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RLH MRCS > DrE: Lumps and bumps > Flashcards

DrE: Lumps and bumps Flashcards

1
Q

Lumps and bumps: Inspection

A

1) Ensure adequate exposure of lump and surounding region
6Ss
Site - anatomical location
Size - size of base
Shape - shape of base and protuberant
Symmetry
Skin - erythematous/punctum/ulceration
Scars - prvious op

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2
Q

Lumps and bumps: Palpation

A

Any pain?

Temperature discrepency?

Surface - rough/smooth

Edges - irregular/regular, infiltrative/well defined

Consistency - hard/firm/soft

Tethered - fixed to skin/underlying tissue/muscle (or within muscle)

Fluctuance - Paget’s sign - index & middle finger of one hand at base to stabilise, middle finger of other hand in middle of lump, fluctuant if edges press/spill over tops (x2 planes)

Expansile/pulsatile - index finger of each hand in parrelel on each edge -> movement up and town in vertical plane = pulsatile, horizontal plane = expansile

Transilluminates - shine a light in one side, seen on other side

Reducible - ask patient to reduce it first

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3
Q

Lumps and bumps: Percussion

Lumps and bumps: Auscultation

A

fluid filled -> fluid thrill/ (in chest) stoney dull

Bowel sounds/bruits

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4
Q

Lumps and bumps: Misc/completion

A

Lymphadenopathy - comparing with contralateral side

Neurovascular status - ensure no encroachment on nerves/vessels via a distal NV examination

General examination - e.g. for mets

Cosmtic & QoL - Ask patient re impact

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5
Q

Ulcers examination

A

SITE =

  • Venous = gaiter area = medial maleolus
  • Arterial = between toes, base of 1st and 5th metatarsals, Heel

SIZE

SHAPE

BEDS

  • Base - grannulation tissue/slough/structures e.g. mucle/vessels/bone
  • Edge
    • Sloping: traumatic/venous
    • Punches out: arterial
    • Undermined TB
    • Rolled: BCC
    • Everted: SCC/Marjolin’s
  • Discharge: serous, sanguinous, serosangionous, purulent
  • Surrounding: cellulitis, excoriations, sensate, LNs

Other: LIMB PULSES + SENSATION AROUND ULCER

Completion:

  • Contralateral/further ulcers
  • Neurovascular examination incl pulses
    • ABPI - note must be >0.8 for compression bandaging
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6
Q

Describe

A

This is a Venous ulceration

Site: of gaiter area & medial malleolus of left lower limb

Shape: it is irregular in shape

Site: and around 15 by 3 cm in size

Base: It’s base is shallow and there is evidence of healthy granulation tissue with some slough

Edges: and sloping edges

Discharge: ?seropurulent

Suroundings: Haemosiderin deposition & lipodermatosclersosis (HAS LEGS + varicose veins)

Palpation: painless, warm, sensate

Haemosiderosis / Atrophie blanche / Swelling / Lipodermatosclerosis / Eczema / Gaiter ulcers / Stars, venous

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7
Q

Causes of ulcers

A
  • Venous - 75%
  • Arterial - 2%
  • Mixed arteriovenous - 15%
  • Neuropathic
  • Pressure
  • Vasculitis e.g. Polyarteritis nodosa
  • Malignancy e.g. BCC, SCC, marjolin’s
  • Systemic e.g. pyoderma gangrenosum
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8
Q

What are the differential diagnoses for a lump?

A

Classified by location/structures

  • Cutaneous
    • Benign: actinic keratosis, campbell de morgan spots, dermatofibroma, keratoacanthoma, naevus, seborrhoeic keratosis
    • Malignant:
      • Epidermal: BCC, SCC, Melanoma
      • Dermal: Dermatofibrosarcoma protuberans (DFSP), Malignant fibrosis histiocytoma
  • Subcutaneous: Cyst
  • Fat: Lipoma
  • Artery: aneurysm
  • Vein: Varicosity
  • Nerve: neuroma
  • Lymph node: lymphadenopathy
  • Muscle: tumour
  • Bone: Tumour, malunited fracture, osteoma
  • Anatomical regions e.g.
    • Hand - ganglion
    • RUQ - liver
    • Groin - hernia
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9
Q
A

Actinic keratosis

  • Most common pre-malignant lesion of the skin caused by chronic sun damage
  • Common on face
  • Present as rough white patches stuck onto an erythematous base
  • Histology - thickening of the keratin (hyperkeratosis) & prickle cell (acanthosis) layers of the skin, increased cell mitosis and dysplasis.
  • May be considered as a SCC in situ & c.10-15% progress to SCC
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10
Q

Treatment options of actinic keratosis

A
  • Conservative:
    • sun protection (prevention is best)
  • Medical:
    • Disclofenac sodium gel aka solarase
    • 5-Flurouracil cream
    • Cryotherapy
  • Surgical:
    • Cautery
    • Cryosurgery
    • Laser
    • Surgical excision
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11
Q
A

Campbell de Morgan spots:

  • Cherry haemangiomas formed by proliferation of dilated venules
  • common with increasing age
  • seen as small, bright red papules on skin
  • Treatment:
    • conservative
    • rarely medical: cryotherapy
    • rarely surgical: curettage, shave excision
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12
Q
A

Dermatofibroma

  • benign neoplasm of dermal fibroblasts or histiocytoma
  • common to have history of trauma e.g. insect bite
  • presents as firm papule 5-8mm in size & roughly circular within the dermis
  • DDx melanoma - due to rapid growth/pigmentation
  • ‘Dimple sign’’ - lateral compression -> central dimpling inwards
  • Treatment:
    • Conservative
    • If concern re diagnosis -> excision biopsy
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13
Q

What is a furnuncle & carbuncle?

A

May affect any hair bearing skin e.g. fact, axilla, groin

  • Furnuncle:
    • perifollicular bacterial infection by staph sureus -> pus containing swelling/boil
    • pus accumulates -> enlargement & punctum
    • when punctum bursts furnuncle discharges spontaneously
  • Carbuncle:
    • cluster of furnuncles that merge -> larger lsion
    • often on back of neck in diabetic patient - ALWAYS investigate HbA1c/glucose patients
    • Treatment:
      • conservative
      • occasionally medical: ABx (& treat DM)
      • Large & resistant lesion, surgical: I&D
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14
Q
A

Keratoacanthoma

  • benign overgroth of hair follicules with central keratin plug
  • spontaneously regress -> scar
  • 4-6mo cycle: enlarge in weeks, static for 2-3mo, resolve
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15
Q

Treatment options of keratoacanthoma?

A
  • Conservative:
    • frequent monitoing - possibility of malignancy
  • Surgical
    • Excision biopsy - enables differentiation from SCC
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16
Q

What is a naevus?

A

Benign proliferation of normal constituent cells of skin

17
Q

Examples of Naevi:

A
  • Melanocytic:
    • Congenital - present at bith, protuberunt, hairy/pigmented (light-dark brown), >1cm in diameter. Risk of developing malignancy <5%
    • Junctional: flat, round, oval pigmented (light-dark brown) macules that are often multiple. 2-10mm
    • Intradermal: dome-shaped, flesh coloured papules, face/neck
    • Compound: pigmented nodule - warty/hairy with radiable pigmentation, <1cm
    • Blu: solitary, blue
    • Becker’s: pigmented hairy naeus, back/shoulder
    • Dysplastic: irregular shape & pigmentation, high risk of malignant change
  • Vascular:
    • Port wine stain: irregular red/pueple macule, often 1 side of fact
    • Salmon patch: c.50% neonates, patches on face often disapear, posterior patch (stork marks) often persist
    • stawberry naevus: capillary haemangioma, 1st few weeks of life -> max size @1yr, fleshy, red naevus, regress spontaneuously by 8 yrs -> area of atrophy
  • Epidermal:
    • warty naevus: linear, pigmented warty lesion -> several cm, recurrence common post surgical excision
  • Connective tissue:
    • shagreen patch - rare soft yellow connective tissue naevus assoc with tuberose sclerosis - lumbar/sacral region
18
Q

What is Seborrhoeic Keratosis?

A

Benign overgrowth of basal cell layer of epidermis

Following histological features:

  1. Hyperkeratosis: thickerning of keratin layer
  2. Acanthosis: thickening of prickle cell layer
  3. Hyperplasia: increased division of variably pigmented basaloid cells
19
Q
A

Serborrheoic keratosis

  • often on face @& trunk
  • variably pigmented lesion with stuck on skin warty appearance
  • Numerous, scratch off easily & bleed
  • Benign
  • Discomfort, irritation
  • Treatment:
    • Usually Conservative
    • Medical: cryotherapy,
    • Surgical: curretage, cautery
20
Q

What is neurofibroma?

A
  • Benign hamartoma of peripheral nerve schwann cells
  • soft, fleshy, pedunculated lesions of skin, gelatinous, violaceous nodules
  • Altered sensation, pain, compressive symptoms may be present e.g. intra-abdo -> bowel obstruction & impingelemt of spinal column -> scoliosis/bone cysts
  • Treatment:
    • Conservative
    • Surgical - excision
21
Q

What is neurofibromatosis?

A

2 similar Autosomal Dominant conditions

  • Type I = Von Recklinghausen’s Disease
    • >=6 cafe-au-lait spots >=0.5cm diam
    • multiple cutaneous neurofibromas that may be v large & can undergo sarcomatous change
    • increased risk of meingioma, acoustic neuroma, optic nerve gangioma
    • Kphosis & bowing of tibia
  • Type II = Bilateral Acoustic Neurofibromatosis
    • Bilateral acoustic neurofibromas
    • Intracranial memingiomas
    • Cranial nerve schwannomas
22
Q
A

Papilloma aka skin tag

  • Benign overgrowth of all layers of skin with vascularised core, fleshy, vary in size
  • Often face & neck
  • TreatmentL surgical excision
23
Q
A

Pyogenic granuloma

  • Acquired capillary haemangioma
  • Assoc with Hx of trauma
  • Soft raised lesion, light red to deep purple
  • Painful & can bleed
  • Management:
    • Surgical - excision - reduced wisk of bleeding & histological diagnosis

WARNING - looks like amelanotic melanoma - particularly if subungal

24
Q

What is a sebacrous (epidermoid) cyst?

A

Abn membranes line sac composed of epitherlial cells containing caseous sbstance composed of: fibrous tissue, fluid, keratin

25
Q
A

Sebaceous cyst

  • fixed to skin, variable size with central punctum, discharge/unceration/infection (aka abscess)
  • Treatment
    • conservative
    • If symptomatic, surgical excision i
26
Q
A

Lipoma

  • benign tumour of mature fat cells
  • Commonly seen on neck, trunk,
  • neither fixed to skin or underlying structures, freely mobile -> slip sign
  • Treatment
    • Conservative
    • Surgical:
      • liposuction - less scaring but more recurrence
      • excision biopsy
27
Q

What is an ulcer?

A

a breakdown in all layers of an epithelial surface

28
Q

What are the causes of ulcers? (& edge type)

A
  • Traumatic:
    • ill fitting shoes/pressure sores
    • E: sloping
  • Venous:
    • deep venous insufficiency & venous hypertension, ?malleoli
    • E: sloping
  • Infective:
    • primary/secondary to infection of colonised chronic ulcer by e.g. staphylococcus/streptococcus
    • E: sloping
  • Arterial:
    • painful, peripheral arterial disease, pressure points e.g. toes/planter surface of foot/heel/metatarsal heads. ?emolism/vasculitis
    • E: punched out
  • Neuropathic:
    • painless, DM/Chronic ETOH/leprosy/syphilis
    • E: punched out
  • Neoplastic:
    • Primary/secondary
    • E: everted - SCC/marjolins, rolled - BCC
29
Q

Treatment option for ulcers

A
  • Conservative
    • Dressing
    • foot elevation
    • orthopaedic foot wear
    • compression stockings - contraindicated if peripheral arterial disease i.e. ankle brachial pressure <0.8
  • Medical
    • Treat underlying cause/optimis e.g.
      • antibiotics
      • diabetic control
  • Surgical:
    • VV - stripping and ligation
    • Neoplastic - surgical excision
    • Skin graft

RLH MRCS (22 decks)

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