Superficial lesions Flashcards
1
Q
Key points in a lump examination
SSSCCCCTTTTFPS
Completion: 3
A
-
S
- site
- size
- shape
-
C
- Colour
- Consistency
- Contour
- Cough impulse
-
T
- Tenderness
- Temperature
- Translumination
-
Tethering deep/superficial
- is it intradermal or subcutaneous?
- Intraderma: cannot draw skin over lump
- sebaceous cyst, neurofibroma, dermatofibroma
- Subcutaneous; can move lump independently from skin
- lipoma, ganglion, LN
- Intraderma: cannot draw skin over lump
- is it intradermal or subcutaneous?
-
FPS
- Fluctuance assess with prest test
- Pulsatile assess for bruits/bowel sounds
- Spreaaaaads (LN)
Completion:
- examine draining LN!
- Examine neurovascular function distral to lump!
- Look for similar lumps elsewhere!
2
Q
Lump history Qs; 3 headings
A
- Onset
- When and why did you notice it?
- Any predisposing event: e.g. trauma?
- Continued Symptoms
- What symptoms does it cause: e.g. pain?
- How has it changed?
- Have you noticed other lumps?
- Treatments and Cause
- What treatments have you tried?
- What do you think the cause is?
3
Q
Lipoma
- Pathology:
- Features:
- Inspection:
- Palpation:
- ‘Viva’-Syndromes: 4
- Management: 2
A
Lipoma
- Pathology: benign tumour of mature adipocystes. Sarcomatous change probably doesn’t occur.
- Liposarcomas arive de novo in; older pt/deeper tissues of lower limbs
- Features:
- Inspection: occur anywhere where fat can expand ie. not scalp or palms incl spermatic cord and submucosa
- Palpation: soft + subcutaneous + imprecise margins + fluctuant
- ‘Viva’-Syndromes: 4
- Dercum’s disease/ adiposis dolorosa:
- multiple, painful lipomas
- associated peripheral neuropathy
- obese, postmenopausal women
- familial multiple lipomatosis
- madelung’s disease
- Bannaya-Zonana Syndrome:
- AD, multiple lipomas, macrocephaly, haemangiomas
- Dercum’s disease/ adiposis dolorosa:
- Management:
- non-surgical; leave
- surgical; excise (but recur!)
4
Q
Sebaceous cyst
- Pathology: 2 types
- Features:
- Inspection:
- Palpation:
- ‘Viva’-Syndromes: 2 + Complications
- Management: 2
A
Sebaceous cyst
- Pathology: Epithelial-lined cyst containing keratin (Two histological subtypes:)
- 1) Epidermal Cyst - Arise from hair follicle infundibulum
- 2) Trichilemmal Cyst / Wen - Arise from hair follicle epithelium, Often multiple, May be AD
- Features:
- Inspection:Occur at sites of hair growth ie scalp, face, neck, chest, back NOT soles or palms, central punctum
- Palpation: Firm + smooth + Intradermal
- ‘Viva’
- Complications: Infection (pus discharge) + ulceration + calcification
- Syndromes:
- Cock’s peculiar tumour: large ulcerating trichilemmal disease on scalp, resemble SCC
- Gardener’s syndrome = FAP + Thyroid Tx + Osteomas + Dental abnormalities + Epidermal cysts (Garden TOAD)
- Management:
- non-surgical
- Surgical
5
Q
Ganglion
- Pathology:
- Features:
- Inspection:
- Palpation:
- ‘Viva’-Differential
- Management: 2
A
Ganglion
- Pathology: cystic swelling related to synovial-lined structures: joint, tendon. Myxoid degeneration of fibrous tissue. They contain thick gelatinous material
- Features:
- Inspection: can be found anywhere e.g. dorsum of hand or wrist. There may be a scar from recurrence. May weakly transilluminate
- Palpation: soft + subcutaneous + teathered to tendon
- ‘Viva’-Differential
- Bursae
- cystic protrusion from synovial cavity of arthritic joint
- Management:
- non-surgical: aspiration followed by 3 wks of immobilisation
- surgical excision: 50% recurrence + risk neovasc damage
6
Q
Seborrhoeic Keratosis
- Pathology: 3
- Features: 3
- Management: 2
A
Seborrhoeic Keratosis
- Pathology: benign hyperplasia of basal cell layer
- hyperkeratosis: coneum thickening
- acathosis: spinosum thickening
- hyperplasia of basal cells
- Features:
- stuck on appearance + dark brown + greasy
- Management:
- non-surgical
- surgical: superficial shaving or cautery
7
Q
Neurofibroma
- Pathology:
- Features:
- Inspection:
- Palpation:
- Extras:
- Viva: syndrome
- Management: 1
A
Neurofibroma
- Pathology: benign nerve sheath tumour arising from schwann cells
- Features: Numerous small violaceous nodules present on the back and forwarm in no particular distribution; neurofibromas
- Inspection: solitary or multiple, pedunculated nodules
- Palpation: fleshy consistency + pressure can -> paraesthesia
- Extras: examine:
- skin: cafe au lait spots
- eyes: lisch nodules
- Acilla: freckles
- CN: 8 (NF2 schwannoma)
- BP: phaeochromocytoma/RAS
- Viva: NF 1
- AD Chr 17
- cafe au lait spots >6 >15mm + freckling + neurofibromas + lisch nodules (iris)
- Management:
- surgical excision ONLY indicated is malignancy suspected
- local regrowth = common!
8
Q
Papilloma
- Pathology: 1
- Features: 3
- Management: 1
A
Papilloma
- Pathology: overgrowth of all layers of the skin with a central vascular core
- Features: Skin tage/fibroepithelial polyp, pedunculated, flesh coloures
- Management: excision + diathermy to control bleeding
9
Q
Pyogenic granuloma
- Pathology:
- Features:
- Inspection:
- Palpation:
- Viva: ?association
- Management: 2
A
Pyogenic granuloma
- Pathology: rapidly growing capillary haemangioma, neither pyogenic nor granuloma!
- Features:
- Inspection:
- most commonly hands, face, gums, lips
- bright red hemispherical nodule
- may have seous/purulent discharge
- Palpation: soft + bleed easily
- Inspection:
- Viva: ?association
- previous trauma? more common in preg
- Management:
- non-surgical: regression is uncommon
- surgical: curretage and diathermy of base
10
Q
Dermoid cyst
- Pathology: congenital vs acquired
- Features:
- Inspection:
- Palpation:
- Viva: ?association
- Management: 2 (C/A)
A
Dermoid cyst
- Pathology: epidermal lined cyst deep to the skin
- congenital/inclusion cyst: developmental inclusion of epidermis along lines of skin fusion e.g. midline of neck and nose, medial and lateral ends of eyebrows
- aquired/implantation cyst: Implantation of epidermis in dermis. often secondary to trauma e.g. piercing
- Features:
- Inspection:
- smooth spherical swelling
- sites of embryological fusion
- scar from recurrence
- Palpation: soft, non-tender, subcutaneous
- Inspection:
- Viva: ?association
- congenital: child/young adult
- acquired: adult- ask re trauma
- Management: 2 (C/A)
- congenital; CT to establish extend and surgical excision
- Aquired: surgical excision
11
Q
Dermatofibroma
- Pathology:
- Features:
- Inspection:
- Palpation:
- Viva: differential
- Management: 1
A
Dermatofibroma
- Pathology: benign neoplasm of dermal fibroblasts
- Features:
- Inspection:
- can occur anywhere, mostly on lower limbs of younf to middle aged women
- small brown pigmented nodule
- Palpation: Firm + woody feel = characteristic, Intradermal + mobile over deep tissue
- Inspection:
- Viva: differential: malignancy e.g. melanoma, BCC
- Management: Excision and HISTOLOGY!
12
Q
Kerato-acanthoma
- Pathology:
- Features: 3
- Management:
A
Kerato-acanthoma
- Pathology: benign overgrowth of hair follicle cells, cytologically similar to well-differentiated SCCs
- Features:
- fast growing
- Dome shaped with keratin plug
- Intraderma;
- Management:
- regress w/i 6 wks
- excise to reduce scarring and obtain histology
13
Q
Thyroid examination
prep/gen inspection/hands/eyes/neck(IPA)/legs/complete
A
-
Preparation Ensure exposure down to the clavicles + Position pt. away from a wall
-
Qs:
- Are you comfortable: not too hot or cold?
- Hoarse voice: recurrent laryngeal nerve palsy
-
Qs:
-
General Inspection
- Nervous/agitated or slow/lethargic
- Body habitus
- Sweaty
- Skin and hair condition
-
Hands
- Thyroid acropachy
- Palmar erythema
- Temperature, sweating
- Fine tremor: piece of paper on out-stretched hands
- Pulse: rate and rhythm (AF in thyrotoxicosis)
-
Eyes
- Sympathetic Overstimulation
- Lid Retraction: sclera between iris and upper lid
- Lid Lag
- Graves:
- Oedema: periorbital and chemosis
- Exophthalmos: inspect from above and side
- Ophthalmoplegia: esp. upgaze palsy
- Sympathetic Overstimulation
-
Neck
- Inspect: from front and side.
- Look for collar scars
- Ask pt. stick out tongue and swallow water
- Look in mouth for lingual thyroid
- Palpate: from behind
- Palpate masses: can you get under it?
- Repeat the swallow and protrusion test
- Lymphadenopathy
- Check for tracheal deviation.
- Percuss: for retrosternal extension
- Auscultate: thyroid bruits (Graves’)
- Inspect: from front and side.
-
Legs
- Pretibial myxoedema: brown swelling above lat. malleoli
- Proximal myopathy: ask pt. to stand from chair (Graves)
- Ankle reflexes: kneel on chair
- Slow relaxing: hypothyroidism
- Brisk: hyperthyroidism
-
Completion
- Observation chart
- History
14
Q
Exophthalmos differential:
A
- Orbital cellulitis
- Trauma
- Masses: meningioma, glioma
- Carotid cavernous fistula: pulsatile exophthalmos
- Idiopathic orbital inflammatory disease
- Graves
15
Q
Goitre differential
Diffuse: smooth/nodular
Solitary
A
Diffuse Enlargement
- Smooth
- Simple colloid goitre
- Graves
- Thyroiditis: Hashimoto’s, de Quervain’s, Riedel’s
- Nodular
- Multinodular goitre
- Multiple adenomas
Solitary Nodule
- Dominant nodule of a multinodular goitre
- Adenoma
- Malignant
- 1O: papillary, follicular, medullary, anaplastic
- 2O: breast
- Cyst
16
Q
Commentest causes of
hyperthyroidism 2
hypothyroidism 3
A
Hyperthyroidism
- Graves’ (~2/3)
- Toxic Multinodular Goitre ( = Plummer’s)
Hypothyroidism
- Primary atrophic
- Hashimoto’s thyroiditis
- Iodine deficiency: commonest Worldwide
17
Q
Thyroid Qs 3
A
- Thyroid status
- Compression symptoms: dysphagia, difficulty breathing
- Previous thyroid medications or surgery
18
Q
Goitre investigations
Nlood/imaging/hisology/laryngoscopy
A
Bloods
- TFTs: TSH, fT3, fT4
- Other: FBC, Ca2+, calcitonin, ESR
- Antibodies: anti-TPO, TSH
Imaging
- CXR: goitre and mets
- High resolution US
- CT
- Radionucleotide (Tc or I) scan: hot vs. cold
Histology or cytology
- FNAC (can’t distinguish adenoma vs. follicular Ca)
- Biopsy
Laryngoscopy: Important pre-op to assess vocal cords
19
Q
Features of multinodular diffuse goitre
A
- Commonest goitre in UK
- Progression of simple diffuse goitre to nodular enlargement.
- Middle-aged women
- Positive family Hx
- Over-activity in parts may → mild thyrotoxicosis
- Plummer’s Syndrome
- Malignant change occurs in 5% of untreated MNGs
20
Q
Management of multinodular diffuse goitre
n.b. most pts do not require intervention
nonsurg vs surg
A
- Most pts. don’t require intervention*
- *Non-Surgical**
- Thyroxine → regression in 50-70% (Suppress TSH)
- Toxic Multinodular Goitre
- Propranolol + carbimazole
- Radioiodine
Surgical
- Indications: 5 Ms
- Mechanical obstruction
- Malignancy
- Marred beauty: cosmetic reasons
- Medical Rx failure: thyrotoxicosis
- Mediastinal extension: can’t monitor changes
- Procedure
- Total thyroidectomy
- Removes risk of malignant change in thyroid remnant.
21
Q
Plumbers Vs graves
- age
- Nod or diffuse?
- extra?
- AF?
- AI features?
A
22
Q
Simple colloid goitre (smooth)
causes
Treatment
A
Hyperplasia of gland 2O to ↑TSH release
Causes
- Iodine deficiency: commonest worldwide
- ↑ physiological demand: pregnancy, puberty
- Goitrogens: e.g. Li, uncooked cabbage
Rx
- Not usually required
- Thyroxine or ↑ dietary iodine
23
Q
Graves disease
epidemiology
- Prevalence:
- XX% of cases of thyrotoxicosis
- Sex:
- Age:
A
- Prev: 0.5%
- 60% of cases of thyrotoxicosis
- Sex: F>>M=9:1
- Age: 40-60yrs
24
Q
Graves disease: features
A
- Diffuse goitre c¯ bruit
- Triggers: stress, infection, child-birth
- Ophthalmopathy
- Oedema: periorbital and chemosis
- Exophthalmos → exposure keratopathy
- Ophthalmoplegia: esp. upgaze palsy
- Optic neuropathy: ↓ acuity and RAPD
- Dermopathy: pre-tibial myxoedema
- Acropachy: periosteal reaction (clubbing is soft tissue
25
Q
Pathology of grave’s eye disease:
exophthalmost
+
Lid-lag
A
- Exophthalmos
- Retro-orbital inflammation and lymphocytic infiltration → orbital oedema
- 2O to anti-TSH abs
- Lid-lag
- Not Graves’ specific
- Sympathetic overstimulation → restrictive myopathy of LPS
26
Q
Grave’s disease associations: (3)
A
- T1SM
- Vitiligo
- Pernicious anaemia
27
Q
Grave’s disease
treatment
A
- medical: propranolol + carbimaxole
- Radioiodine
- surgical: subtotal or total thyroidectomy
28
Q
Grave’s vs thyroiditis (and 4 example)
uptake?
A
Graves; high uptake
thyroiditis: low uptake e.g.
- hashimoto’s
- de Quervain’s
- Subacute lymphocytic: post-partum
- Riedel’s
29
Q
Follicular adenoma (benign solitary thyroid nodule)
Features
Management
A
Follicular adenoma (benign solitary thyroid nodule)
- Features:
- 2-4cm mass
- +/- thyrotoxicosis
- Indistinguishable from follicular Ca on FNAC- need excision histology to confirm Dx
- Management
- Hot:
- <3cm: radioiodine
- >3cm: surgical excision
- COLD: excision!
- Hot:
30
Q
thyroid cyst (benign solitary thyroid nodule)
Features
Management
A
- Features:
- true cysts= RARE
- Mostly colloid degeneration, necrosis of H’gge wi benign or malignant tymours
- Only benign if abolished by aspiration!
- Management
- cytology can be false negative in 30%!
- <4cm: aspirate and reciw in 4/12
- surgical excision if:
- >4cm
- blood stained aspirate
- recurrence after aspiration
42
Q
Quick differential for neck lumps
anywhere
midline: solid/cystic
ant triangl: solid/cystic
Post triangle: solic/cystic
A
