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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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