
• Tethering
• Fixation
• Puckering
• Peau d’ orange
Lymph drainage:
• Axillary + supraclavicular
• Internal mammary nodes
• Cervical nodes
Lymphoedema of arm + venous thrombosis
• Both breasts may be affected
Metastases:
• NB to exclude on examination:
• Bone
• Lungs
• Liver
• Skin
• Brain
• ALWAYS DO A RECTAL!
Special investigations:
• FNA
• Needle biopsy
• Excisional biopsy
• Mammogram
Presentation of breast disease:
Painless lump:
• Ca
• Cyst
• Nodular fibroadenosis
Painful lump:
• Fibroadenosis
• Cyst
• Abscess
• Ca
• Periductal mastitis
Nipple discharge:
• Cyst
• Duct ca
• Duct papilloma
• Duct ectasia
Changes in nipple and areola:
• Nipple retraction
• Congenital inversion
• Duct ectasia
• Carcinoma
• Paget’s disease
• Eczema
Changes in breast size:
• Pregnancy
• Ca
• Benign hypertrophy
• Giant fibroadenoma
• Philoide’s tumour
• Sarcoma
Nipple discharge:
Non-bloody:
• Duct ectasia
• Fibradenosis
Bloody:
• Ca
• Duct ectasia
• Infections
13. Female breast+arms, small nodules over chest and breasts: Neurofibromatosis
[pic][pic]
[pic]
14. Abdominal XR – air under diaphragm: Abdominal Viscus perforation
[pic]
• Perforated peptic ulcer (most commo)
• Bowel obstruction
• Ruptured diverticulum
• Penetrating trauma
• Ruptured inflammatory bowel disease (e.g. megacolon)
• Bowel Cancer
• Ischemic bowel
• Steroids
• After laparotomy
• After laparoscopy
Management:
Explorative laparotomy
15. Diff Dx of abdominal mass:
[pic]
EPIGASTRIC MASS:
| |M |I |N |T |
| |Malformation |Inflammation |Neoplasm |Trauma |
|Abdominal Wall |Hernia |Cellulitis |Lipoma |Contusion |
| | |Carbuncles |Sebaceous cyst | |
|Diaphragm |Hiatal hernia |Subphrenic abscess | | |
|Liver |Cyst |Abscess |Hepatoma |Contusion |
| |Hemangioma |Hepatitis |Metastatic carcinoma |Laceration |
|Omentum |Adhesion |Peritonitis |Metastatic carcinoma |Traumatic fat necrosis |
| |Cyst |Tuberculoma | |Hemorrhage |
|Stomach |Hypertrophic pyloric stenosis |Gastric ulcer |Gastric carcinoma |Hemorrhage |
| | |Gastric dilatation | |Stab wound |
| | |Gastric syphilis | | |
|Colon |Hirschsprung disease |Diverticulitis |Colon carcinoma |Contusion |
| |Intussusception |Toxic megacolon |Polyp |Laceration |
| |Volvulus | | | |
|Pancreas |Cyst |Pancreatitis |Carcinoma of pancreas |Contusion |
| |Pseudocyst | | | |
|Retroperitoneal Lymph Nodes | |Tuberculosis |Lymphoma | |
| | | |Sarcoma | |
| | | |Metastatic carcinoma | |
|Aorta |Aneurysm | | | |
|Spine |Lordosis |Tuberculosis |Metastatic carcinoma |Fracture |
| |Scoliosis |Arthritis |Myeloma |Herniated disc |
| | |Osteomyelitis |Hodgkin disease |Hematoma |
16. Indirect inguinal hernia
[pic]
• Develops lateral of Hesselbach’s triangle through spermatic cord
• Congenital usually
• Non-closure of processus vaginalis
• Swelling in inguinal canal which may extend into scrotum
• Scrotum passes above and medial to pubic tubercle
• Cough impulse
• Bowels sounds – scrotum
DiffDx for mass in groin:
• Inguinal hernia – direct/indirect
• Femoral hernia
• Enlarged LN
• Ectopic testes
• Femora aneurysm
• Hydrocele
• Lipoma of cord
• Psoas bursa
• Psoas abscess
17. Direct inguinal hernia
[pic]
• Develops through Hesselbach’s triangle (Inf epiastric vessels, rectus abdominus, inguinal ligament)
• Elderly men
• Acquired
• Protrudes directly to the front
• Rx:
• Herniorrhaphy
18. Venous ulcer
[pic] [pic]
• The most common cause of chronic leg ulcers is poor blood circulation in the legs. These are known as arterial and venous leg ulcers.
Other causes include:
• injuries - traumatic ulcers
• diabetes - because of poor blood circulation or loss of sensation (nerve damage) resulting in pressure ulcers
• certain skin conditions
• vascular diseases (stroke, angina, heart attack)
• tumours
• infections.
Rx:
Bisgaard regimen
4E's - education, elevation, elastic compression and evaluation.
19. Gangrene of foot:
[pic] [pic] [pic]
Special investigations:
Blood cultures
Rx:
• Surgical debridement
• Antibiotics
20. Peri-anal abscess
[pic][pic][pic]
DiffDx:
• Crohn’s disease
• Ulcerative colitis
• TB
• Pilonidal abscess
Rx:
• Antibiotics
• Drain (leave open)
• Sitz baths
21. Gallstones
[pic]
Special investigations:Obstructive jaundice:
• Bloods – LFT – tot. bilirubin increased, ALP increased, GGT increased
• U/S – dilated bile ducts, stones
• ERCP – PTC (percutaneous trans-hepatic cholangiogram)
Complications of obstructive jaundice:
• Bleeding tendency (decrease vit ADEk, decreased prothrombin)
• Hepatorenal syndrome
• Preop bile duct decompression
• Pruritis
Rx:
• Cholecystectomy
• Lithtrypsy (?)
Diffdx Cholecystitis:
• Peptic/duodenal ulcer
• Gastritis
• Pancreatitis
• Diverticulitis
• Angina pectoris
22. DVT
[pic] [pic]
Risk factors:
• Elderly patient
• Obesity
• Prev Hx of DVT
• Post-op
• Varicose veins
• Hip # (orthopedic #)
• Immobilization
• Contraceptive pill (high in oestrogen)
• pregnancy
Wells score or criteria:
(Possible score -2 to 8) C3PO+R2D2" to remember the Wells criteria: Cancer, Calf swelling >3cm, Collateral veins (C times 3), Pitting oedema, Previous DVT, Oedema of whole leg, Tenderness (the t resembles a + sign), Recent immobilization, Recently bedridden (R times 2), Differential diagnosis equally likely (D times two points).
1. Active cancer (treatment within last 6 months or palliative) -- 1 point
2. Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity) -- 1 point
3. Collateral superficial veins (non-varicose) -- 1 point
4. Pitting edema (confined to symptomatic leg) -- 1 point
5. Previous documented DVT-1 point.
6. Swelling of entire leg - 1 point
7. Localized pain along distribution of deep venous system—1 point
8. Paralysis, paresis, or recent cast immobilization of lower extremities—1 point
9. Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 4 weeks—1 point
10. Alternative diagnosis at least as likely—Subtract 2 points
Clinical presentation:
• Asymptomatic
• Pain
• Oedema
• Homan sign: Pain on dorsiflexion
• Warm limb
Special investigations:
• D-dimer
• Duplex Doppler
• Coagulation studies
• U/S
• Venogram
Rx:
• Anticoagulants:
• Heparin IV bolus 7500 units STAT
• Heparin 10 days
• Oral:
• Warfarin from day 5
• Pressure stockings
Complications:
• Pulmonary embolism
• Postphlebitic limb
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