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TRANSCRIPT
Surgery spots 2011:
1. Ulcer on sole of foot with pigment around it: MELANOMA
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Types: LLNS
1. Lentigo maligna melanoma
-- Black or brown spot on sun-exposed areas e.g. face- >60 years
2. Superficial spreading melanoma
3. Nodular malignant melanoma
-- Most malignant- Dark blue/black
4. Lentigo maligna acrale NB!!
-- 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, contourB- Borders – irregular, ill-definedC- Colour – black ,brown, blue, red, gray, whiteD- Diameter - >5mm
Staging:
1. Clarke’s levels (histology)2. Clinical staging (I-III)3. Breslow’s infiltration depths: - <0.76mm no death- 0.76 – 1.5mm 25% mortality in 5 years- 1.5 – 3mm >50% mortality in 5 years- Deeper than 3mm >75% mortality in 5 years
2. Female: anal/vaginal growth
Diff.dx:- Anal carcinoma (squamous cell carcinoma)- Vaginal ca- Sarcoma- Rectal ca- TB
Confirm:
Biopsy
3. Flat breast: Mastectomy
-- 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
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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:
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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
- 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- Thyroiditis, - Thyroid cyst (moves when tongue protrudes)
Thyroid cyst/hemorrhage- Laryngocele, ventricular- 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
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:
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
Symptoms:
Dysphagia Haematemesis Regurgitation Weight loss Haemoptysis Hoarseness (aspiration) Recurrent pneumonia (aspiration) Cough after meal (aspiration)
Confirm: Gastroscopy Biopsy
8. Jaundice
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
9. Parotid mass
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)
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
12. Breast lump: Deformed breast: Breast ca
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
14. Abdominal XR – air under diaphragm: Abdominal Viscus perforation
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:
EPIGASTRIC MASS: M I N T Malformation Inflammation Neoplasm TraumaAbdominal Wall Hernia Cellulitis Lipoma Contusion Carbuncles Sebaceous cyst
Diaphragm Hiatal herniaSubphrenic abscess
Liver Cyst Abscess Hepatoma Contusion
Hemangioma HepatitisMetastatic carcinoma
Laceration
Omentum Adhesion PeritonitisMetastatic carcinoma
Traumatic fat necrosis
M I N T Malformation Inflammation Neoplasm Trauma Cyst Tuberculoma Hemorrhage
StomachHypertrophic pyloric stenosis
Gastric ulcer Gastric carcinoma Hemorrhage
Gastric dilatation
Stab wound
Gastric syphilis Colon Hirschsprung disease Diverticulitis Colon carcinoma Contusion
IntussusceptionToxic megacolon
Polyp Laceration
Volvulus
Pancreas Cyst PancreatitisCarcinoma of pancreas
Contusion
Pseudocyst Retroperitoneal Lymph Nodes
Tuberculosis Lymphoma
Sarcoma
Metastatic carcinoma
Aorta Aneurysm
Spine Lordosis TuberculosisMetastatic carcinoma
Fracture
Scoliosis Arthritis Myeloma Herniated disc Osteomyelitis Hodgkin disease Hematoma
16. Indirect inguinal hernia
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
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
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 regimen4E's - education, elevation, elastic compression and evaluation.
19. Gangrene of foot:
Special investigations:
Blood cultures
Rx:
Surgical debridement Antibiotics
20. Peri-anal abscess
DiffDx:
Crohn’s disease Ulcerative colitis TB Pilonidal abscess
Rx:
Antibiotics Drain (leave open) Sitz baths
21. Gallstones
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
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 point2. 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