Surgery spots 2011:

1. Ulcer on sole of foot with pigment around it: MELANOMA

-

-

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

-

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:

-

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