Presented by Medicawy

NEW EDITION

5 th YEAR

General Surgical www.medicawy.com

28

Presented by Medicawy .© " ONE VISION ONE MISSION "

Scheme1. Swellings

Differential Diagnosis of swelling case If the Pt. told you that it was after trauma Haemangioma.

If the swelling has an expansile pulse Aneurysm.

If the swelling has a transmitted pulse Swelling over an artery.

The swelling is reducible & shows expansile impulse on cough Hernia or Saphena varix.

The swelling moves up and down with deglutition Thyroid enlargement or thyroglossal cyst.

The swelling moves with protrusion of the tongue Thyroglossal cyst.

The swelling increase in size in very short period A tumor.

Not one of these so by exclusion Lipoma or Sebaceous cyst.

How to diagnose a swelling?a.Anatomically: organ involved.

b.Etio-pathological diagnosis:Traumatic, Inflammatory (F.H.M.A), Neoplastic.

c. Functional diagnosis "compensated or not".

Examplesi. "Examine the Back".

State True or False:

1. The swelling has slippery edges.2. The swelling is sub muscular.3. The most common complication is malignant

transformation.

What is your diagnosis?

28


Subcutaneous lipoma of the back.

2. Hernia

A Swelling shows

- Expansile impulse on cough.- Reducible, and …..

Near linea alba, so the hernia may be

Umbilical "it is rounded; usually there is absence of the shape of umbilicus".

Para umbilical "it is cresenteric, usually presence shape of the umbilicus"

Other with no incision Epigasteric.

Any where at a site of an incision, the hernia may be

Incisional "A scar of previous operation other than hernia".

Recurrent hernia "A scar of previous hernia operation".

At the inguinal region & above the inguinal ligament, hernia may be

Direct "At Hassel Bach's triangle, Reduced backwards & don't descend to scrotum".

Indirect "Hernia reduced upwards, backwards and laterally & may descend to scrotum".

Saphena varix:

Site: at femoral triangle. With Trendlenberg test incompetent sapheno-

femoral junction.

Examples

28


i. "Examine both Groins". State True or False:

1. The swelling doesn't reach the scrotum.2. This is a direct hernia.3. Internal ring test is negative.


Right indirect inguinal hernia in a male patient, non complicated, enterocele, fit for surgery.

ii. "Examine both Groins". Rt. Indirect inguinal hernia .


1. The patient has oblique inguinal hernia.2. The patient has left femoral hernia. 3. The hernia is irreducible.4. This is a case of recurrent hernia.

iii. "Examine both Groins". Rt. indirect inguinal hernia .


1. There is a scar in left groin.2. It shows malgaigne bulging.3. It is downward & lateral to pubic tubercle.4. It is strangulated.5. There is sliding bladder.

iv. "Examine Right Groins".

28


Rt. indirect inguinal hernia .


1. This is oblique uncomplicated hernia.2. It is partially irreducible.3. It shows transmitted impulse.4. The patient is kept in the hospital for herniotomy.5. Internal ring test is positive.

v. "Examine the Abdomen". State True or False:

1. The abdomen is distended.2. The swelling is not completely reducible.3. The most urgent complication is strangulation.


Supraumblical hernia, non complicated, in a female patient.

vi. "Examine the Abdomen". State True or False:

1. The hernia is reducible.2. The hernia is obstructed.3. There is Gurgling sensation on palpation.


Epigastric hernia in a male patient, non complicated, omentocele .

vii. "Examine the Abdomen". Incisional & Para umbilical hernia.


1. There is only Para umbilical hernia.2. Mid line previous incision.3. It is tender.4. It shows an expansile impulse on cough.5. Appears more on contraction of abdominal

muscles.

28


viii. "Examine the Abdomen". Para umbilical, Incisional hernias & 2 scars "one above the umbilicus & the

other at inguinal region". State True or False:

1. There is Para umbilical hernia.2. There is incisional hernia.3. More than one scar.4. Both hernias are reducible.5. Malgaigne bulge is seen.

ix. "Examine the Abdomen". Umbilical hernia.


1. It is a paraumblical hernia. 2. There are signs of inflammation.3. There is an ulcer.4. The swelling shows impulse on cough. 5. There is a scar of previous operation.

x. "Examine the Abdomen". Umbilical hernia.


1. The mass has an expansile impulse in cough.2. Occupation is important to be asked in this case.3. It is not complicated.4. Abdominal & pelvic sonar is important.5. Strangulation could occur due to twisting of 2 loops

of intestine.

28


3. Thyroid

إيه احتماالت الـ Neck lumps اللي ممكن نالقيها في الـ Neck

Enlarged lymph node, thyroid enlargement, thyroglossal cyst, and tumour.

حاالت االمتحان في الـ Thyroid غالبا واحدة من اآلتي

Simple goitre, solitary nodule, 1ry thyrotoxicosis or 2ry thyrotoxicosis autonomous toxic nodule.

What are the suggestive of malignant goitre??

1. Recent rapid increase in size.2. Hard consistency.3. Fixation to the surroundings.4. Local pain referred to the ear.5. Fixed hard cervical lymph nodes.6. Signs of distant metastasis.

Examplesi. "Examine the Neck".


1. The Pulse is less than 80/min.2. The patient has +ve stellwag sign.3. The patient has no fine tremors on extremities.


Primary toxic goiter.

ii. "Examine the Neck".

28



1. The patient pulse is more than 100/min.2. The swelling moves up and down with deglutition

and with protrusion of the tongue.3. The swelling has nodular surface.


Simple nodular goiter.

iii. "Examine the Neck". 1ry toxic goiter.


1. There is pretibial myxedema.2. +ve Vongrafe sign.3. Moves up & down with deglutition and with

protrusion of tongue.

iv. "Examine the Neck". Simple nodular goiter.


1. It is in posterior triangle.2. Superficial to sternomastoid.3. There is a retrosternal extension.

v. "Examine the thyroid". There may be a Stethoscope near the patient, so take care.


1. There is thrill over upper pole.2. The swelling is pulsating.3. The skin shows a scar.4. The right lobe is enlarged.5. There is a retrosternal extension.

28


vi. "Examine the Neck". 2ry toxic goiter.


1. The trachea is central.2. There are nodules in both lobes.3. There are visible pulsations over the superior pole

of thyroid.4. There is audible bruit over the thyroid.

vii. "Examine the Neck". 1ry toxic goiter.


1. There is thrill on upper pole.2. The Berry's sign is +ve.3. The pemperton sign is -ve.4. There is a dull sternum.5. The swelling moves up & down with deglutition.

viii. "Examine the Thyroid". State True or False:

1. This is a case of secondary toxic goiter.2. The gland is nodular asymmetrical.3. There is retrosternal dullness.4. The best line for treatment of this case is surgery.5. The gland moves upwards with deglutition and

protrusion of the tongue.

ix. "Examine the Thyroid". State True or False:

1. There is thyroid enlargement.2. There is scar of previous operation.3. The swelling is completely covered with

sternomastoid.

28


4. RT supraclavicular LN is enlarged.5. The swelling moves with protrusion of tongue.

x. "Examine the Thyroid". Simple nodular goiter.


1. The swelling moves with deglutition. 2. The swelling is hard.3. The swelling moves with protrusion of tongue.4. The swelling is bilateral.5. The swelling is attached to skin.

xi. "Examine the Neck". 2ry thyrotoxicosis.


1. It is a case of 1rythyrotoxicosis.2. The patient has a fine tremor.3. The pulse > 100.4. The only line of ttt is surgical.

28


4. Ulcers

a. Vascular venous ulcer, ischemic ulcer, lymphoma ulcer.

b. Traumatic direct trauma or bed sore.

c. Infection chronic osteomylitis, T.B & syphilis.

d. Neoplastic: Primary skin ulcer "epithelioma, melanoma, basal

cell carcinoma". Marjolin's ulcer "epithelioma on top of ulcer, burn". Ulcerative deep malignancy "bone tumours".

e. Others: neuropathy & rheumatoid ulcer.

Venous Ask about history of DVT. Ischemia Ask about history of Claudication pain, Color

change & Atrophic tissue. Neuropathy

ممكن يكون عنده سكر وممكن أل

نسأله كان عنده قبل كده تنميل، شكشكة؟؟بنسأله إحساسه باألرض ناشفة وال أل؟؟إحساسه بالميه سخنة أو باردة من رجله زي إحساسه من إيده زي

إحساسه من وشه؟؟

Malignant بعرفها من الـcourse .إنها كبرت بسرعة في وقت قصير جدا

Others From the shape of the edge.

The most common is venous ulcer.

غالبا اللي هيجي لك في االمتحان هيبقى

28


Complication of thrombophlebitic limb or complication of 2ry varicose veins.

Examplesi. "Examine the Face".


1. The condition is related to sun exposure.2. The safety margin of excision is more than 5 mm.3. Distant metastasis is the most common

complication.


Basal cell carcinoma of the nose "Rodent Ulcer".

ii. "Examine the Face". Squamous cell carcinoma at angle of mouth.


1. Safety margin is less than 5mm.2. It is related to nicotine.

SOME OTHER CASES

i. "Examine Both Lower Limbs". State True or False:

1. The patient has +ve Fagan test.2. The condition is unilateral.3. There is Saphenofemoral incompetence.


Bilateral 1ry varicose veins non complicated.

ii. "Examine Both Lower Limbs". State True or False:

1. There is competent Saphenofemoral junction. 2. There is no thrill on Saphenous opening.

28


3. The condition is bilateral. What is your diagnosis?

2ry varicose veins in left limb & complicated.

iii. "Examine Left Leg". 1ry unilateral varicose veins.


1. There is Saphenofemoral incompetence.2. There is affection of the short Saphenous vein.3. There is venous ulcer.4. There is no pigmentation.

iv. "Examine Both Lower Limbs". State True or False:

1. Dorsalis pedis pulse is present.2. 2ry to incompetent right Saphenofemoral junction.3. Right leg is longer than left.4. There is atrophy blanche.v. "Examine Both Lower Limbs".


1. Short saphenous vein is palpable.2. Venous refill takes longer than 10 min.3. There is evidence of lipodermatosclerosis. 4. There is evidence of haemosiderosis.

vi. "Examine Both Lower Limbs". Old obese female.


1. This is a case of secondary varicose.2. Varicosities appear along the course of short

saphenous.3. Veins are pulsating.4. There is incompetent Saphenofemoral junction.

28


5. Modified Perth's test is positive for this case.

vii. "Examine Both Lower Limbs". Unilateral 2ry varicose veins.


1. The prominent system affected is short saphenous.2. The long saphenous is pulsating.3. There is apparent sahena varix.4. There is pigmentation.5. This is a case of 2ry varicose veins.

viii. "Examine Both Lower Limbs". 2ry varicose veins.


1. A case of 1ry varicose veins.2. There is an incompetent perforator.3. The ulcer is healed.4. It is not complicated.5. The treatment is surgical.6. Venograhy is the best investigation to be done.

ix. "Examine Both Lower Limbs". 1ry varicose veins in right side.


1.The dilated veins are bilateral.2.There is an ulcer in the right side.3.There is a scar in the right side.4.The shape of dilatations is saccular. 5.There are dilatations in sapheno femoral junction.

x. "Examine the Neck". Lymphadenopathy following sore throat.


1.This is anatomical site for lymph node.

Endأسئلة امتحانات الـ Roundلبعض الوحدات

28


2.It is related to throat condition.3.Submental LN is palpable.4.It is soft in consistency.5.Pagets test is +ve.

OSCE Exam Questions

o

Case 1 "Examine the Right Elbow". Cystic Swelling in the elbow.


1.The skin is abnormal.

2.The swelling is deep to the muscle.

3.The swelling is solid.

4.The skin over the swelling showed dimpling on movement.

5.Paget test is a fluctuation test for large swelling.

o Case 2 "Examine Both Groins". Hernia (indirect) "patient above 40 years".


1.This is oblique uncomplicated hernia.

2.It is partially irreducible.

3.It shows transmitted impulse.

4.The patient is kept in the hospital for herniotomy.

These are a group of questions from the previous end round exams.In the OSCE exam you are asked to examine a Case, and then you answer on those questions & just to state if these

وحدة دكتور " عليمفتاح "

28


5. Internal ring test is positive.

o Case 3 "Examine the Neck". 2ry toxic goiter "Female 33 years".


1. This is a case of secondary toxic goiter.2. The gland is nodular asymmetrical.3. There is retrosternal dullness.4. The best line for treatment of this case is surgery.5. The gland moves upwards with deglutition and

protrusion of the tongue.

o Case 4 "Examine Left Leg". 1ry varicose veins "Old obese female".


1. This is a case of secondary varicose.2. Varicosities appear along the course of short

saphenous.3. Veins are pulsating.4. There is incompetent Saphenofemoral junction.5. Modified Perth's test is positive for this case.

o Case 5 "Examine the Abdomen". Para umbilical, Incisional hernias & 2 scars " one above the

umbilicus & the other at inguinal region". State True or False:

1. There is paraumbilical hernia.2. There is incisional hernia.3. More than one scar.4. Both hernias are reducible.5. Malgaigne bulge is seen.

28


o Case 6 "Examine the Neck". Simple nodular goiter.


1. There is thyroid enlargement.2. There is scar of previous operation.3. The swelling is completely covered with

sternomastoid.4. Rt. supraclavicular LN is enlarged.5. The swelling moves with protrusion of tongue.

o Case 7 "Examine Both Legs". Unilateral 2ry Varicose Veins.


1. The prominent system affected is short saphenous.2. The long saphenous is pulsating.3. There is apparent sahena varix.4. There is pigmentation.5. This is a case of 2ry varicose veins.

o Case 8 "Examine the Scapula". Sebaceous cyst.


1. The swelling is tender.2. The swelling is pulsating.3. The swelling is attached to skin.4. It has a well defined edge.5. The draining LN is enlarged.

28


o Case 1 "Examine the Neck & Face". Dermoid cyst.


1.The swelling is cystic.

2.The swelling has slippery edges.

3.The swelling is attached to skin.

4.There is a scar.

5.It is a sebaceous cyst.

o Case 2 "Examine Both Legs". Primary varicose vein in right side.


1.The dilated veins are bilateral.

2.There is an ulcer in the right side.

3.There is a scar in the right side.

4.The shape of dilatations is saccular.

5.There are dilatations in Saphenofemoral junction.

o Case 3 "Examine the Abdomen". Umbilical hernia.


1.It is a paraumbilical hernia.

2.There are signs of inflammation.

3.There is an ulcer.

4.The swelling shows impulse on cough.

5.There is a scar of previous operation.

وحدة دكتور " رأفتجوهر "

28


o Case 4 "Examine the Neck". Simple nodular goiter.


1.The swelling moves with deglutition.

2.The swelling is hard.

3.The swelling moves with protrusion of tongue.

4.The swelling is bilateral.

5.The swelling is attached to skin.

o Case 1 "Examine the Neck". 2ry thyrotoxicosis.

State Yes or No:

1. Is the swelling hard?2. Is the swelling attached to the skin?3. Is the ttt conservative?4. FNAC is an essential of diagnosis?5. Is the swelling present in the digastric triangle?6. Is the swelling nodular?7. Cancer in this case is more common in males than

females?8. Does the swelling move up &down with protrusion

of the tongue?9. Does the swelling arise embriologically from the

tongue?

o Case 2 "Examine the Back". Lipoma at the left side of the back.

State Yes or No:

1. Is the swelling compressible?2. Are the edges well defined?3. The main line of ttt is excision?

وحدة دكتور " أحمدالشرقاوي "

28


4. This swelling usually turns malignant?5. Does this swelling have impulse on cough

o Case 3 "Examine Both Groins". Right inguino-scrotal hernia.


1. This hernia may contain urinary bladder?2. This hernia may contain intestine?3. This hernia may be obstructed?4. The main line of ttt is essentially surgical?5. The hernia is more common in elderly?6. The hernia is bilateral in 60% of cases?7. Does the hernia have impulse on cough?8. Is this hernia reducible?

o Case 4 "Examine Both Groins". Left inguinal hernia "indirect".


1. This hernia has +ve cross fluctuation?2. This hernia may contain sigmoid colon?3. This hernia protruded through the superficial

inguinal ring?4. This hernia is common in elderly?5. This hernia is bilateral in 60% of cases?6. This hernia has expansile pulsations?7. This hernia occurred due to direct trauma?8. The direction of this hernia is forwards?

o Case 1 "Examine the Abdomen". Incisional hernia.


وحدة دكتور " أشرفهدايت "

28


1. The mass is seen on cough and standing and disappear on lying down.

2. Treatment is herniotomy only.3. It is not complicated now.4. Complications don't occur in this type of hernia.

o Case 2 "Examine the Neck". 2ry thyrotoxicosis.


1. It is a case of 1ry thyrotoxicosis.2. The patient has a fine tremor.3. The pulse > 100.4. The only line of ttt is surgical.

o Case 3 "Examine the Abdomen". Umbilical hernia.


1. The mass has an expansile impulse in cough.2. Occupation is important to be asked in this case.3. It is not complicated.4. Abdominal & pelvic sonar is important.5. Strangulation could occur due to twisting of 2 loops

of intestine

o Case 4 "Examine Both Legs". 2ry Varicose veins.


1. A case of 1ry varicose veins.2. There is an incompetent perforator.3. The ulcer is healed.4. It is not complicated.5. ttt is surgical.6. Venograhy is the best investigation to be done.

28


o Case 5 "Examine Both Groins". Inguinal hernia.


1. This case may be complicated.2. There is a scar for an operation.3. Hernia is partially reducible.

o Case 6 "Examine the Neck". Thyroid Case.


1. There is a thrill.2. The gland superficial to sternomastoid muscle.3. Carotid pulse can be felt.4. Surface is irregular.

o Case 1 "Examine the Swelling". Lipoma.


1. The swelling has slippery edges.2. It is pseudo fluctuant.3. It is translucent.4. It is partially attached to the skin.5. Its consistency is soft.

o Case 2 "Examine the Neck". A thyroid case.


1. Enlargement in the Rt. lobe only.2. There is retrosternal extension.3. Trachea is central.4. Pretracheal lymph node palpable.

وحدة دكتور " هانيحفني "

28


o Case 3 "Examine the Neck". A thyroid case.


1. Carotid pulse on both sides can be felt.5. Left deep cervical LN can be palpable.2. Swelling in the submandibular region.3. There is sinus in the skin.

o Case 4 "Examine the Back". Sebaceous cyst.


1. The swelling has slippery edges.2. It is soft in consistency.3. It is Pseudo fluctuant.4. It is translucent.5. It is partially attached to the skin.o Case 5 "Examine Both Groins".

Hernia Case.


1. It is idiopathic hydrocele.2. Inguinal LN are impalpable.3. There is left oblique inguinal hernia.

o Case 6 "Examine Both Legs". An ulcer in the leg.


1. The base is indurated.2. Unhealthy granulation tissue present.3. There is everted edge at one side.4. There are varicose veins.o Case 7 "Examine Both Groins".

Hernia case.


28


1. There is Rt. direct inguinal hernia.2. There is infantile hydrocele.3. There is enlarged epididymis.4. There is enlarged spermatic cord.5. There is loss of Rt. testicular sensation.

o Case 8 "Examine the Neck". A case of lymphadenopathy.


1. Swelling seen in the left side of neck.2. The swelling is in the carotid triangle.3. There is intra oral ulcer.4. Supraclavicular LN is palpable.

o Case 1 "Examine the Abdomen". Incisional & paraumbilical hernias.


1. Patient has 2 scars.2. Incisional hernia over Cesarean section produced.3. Both hernias are reducible.4. Patient has paraumbilical hernia.5. It shows malgaigne sign.

o Case 2 "Examine the Neck". Thyroid case " No thyrotoxicosis or malignant symptoms".


1. The thyroid gland is enlarged.

وحدة دكتور " وائلالغفير "

28


2. Rt. supraclavicular LN is enlarged.3. There is previous scar in the neck.4. The swelling is covered by sternomastoid muscle.5. It moves up & down with protrusion of tongue.

o Case 3 "Examine Left Leg". Varicose veins case.


1. The prominent system affected is short saphenous.2. Saphena varix is present.3. The varicosity is secondary.4. There is pigmentation around medial malleoulus.5. The affected veins pulsate.

o Case 4 "Examine the Swelling". A swelling in the Rt. Lid.


1. The swelling is attaching to the skin.2. There is enlarged LN.3. It has a well defined edge.

o Case 1 "Examine Both Groins". oblique inguinal scrotal hernia


1.There is an expansible impulse on cough 4 cm below and lateral to the pubic tubercle.

2.The swelling reaches the bottom of the scrotum.

3.The swelling lies below the groin crease lateral to the inferior epigastric vessels.

امتحان الراوند األول لبعض الوحدات لهذا العام2009/2010

وحدة دكتور اشرفهدايت

28


4.After reduction pressure on the internal ring doesn't prevent the appearance of the swelling.

5.There are local signs of strangulation

o Case 2 "Examine Both Legs". ulcer in the left leg


1. There are 2ulcer

2. Margin show pigmentation

3. Edge is raised and everted

4. Floor show dried out tissue

5. There is ascar of previos operation

o Case 3 "Examine the Abdomen". epigastric hernia


1. There is expansible impulse on cough

2. Defect is in the semi lunar line

3. There is erythema in the overlying skin

4. Scar healing by primary intention is present

5.There are local signs of strangulation

o Case 4 "Examine the Neck". thyroid on the left side


1. Enlargement in the left lobe

2. Berry sign is positive

3. Attached to sternomastoid muscle

4.There is retrosternal extension

وحدة الدكتور هاني وحدة دكتور " حفني

28


o Case1"Examine the neck " Simple nodular goiter


1. Patient present with hard swelling in thyroid gland

2. No retrosternal extension of neck swelling

3. Palpable pretracheal lymph nodes

4. No palpable right cervical lymph node

5. Carotid pulses are palpable on both sides

o Case 2 "Examine the Swelling". Paraumbilical hernia


1. Swelling is tender

2. It is reducible

3. It has well defined edge

4. One of its complication is obstruction

5. Mesh hernioplasty is the main surgical ttt

o Case 3 "Examine Both Legs". venouse ulcer


1. Visible varicose veins are noted

2. It is ischemic ulcer

3. It has sloping edge

4. No palpable inguinal lymph node

5. Healthy granulation is covering floor

o Case 4 "Examine the Swelling". sebaceous cyst


1. It is benign lesion

2. It is cystic

3. It has well defined edge

28


4. Treatment is essential medical

5. It has a frequent malignant potentially

o Case 1 " Inspect the abdomin & the scrotum".

Left inguino-scrotal hernia


1. There is right scrotal swelling2. The swelling is tender 3. There is a scar below the umbilicus4. There is small paraumbilical hernia 5. There are dilated veins around the umbilicus

o Case 2 "Palpate the Left axilla ". Lipoma in the left axilla


1. The swelling is hard2. The swelling is severly painful3. It is attached to the muscle4. It has well defined edges5. It is attached to the muscle

o Case 3 " Inspect the Abdomen". Incisional hernia


1. The swelling extends below the umbilicus2. The swelling shows expansile impulses on cough3. The skin is red denoting inflammation4. There is a scar overlying the swelling5. There is healing with 2ry intention

o Case 3 " Inspect the front of the neck ". Simple nodular goiter right lobe


1. The swelling is more prominent on the left side2. There are large dilated veins

وحدة دكتور " وائلالغفير "

28


3. The swelling moves up & down with deglutition4. The skin is red & hot denoting inflamation5. The swelling is deep to sternomastoid muscle

Other notes produced by Medicawy

Your way for easy surgery

These Notes Contain

- Full detailed lectures of Prof.Dr. Hussein Khairy.- Hints from notes of Dr. Wael Metwaly.- Hints from notes of Dr.Amr El Shayeb. - Our curriculum from Oral book.

Presented by Medicawy

Documents

Transcript of Presented by Medicawy