Download - Surgical Short Cases
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Surgical Short Cases
Jonny LenihanSurgical CT1 NWTD
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Overview• Common pathologies• Examination technique • Presentation skills• Background Information• X-rays• Summary• Questions
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Describing
• Site• Size• Shape• Consistency• Colour• Tenderness• Temperature
• Surface• Edge • Pulsatility• Mobility• Transillumination• Auscultation• Local lymph nodes
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Hypertrophic and Keloid Scars• Types of wound prone to these:
– Infection; trauma; burns; tension
• Hypertrophic occur soon after insult; spontaneously regress
• Keloid scars appear months after and continue to grow
• Rx:– Mechanical pressure dressings with topical agents– Surgical excision– Intralesional steroid therapy
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Hypertrophic scars Keloid Scars
Appearance Confined to wound margins Extend beyond wound margins
Site Flexor surfaces and skin creases Earlobes, chin, neck, shoulder, chest
Age Any age (commonly 8-20) Puberty to 30
Gender M=F F>M
Race Any Black and Hispanic
Pathology Normal rate of collagen synthesis, but increased rate of collagen breakdown
Increased rate of collagen synthesis and increased rate of collagen breakdown
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Examination of an ulcer• Site• Size• Shape• Colour• Depth• Discharge• Tenderness• Temperature• Local lymph nodes• Local tissues
• Edge:– Sloping = healing ulcer– Punched out = syphilis, trophic– Undermined = TB– Rolled = BCC– Everted = SCC
• Base:– Red = granulation tissue– Grey = slough
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Management
• Keep clean and dry• Antibiotics if infected• Topical agents• Dressings:
– 4 layered bandaged technique for venous ulcers
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Triangles of neck
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Lumps in the neck
Anterior Triangle• Pulsatile
– Carotid artery aneurysm– Tortuous carotid artery– Carotid body tumour(Chemodectoma)
• Non-Pulsatile– Thyroglossal cyst– Dermoid cyst– Ectopic thyroid tissue– Branchial cyst
Posterior Triangle• Lymph nodes• Cervical rib• Cystic hygroma• Pancoast’s tumour• Subclavian artery aneurysm
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EXAMINATION
1. Introduction - ?obvious swelling ?scars2. HANDS:
– Thyroid acropachy and palmar erythema– Temperature and pulse– Fine tremor
3. EYES:– Exophthalmos– Eye movements ?lid lag– Proptosis (stand behind patient)
4. Stand in front: ask to swallow5. Protrude tongue6. Stand behind: palpate each lobe separately; does it move on
swallowing?7. Palpate for local lymph nodes8. ?Tracheal deviation9. Percuss sternum ?Retrosternal thyroid10. Listen for bruit (Grave’s disease)11. Ask patient to stand – proximal myopathy
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Focused history• Symptoms of hyper/hypo – thyroidism:
– Weight, Appetite, Sweating, Tremor, Palpitations, Menstrual irregularities, Irritability, Diarrhoea
• Have they noticed a lump– Change in size over time?
• Change in voice? • Any pressure symptoms?
– Dyspnoea, Dysphagia
• Diet (deficient in Iodine)• Any history of radiation exposure?• Family history
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INVESTIGATIONS• Biochemistry:
– Thyroid status: T3, T4 and TSH– FBC, U+Es, Ca2+, LFTs and ESR
• Radiology:– CXR– Ultrasound (solid, cystic masses)– CT scan
• Special:– Fine needle aspirate (not reliable for follicular
adenoma/carcinoma)– Tru-cut biopsy– Radioisotope scan (Tc99)– Laryngoscopy (?paralysis of vocal chords pre-operatively)
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Management of Thyrotoxicosis• MEDICAL
– Pharmacological:– Carbimazole; Propylthiouracil; Propanolol
– Radioiodine (nb: teratogenic)– >50yrs old, recurrent episodes or post surgery
• SURGERY– Once medical therapy failed or pressure symptoms– Sub-total thyroidectomy (after antithyroid drugs)
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Dermoid cysts
1. Inclusion dermoids:– At site of embryological fusion: midline neck,
angle of orbit– Firm, not attached to skin – Rx = excise
2. Implantation dermoids:– Subcutaneous swellings after penetrating injury– Epidermal tissue introduced beneath skin
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Complications
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HOW WOULD YOU TREAT?
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WHAT WOULD YOU DO???
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WHAT WOULD YOU DO????
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WHAT WOULD YOU DO???
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Summary
• Covered common presentations for Finals• Examination methods• Presenting your findings• Typical XRs in shorts• Google pathology• Questions?