SURGICAL DISEASES DIAGNOSIS
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Transcript of SURGICAL DISEASES DIAGNOSIS
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HYSTORY CLINICAL EXAMINATION
LAB.TESTSIMAGISTIC
INVESTIGATIONS
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Symptom- what the patient feelsPhysical sign- what the doctor finds at
clinical examination of the patient’s segments.
Symptom is subjectivePhysical sign is objectiveClinical diagnosis = symptoms + signsFinal diagnosis= symptoms + signs +
lab.tests + investigations.
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SURFACE LANDMARKS OF THE HEADNasionExternal occipital protuberanceVertexSuperior nuchal lineMastoid process of the temporal boneZygomatic archSuperficial temporal arteryFacial arteryParotid duct
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Surface landmarks
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Sebaceous cysts
Swelling - cystic mass - cystic tumor - lumpHairy parts of the body- scalpThe mouth of the seb. gland opens into the
hair follicleIf blocked mouth, seb. gland becomes
distended
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Seb. Cyst
History- slow growingSymptoms-a lump that gets scratched when
the patient is combing the hairSuch scratches may get infectedIf the cyst becomes infected it enlarges
rapidly and becomes acutely painful
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Seb. Cyst- examination-physical signs
Position-hairy parts of the bodyColor- the skin overlying the cyst normal unless it
is infectedTenderness- not tender unless infectedTemperature-normal except when infectedShape- sphericalSize- variable: mm-4-5 cm.Surface- smoothEdge-well definedComposition- hard depending on the pressure in
the cust “cheesy material”
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Seb. cyst of the scalpParietal region
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Seb. cyst- lateral view
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Seb. cyst of the scalp
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Seb. cyst of the scalp
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Surgical treatment- excision
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Intact sebaceous cyst-specimen
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Cut section- seb.cyst- “cheesy material”-sebum
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Lipoma-case report
A 59-year-old woman was admitted with a 10 years' history of a painless swelling at the right thigh. The lesion became ulcerative over the past few months with mild pain.
She had no significant medical and surgical history.
Examination revealed normal vital signs, chest, heart, abdominal and rectal examinations.
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LipomaOn local examination, a large mass
occupying the posterior aspect of the lower two thirds of the right thigh was confirmed.
There was an ulcerative lesion at the posteromedial aspect of the mass.
The right popliteal artery was difficult to palpate, but the posterior tibial and dorsalis pedis were normal.
There was no neuronal abnormality.
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Lipoma- case reportBlood tests showed normal blood count, liver
function, urea and electrolytes as well as ESR. She had a normal chest and abdominal X-ray. The X-ray of the right thigh showed a soft
tissue shadow and normal bone.
Surgical excision was performed and the findings were consistent with a giant lipoma.
The wound was closed easily as there was redundant skin because of the size of the mass.
The weight of the specimen was 3.2kg.
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Lipoma- case report
The patient had an uneventful recovery and was discharged home with a very good condition.
Histology of the specimen reported benign lipoma.
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Huge lipoma of the thigh
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Ulcerated lipoma on the post-medial thigh
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Specimen- 3.2 Kg.
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LipomaLipoma - a benign
tumor of adipocyte origin. •The bright yellow color is typical of fat. •Note the lobulated appearance - typical of this lesion. •This particular tumor arose in the subcutaneous fat (note the small strip of skin ).
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Case Report-lipoma
A 60 year old male presented in out patient clinic with history of progressively increasing swelling in right thigh, which he noticed 3½ years back. Swelling was otherwise asymptomatic except that he had to wear loose fitting trousers.
On examination, right thigh girth was grossly increased as compared to the left thigh.
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Lipoma
There were erythema ab agni over the medial aspect of both thighs (as is usual in Kashmiri people because of Kangri – “the fire pot”).
The swelling was firm, non-tender and free from underlying structures.
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Lipoma
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CT scan of the right thigh was done which revealed a hypodense mass in the posterior compartment of the thigh beneath the hamstring muscles
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Lipoma- case reportFNAC of the swelling revealed mature fat cells,
suggestive of lipoma.
The patient was operated on under general anaesthesia, in prone position and the tumour was found beneath the hamstring muscles and was dissected out easily because of the capsule.
Wound was closed in layers, leaving a suction drain inside the cavity. Healing progressed uneventfully.
Histopathological examination revealed features consistent with lipoma.
The tumour removed measured 21x17x14cm in size and weighed 2,95 Kg.
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Specimen.Six months after surgery, the patient is symptom free and has no signs of recurrence
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LipomaLipoma is one of the commonest benign
mesenchymal tumour in the body composed of mature adipose cells.
It is found in almost all the organs of the body where normally fat exists.
Most of the lipomas present as small subcutaneous swellings without any specific symptom.
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LipomaGiant lipomas, though rare, can present in
thigh, shoulder or trunk. Clinical features of these giant lipomas are
mainly because of their size which includes pain because of stretching of adjacent nerves,(restriction in movements of the part involved or social embarrassment because of mere size of the swelling).
Definitive diagnosis of giant lipoma can be made only by histopathological examination.
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LipomaSurgery is the treatment of choice
The dissection of these lipomas is usually easy because of a well defined capsule.
Dead space created because of dissection of the giant lipomas is usually drained with the help of a suction drain to avoid collection.
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LIPOMA
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Surgical specimen
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Hemangioma Benign skin lesion consisting of dense, usually
elevated masses of dilated blood vessel. Benign neoplasm characterized by blood
vascular channels. A cavernous hemangioma consists of large
vascular spaces. A capillary hemangioma consists of many small
blood vessels. A collection of dilated small vessels, 3 types: strawberry nevus, port-wine stains, spider nevus
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Cavernous hemangioma
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HemangiomaCongenital benign tumour made of blood vessels in the skin. Capillary hemangioma , an abnormal mass of capillaries on
the head, neck, or face, is pink to dark bluish-red and even with the skin.
Size and shape vary. It becomes less noticeable or disappears with age.
Hemangioma simplex/strawberry mark, a reddish nub of dilated small blood vessels, enlarges in the first six months and may become ulcerated but usually recedes after the first year.
Cavernous hemangioma, a rare, red-blue, raised mass of larger blood vessels, can occur in skin or in mucous membranes, the brain, or the viscera.
Hemangiomas can often be removed by cosmetic surgery.
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Strawberry hemangiomaIntradermal, subdermal collection of dilated
blood vesselsCongenital lesion- present at birthLooks like a strawberryOften regress spontaneously in months/years
after birthRubbed or knocked they may ulcerate and
bleed
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Strawberry hemangioma
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Physical examinationPosition- any part of the body- head/neck>Color- bright or dark redShape- protrude from the skin surfaceSize- usually- 1-2 cm.Surface-irregularConsistence- soft, compressible not pulsatileRelations- confined to the skin, freely mobile
over the deep tissues
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Port-wine stain-extensive intradermal hemangioma, mostly venous
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PORT-WINE STAIN
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Cavernous hemangioma on the tongue
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Meningocele
Meningocele (MM):Protrusion of the membranes that cover the spine and part of the spinal cord through a bone
defect in the vertebral column. MM is due to failure of closure during embryonic life of
bottom end of the neural tube.The term spina bifida refers specifically to the bony defect
in the vertebral column through which the meningeal membrane and cord may protrude (spina bifida cystica) or may not protrude so that the defect remains hidden, covered by skin (spina bifida occulta).
The risk of MM (and all neural tube defects) can be decreased by the mother eating ample folic acid during pregnancy.
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A birth defect involving an abnormal opening in the spinal bones (vertebrae) is called spina bifida.The spinal vertebrae have not formed and joined normally, leaving an opening
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A defect which also includes a small, moist sac (cyst) protruding through the spinal defect, containing a portion of the spinal cord membrane (meninges), spinal fluid, and a portion of spinal cord and nerves is called a meningocele, myelomeningocele, or meningomyelocele
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Surgical treatment is needed to repair the defect and is usually done within 12 to 24 hours after birth to prevent infection, swelling, and further damage.Under general anesthesia, an incision is made in the sac and some of the excess fluid is drained off. The spinal cord is covered with the membranes (meninges) and the skin is closed over the protruding meninges, spinal cord, and nerves.
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The long-term result depends on the condition of the spinal cord and nerves. Outcomes range from normal development to paralysis (paraplegia).Infants may require about 2 weeks in the hospital after surgery.
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Physical signs in head injuryExamination of a case of recent head injuryThe patient is unconscious
Examine the scalp for a wound or local bruising or hematoma
Examine the nostrils and ears for evidence of blood diluted with CSF
Compare the size of the pupils and test their reaction to light
Make a general survey of the body for other injuriesSearch for paralysisPalpate and percuss the hypogastrium for evidence
of an overfull bladderTemperature, pulse rate, RR-charted every half-hour
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Head injuryRadiographs of the skull should be taken at
the first opportunity compatible with safety
Brain injury is more likely in the presence of a skull fracture BUT skull fracture of itself does not indicate brain injury
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COMA
Coma is a state of absolute unconsciousness in which the patient does not respond to any stimulus
Reflexes are absent, including the corneal and swallowing reflexes.
Semi-coma- the patient responds only to painful stimuli and reflexes are present
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Head injuryThe patient is conscious or semi-consciousPatient with skull fracture – hospital admissionClose observation: PR, BP, RR, pupil size and
reaction/ every ½ h.Signs of neurological deterioration:
Falling pulse rateReduced respiratory rateFalling GCSDilatation of pupilsLoss of light reaction or developing asymmetry
of pupils
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Complications of traumatic brain injuryCranial bleedingCerebral hypoxiaInfectionPosttraumatic intracranial bleeding may be:
- extradural - subdural - intracerebralCT of the brain documents the lesionsLocal brain compression- focal neurological effects
- raised intracranial pressure
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Types of skull fracturesLiniar fractures - involve the skull vault,
- overlying scalp bruising or swelling
Depressed fractures - caused by blunt injuries,
- the scalp is severely bruised
Fractures of the base of the skull- anterior fossa
- middle fossa
- posterior fossa
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Basilar skull fractures
a fracture of the base of the skull - the temporal, occipital, sphenoid and ethmoid bones.
Such fractures can cause tears in the cerebral meninges - leakage of the cerebrospinal (CSF), hematoma formation and meningitis
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Physical signs - pathognomonic for basilar skull fracture.
1. Otorrhea – leakage of CSF from the auditory canal2. Leakage of CSF into the nasopharynx via the eustachian
tube, causing a salty taste. 3. Rhinorrhea – leakage of CSF from the nasal passages4. Hematoma presentation surrounding the orbits and ears as
blood is flushed to the surface of the facial tissues.
5. Bleeding from the nose and ears 6. Deafness, nistagmus, vomitus
7. Battle’s sign is bruising over the mastoid sinus and is a delayed physical finding associated with basilar skull fractures.
8. Hemotympanum (blood behind the ear drum) 9. Periorbital bruising “raccoon eyes”
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Fracture of the anterior cranial fossa
Periorbital hematomaSubconjunctival hemorrhageCSF or blood running from the nose
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Fracture of the middle cranial fossa
CSF running from the ear or blood escaping from the ear
Bruising behind the ear over the mastoid area
Risk of facial paralysis or deafness
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Fracture of the posterior cranial fossa
Deep comaBruising on the posterior wall of the pharynx
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Raccoon eyes are always bilateral in closed-head trauma and appear in 2-3 daysBlack eyes associated with facial trauma can affect one or both eyes and appear within hours from injury
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Raccoon: medium-sized mammal native to North America
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Battle signPatients are prone to meningitis due to CSF leakage and meningeal trauma increasing the microbial portal of entry and menigeal integrity.
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Basilar skull fractureBasilar skull fractures, breaks in bones at
the base of the skull, require more force to cause than cranial vault fractures.
Thus they are rare, occurring as the only fracture in only 4% of severe head injury patients.
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SKULL VAULT FRACTURESLinear skull fractures, the most common type
of skull fracture, occur in 69% of patients with severe head injury. Usually caused by widely distributed forces.
In rare cases, a linear fracture can develop and lengthen as the brain swells, in what is called a growing fracture.
Diastatic fractures are linear fractures that cause the bones of the skull to separate at the skull sutures in young children whose skull bones have not yet fused. They are usually caused by impact with a wide area such as a wall.
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SKULL FRACTURESComminuted skull fractures, those in which a
bone is shattered into many pieces, can result in bits of bone being driven into the brain, lacerating it.
Depressed skull fractures, a very serious type of trauma are comminuted fractures in which broken bones are displaced inward.
This type of fracture carries a high risk of increasing pressure on the brain, crushing the delicate tissue. Complex depressed fractures are those in which the dura mater is torn. Depressed skull fractures may require surgery to lift the bones off the brain if they are causing pressure on it.
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Depressed skull fracture
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Liniar skull fractures
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Liniar skull fracture
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Epidural hematoma
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Subdural hematoma
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Intracerebral hematoma
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TRAUMA
1. Prehospital care
2. Primary survey
3. Resuscitation
4. Secondary survey
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PREHOSPITAL CARE
Prehospital providers- tasks:
Assessment of the injury scene
Stabilization of the injured patient
Monitoring and transport of critically ill patient
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Efficient method for reporting by the prehospital providers to the trauma team on arrival in A&E Unit:
M I V TM= mechanism of injuryI= injuryV= vital signsT= therapy
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VITAL SIGNS
LEVEL OF CONSCIOUSNESS- GLASGOW’S COMA SCORE
STABLE / UNSTABLE HEMODINAMICALLYRESPIRATION- spontaneous or ventilated
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GCSLess than or equal to 8 at 6 h.- 50% dieSevere head injury 3 – 8Moderate head injury 8-13Mild head injury 14-15False- hypothermia, intoxication, sedationImpossible to evaluate- dysphasic, intubated
pts. and with facial or spinal cord injury
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INITIAL EVALUATION AND PRIMARY SURVEY
HISTORY: A M P L E
PRIMARY SURVEY: A B C D E
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HEAD
LACERATIONSSTEP-OFFSGCSPUPILSCT
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NECK
HARD NECK COLLARSPINE X RAYLOCAL TENDERNESSHEMATOMASSUBCUTANEOUS EMPHYSEMA