Superficial lesions Flashcards by Simon Thackray

What are you looking for on examination of a lump?

SCT FPS

Site
Size
Shape

Colour
Consistency
Contour
Cough impulse

Tenderness
Temperature
Transilluminence
Tethering

Fluctuant
Pulsatility
Spread

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How would you complete your lump examination?

Examine relevant LNs
Examine NV function distally
Look for similar lumps elsewhere

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What are the features of a lipoma, and name one syndrome with which they are associated?

Soft, subcutaneous, with imprecise margins and are fluctuant

Familial Multiple Lipomatosis

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What is the structure of a sebaceous cyst?

Epithelial lined cyst containing keratin

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What would you find on inspection and palpation of a sebaceous cyst?

Inspection
Occur where hair grows
Central puncture

Palpation
Firm
SMooth
Intradermal

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What are the complications of a sebaceous cyst?

Infection
Ulceration
Calcification

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What is Gardener’s syndrome?

FAP 
Thyroid tumours
Osteomas
Dental abnormalities
Epidermal cysts

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What is a ganglion?

A cystic swelling related to a synovial lined structure which contains a thick, gelatinous material

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What would you find on inspection and palpation of a ganglion?

Inspection
Often at dorm of hand or wrist

Palpation
Soft
Subcutaneous
May be tethered to tendon

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What is the management of a ganglion?

Non-surgical
Aspiration followed by 3/52 immobilisation

Surgical
Excision - recurrence in 50% and risk of NV damage

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What are seborrheic keratoses?

Benign hyperplasia of the basal cell layer causing hyperkeratosis

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What would you find on inspection and palpation of a seborrheic keratosis?

Stuck on appearance
Dark brown
Greasy

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What is a neurofibroma?

A benign nerve sheath tumour arising from schwann cells

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What would you find on inspection and palpation of a neurofibroma?

Inspection
Solitary or multiple?
Pedunculated nodule

Palpation
Fleshy consistency
Pressure ->parasthesia

Other
Lisch nodules
Cafe au lait spots
Axillary freckles

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What are the features of neurofibromatosis 1?

AD inheritance 
>6 CaL spots
Axillary freckling
Neurofibromata
Lisch nodules

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What is a pyogenic granuloma?

Neither pyogenic nor granulomatous, but a rapidly growing capillary haemangioma

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What would you find on inspection and palpation of a pyogenic granuloma?

Inspection
Commonly on hands, face gums, lips
Bright red hemispherical nodule +- discharge

Palpation
Soft
Bleed easily

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What would you find on inspection and palpation of a dermoid cyst?

Inspection
Smooth spherical swelling
Scar from recurrence

Palpation
Soft non tender
Subcutaneous

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What is a keratoacanthoma?

Benign overgrowth of hair follicle cells cytologically similar to SCC

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What would you find on inspection and palpation of a keratoacanthoma?

Fast growing
Dome shaped with a keratin plug
Intradermal

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What are the components of a thyroid examination?

Inspection:
Nervous/agitated or slow/lethargic
Body habitus
Sweat
Skin/hair condition

Hands
Thyroid acropachy
Palmar erythema
Sweating/temp
Fine tremor (paper)
Pulse (AF?)

Eyes
Lid retraction and lid lag seen in sympahthetic overstimulation
Graves -> Oedema, exophthalmos, ophthalmoplegia

Neck

Inspect from front and side, stick out tongue and swallow water, look in mouth for lingual thyroid

Palpate from behind
Swallow and protrusion test
Laopathy
trach deviation

Percuss for retrosternal extension

Auscultate for bruits

Legs
Pretibial myxoedema (brown swelling above lat malleoli)
Proximal myopathy (stand arm crossed)
Ankle reflexes

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What are the differentials for a diffuse goitre?

Smooth
Simple colloid
Graves
Thyroiditis (Hashimoto/Quervains/Reidels)

Nodular
Multinodular goitre
Multiple adenomata

What are the differentials for a solitary thyroid nodule?

Adenoma
1ary or 2ary (breast) malignancy
Cyst

What is a multi nodular goitre?

Commonest goitre in the UK, commonly in middle aged women with a mild thyrotoxicosis due to overactivity in parts of the thyroid

Malignant change in 5%

What is the management of a multi nodular goitre?

Medical Thyroxine to suppress TSH If toxic, -> propranolol, carbimazole, radio iodine Surgical Total thyroidectomy

What are the indications for thyroidectomy?

5Ms ``` Malignancy Mechanical obstruction Marred beauty Mediastinal extension Medical Rx failure ```

What other conditions is Grave's disease associated with?

T1DM Vitiligo Pernicious anaemia

What is the management of a follicular adenoma?

Hot + <3cm - radioiodine Hot + >3cm - excision Cold - excision

What is the commonest type of thyroid malignancy, and what is its prognosis?

Papillary (80%) seen in 20-40 year olds >95% 10 year surivval

Which type of thyroid disease is most associated with syndromes?

Medullary (MEN2_

Which thyroid cancer has the worst prognosis?

Anaplastic (<1% 10 year)

What are the complications of thyroid surgery?

``` Early Reactionary haematoma Rec laryngeal nerve palsy Hypocalcaemia Thyroid storm ``` Late Hypothyroid/hypoparathyroid Recurrence Keloid scar

How would you examine a neck lump?

Inspect - scar, sinus, mass Neck Mouth Eyes Palpate From behind on swallow LA opathy Trach deviation Percuss Auscultate

What are the differentials for a midline neck lump?

Thyroid isthmus mass Thyroglossal cyst Lipoma Sebaceous cyst

What are the differentials for an anterior triangle neck lump?

``` LNs Goitre Parotid tumour Branchial cyst Laryngocele ```

What are the differentials for a posterior triangle neck lump?

``` LNs Cervical rib Pancoast tumour Cystic hygroma Pharyngeal pouch ```

What are the borders of the anterior triangle?

SCM Midline Mandible

What are the borders of the posterior triangle?

SCM Trapezius Omohyoid muscle inferiorly

What is a Richter's hernia?

Where only part of the circumference of bowel is within the sac, commonly seen as femoral hernias, they can strangulate without obstruction

What is: Herniotomy Herniorrhaphy Hernioplasty

Herniotomy is excision of the hernial sac Herniorrhaphy is suture repair of hernial defect Hernioplasty is mesh repair of a hernial defect

What is the aetiology of congenital and acquired hernias?

Congenital Patent processus vaginalis which should be obliterated following testicular descent Acquired Raised intra-abdominal pressure

What are the two primary types of hernia?

Indirect 80% - common in younger ppl Emerge through deep ring Commonly strangulate Indirect 20% - common in elderly ppl Emerge through Hesselbach's triangle Rarely strangulate or descend into scrotum

What are the borders of Hesselbach's triangle?

Medial - lateral rectus Lateral - inferior epigastric vessels Inferior - inguinal ligament

What is the management of inguinal hernias?

Medical Treat RFs e.g. constipation Lose weight Truss Surgical Tension free meshes better than suture repair Primary unilateral hernias should be open incisions

What are the complications of inguinal hernia surgery?

``` Early Haematoma IA injury Infection Urinary retention ``` Late Recurrence Ischaemic orchitis Chronic groin pain/parasthesia

Which gender experiences more femoral hernias and why?

Females due to pelvis shape accommodating for child birth

What are the clinical features of a femoral hernia?

Groin lump inferolateral to the pubic tubercle Often irreducible Commonly strangulate -> tender, red, hot, pain, vomiting, constipationd, distension

What is the management of a femoral hernia?

50% strangulate in 1 year so requires urgent surgery Elective Lockwood approach or Emergency McEvedy approach

What are the risk factors for an incisional hernia?

``` Pre-op Old age Obesity Comorbidities Steroids, chemo, radio ``` Intra-op Surgical technique/skill Incision type Presence of drains through wound Post-op Raised IAP e.g. cough, ileus Infection Haematoma

What is the management of incisional hernias?

Conservative Manage RFs Weight loss Corset/truss Surgical Pre-op care Re RFs and surgical technique

What are the risk factors for umbilical hernias?

Afro-carribean T21 Congenital hypothyroidism

What is the management of umbilical hernias?

Usually resolve by 2/3 years of age

What are the features of paraumbilical hernias?

Middle aged obese man | Defect in linea alba above/below the umbilicus

What is the management of a paraumbilical hernia?

Mesh repair