781265
| Question | Answer |
| risk factors for malignancy in a thyroid nodule | - age and sex: male - history of irradiation - family history - geographic - pressure symptoms - nature of mass: solitary VS multiple nodules, nodule characteristics - recurrent laryngeal palsy - cervical lymph nodes |
| Ix for thyroid nodule | - MOST IMPORTANT: thyroid function test, USG +/- FNAC - other blood test: ESR, autoantibodies, calcitonin, genetic diagnosis - diagnostic scans: CXR, scintigraphy, CT/MRI, PET - additional scans: DL, OGD |
| Indications for FNAC VS surgery without FNAC | for FNAC: - any complex, palpable, clinically worrisome nodule seen on USG - dominant or atypical nodule of MNG - recurrent or complex cystic nodule - with palpable or USG abnormal LN - suspicious USG features: micro calcifications, elongated shape, hypo echoic solid, irregularity/spiculated margin, intranodular vascularity, perilesional flow surgery without FNAC: - large and symptomatic goiter - MNG with pressure symptom - Grave's + nodule - solitary hyperfunctioning - high-risk: family history, MEN II, radiation exposure to H&N |
| presentation of malignant CA thyroid | - primary Sx: palpable nodule/symptomatic (usually euthyroid), pressure symptoms e.g. hoarseness of voice due to RLN palsy, incidental finding on imaging - metastasis: cervical LN (paratracheal level VI), distant to bone, lung - occult microcarcinoma in thyroidectomy speicmens - papillary most common spread by LN, followed by follicular spread by blood - medullary important in MENIIa, b family MTC (1/3), uses calcitonin as marker - anaplastic aggressive and poor prognosis |
| advantage of total/near total thyroidectomy over subtotal | - multifocality - reduce recurrence (which means difficult surgery) - allows post-op radiotherapy - allows thyroglobulin to be used as a tumor marker |
| Rx and Mx for CA thyroid | - total thyroidectomy with central/lateral neck dissection - T4 suppressive therapy by hsTSH - I131 ablation and whole body scintigraphy (WBC) - repeat I131 if distant micrometastasis/external irradiation of incomplete resection/residual tumor - thyroxine replacement when hypothyroidism (can be delayed) - follow-up regularly with TFH test, CXR, neck exam/USG - Tg monitoring: basal/stimulated (withdrawing T4 or giving hsTSH) - suspected recurrence: USG+/-FNAC, WBC, CT/MRI, PET |
| benign features of thyroid nodule on USG | - isoechoic - thin halo - complex - cystic - spongioform - comet tail - absence of calcification |
| Anatomy in groin and scrotum | - SIR: above and medial to pubic tubercle - DIR: mid-point of inguinal ligament, which spans from ASIS to pubis symphysis - Hasselbach's triangle: (lateral) inferior epigastric vessels, (medial) lateral border of rectus abdominus muscle, (inferior) inguinal canal - femoral triangle: (medial) pubic bone, lacunar ligament, (superior) inguinal ligament, (posterior) pectineal ligament, (lateral) femoral vein - saphenous opening: (3-4cm) below and lateral to the pubic tubercle |
| Ddx of groin mass | 1. Skin and subcutaneous tissue: - lipoma, sebaceous cyst - lymph node - saphena varix 2. Inguinal canal: - inguinal hernia - encysted hydrocele of spermatic cord - lipoma of spermatic cord 3. Femoral hernia |
| Ddx of scrotal mass | 1. Skin and subcutaneous tissue: lipoma 2. spermatic cord: - funiculitis (inflammation) - varicocele (usu left-sided, look for a renal mass, nutcracker syndrome) - inguinal-scrotal hernia (extension since large) 3. Epididymis: - epididymitis - epididymal cyst 4. Testis: - torsion - hydrocele - orchitis - testicular tumor |
| Typical history of a scrotal/groin swelling | - reducible groin mass: inguinal hernia - painful scrotal swelling: epididymo-orchitis/torsion (can be distinguished clinically) - non-painful scrotal swelling: hydrocele/testicular tumor (MUST do USG to r/o reactive hydrocele due to tumor) - fullness/bag of worms: varicocele - true scrotal swelling can be got above |
| P/E for inguinal/scrotal/groin swelling | - ensure privacy, gloves - scar, swelling, BOTH sides - palpate swelling, it's relationship with pubic tubercle - cough impulse - reduction by patient - occlusion test - abdomen to look for ascites and mass that predispose to hernia/renal mass - check testicular atrophy if indirect inguinal hernia - stand patient up to look for incarceration or strangulation of hernia |
| Rx for inguinal/scrotal/groin mass | - inguinal hernia: mesh repair most common (Lichtenstein repair), tension free most important - laparoscopic associated with less wound/nerve pain, but higher recurrence in inexperienced hands, indicated if recurrent, bilateral and concurrent laparoscopic procedures - femoral hernia: primary closure of femoral ring (under tension, hence higher recurrence), plug hernioplasty (tension-free) - hydrocele: Jaboulay procedure - testicular tumor: inguinal radical orchidectomy to avoid seedling |
| Clinical features of sebaceous cyst | - from epithelium, NOT sebaceous gland - punctum - multiple: Gardner's syndrome - can be inflamed/infected |
| Clinical features of lipoma | - benign tumor of adipocytes - can be multiple - if multiple and painful Dercum's disease - observed VS excised |
| Clinical features of sebaceous naevus | - potential to become basal cell carcinoma later - present at birth, more obvious in puberty - excision |
| Clinical features of keloid VS hypertrophic scar | Keloid: - appear 3 months or year after - not confined to original border of wound - more difficult to treat as it can recur and does not regress Hypertrophic scar: - 1 month after - confined, can still be raised - more responsive to treatment and can regress |
| Clinical features of keratoacanthoma | - looks like SCC, must r/o - central necrotic base with keratinized edge - can regress spontaneously 6-9 months later (VS keratin horn will not) |
| Types of malignant ulcers | - in-situ: Bowen's dx (->SCC), extramammary Paget's (peno-scrotal region) - skin cancers: SCC, BCC, melanoma - angiosarcoma |
| BCC VS SCC | SCC: - raised, everted edge - red-brown due to vascularity - central necrotic base with keratinized edge - grows MORE rapidly - Marjolin's ulcer BCC: - raised, rolled-in edge - fine pink tinge with telangiectasia - grows slowly |
| Types of malignant melanoma | - superficial spreading: commonest - nodular: most aggressive - lentigo maligna: in areas with sun exposure - acral lentiginous: rare in white, not related to sun exposure, can be in hairy skin - subungal: nail bed - neurotropic/desmoplastic: rare, in H&N, mimic scar/naevi - Asymmetry, irregular border, variegation in color, diameter >6mm, elevation |
| risk factors and Rx of melanoma | Risk factors: - sun - fair skin - >20 naevi - positive Fhx in 1st-degree relative Rx: - excision with sentinel LN biopsy and selective lymphadenectomy if positive - adjuvant usually not effective, RT/CT |
| Triple assessment | - Clinical - Radiological - Pathological: both cytological and histological |
| Mammogram and USG features of malignancy | Mammogram: - fixed - irregular border - microcalcifications: segmental/clusters/satellite/pleomorphic - disruption of cooper's ligaments - involvement of pec major muscle - involvement of axillary LN - skin retraction/thickening - asymmetrical thickening USG: - good at picking up cyst - less sensitive for micro calcifications - better for breasts with higher density - taller than wider, irregular edge, not compressible |
| Clinical features of benign disease | - physiological swelling and tenderness - nodularity: no definite mass - mastalgia (cyclical related to menstruation, non-cyclical related to costochondritis, muscle pain) - discharge: galactorrhea, abnormal discharge - dominant lump: gross cyst, galactoceles, fibroadenoma, fat necrosis - infections: post-partum mastitis, lactational mastitis, lactational breast abscess - extrinsic infections e.g. cellulitis, lipoma, sebaceous cyst |
| clinical features of fibroadenosis/fibrocystic disease | - anomaly of development and involution - 30-40 years of age - premenstrual swelling, mastalgia, nodularity, lumpiness, improves after each cycle - more marked in UOQ (similar to CA) |
| Causes of various nipple discharge | - red/brown: papilloma, CA (usually one-sided, single duct) - yellow/greenish: mastitis, abscess - creamy white: milk from galactorrhea - colorless/serous: physiological, ductal ectasia |
| Causes of palpable breast lumps | - most common: macro cyst, galatoceles, fibroadenoma - rarer: lipoma, sebaceous cyst, fibroma, fat necrosis, DM mastopathy |
| Clinical features of fibroadenoma | - in younger women than seen in fibrocystic dx - mobile firm mass - will not regress, tends to grow - but malignant potential very low - can be multiple - distinct entity: giant fibroadenoma in 10-12 y/o girl with very rapid growth and tenderness affecting pubertal development --> deformed breast hence requires excision |
| Infections in breast | - post-partum mastitis - lactational mastitis - lactational abscess - chronic recurrent subareolar infection - acute mastitis associated with macro cyst - extrinsic infections e.g. cellulitis - Rx: antibiotics, I&D of abscesses, needle aspiration - duct excision for chronic abscesses from duct ectasia |
| Cytology report for breast lesion | C1: inadequate C2: benign C3: atypia probably benign C4: suspicious of malignancy C5: malignant |
| Methods of Bx | If palpable: - FNAC - trucut i.e. core i.e. incisional - excisional If non-palpable: - if seen on MMG: stereotactic (MMG-guided) - if seen on USG: USG-guided - MRI guided |
| Clinical features of CA breast | - upper and outer quadrant most common, do not miss middle and behind nipple - multi-centric (different quadrants) VS multi-focal (same quadrant) - 80% invasive ductal - risk factors: nulliparity, early menarche, late menopause, BRCA, use of HRT, history of breast biopsy showing premalignant conditions, smoking, diet, exercise |
| staging Ix for CA breast | - the relevant breast scans - CT thorax, abdomen and bone scan - alternative: PET-CT if affordable - site of met: lung, bone, brain, liver |
| Rx choices for CA breast | - Breast conservation therapy (BCT): whole breast irradiation + wide local excision and axillary dissection - modified radical mastectomy +/- breast reconstruction - CI to BCT: big tumor, cannot tolerate irradiation e.g. SLE, tumor behind nipple, multifocal cancer - LN level I: lateral, II: posterior, III: medial - standard: level I and II |
| blood-taking procedures | - arterial gas: radial artery (most superficial), check ulnar artery patency by Allen's test beforehand - venous blood: first try antecubital fossa then palmar side if hand |
| IV line procedure | - 14-16G large bore for resuscitation - 22G for adult, larger size for pregnant woman - 26G for children - G bigger size smaller - first palmar than cubital fossa - Cx: thrombophlebitis, drip site infections e.g. small abscess, cellulitis, leg gangrene, bleeding - caution: remove any tourniquet after success |
| Central venous catheter procedure | - internal jugular vein approach: central/posterior inferior - subclavian vein approach - Cx: a. pain b. intra-vascular injection of LA c. bleeding: if high bleeding tendency + emergency -> femoral vein d. pneumo/hemothorax e. central line infection -> sepsis/endocarditis f. air/guidewire embolism g. AV fistula |
| Foley's catheter procedure | - difficult if BPH, urethral stricture, phimosis - usually use 16 Fr size - Fr bigger, size bigger - alternative: suprapubic - CI of suprapubic approach: non-palapble bladder, previous pelvic surgery, coagulopathy - Cx of suprapubic: pain, bleeding, perforation of bowel, infection |
| Cx of centesis | - abdominal: bleeding, perforation of bile, hypotension due to fluid shift - thoracocentesis (chest tapping, from 8-9th ICS posterior): pain, pneumothorax, bleeding - chest drain (anterior MAL 5th ICS): similar, indicated for pneumo/hemothorax, empyema, massive pleural effusion |
| causes for H&N midline mass | - thyroid swelling/cyst - lipoma - sebaceous/dermoid cyst - pharyngeal pouch - LN - plunging ranula - subhyoid bursa |
| causes of lateral neck mass | - LN - cold abscess (chronic TB infection) - salivary glands - lipoma/sebaceous cyst - branchial cyst (anterior), cystic hygroma (posterior) - carotid artery tumor/aneurysm (anterior), subclavian artery tumor/aneurysm (posterior) - SCM tumor (anterior), tumor of clavicle, cervical rib (posterior) |
| Hx must be taken in H&N mass | - pain - recent infection, fever etc. - swelling/ulceration/bleeding - progression of swelling - pressure sx: dysphagia, difficulty in breathing - hoarseness of voice - hearing loss |
| Fluid therapy | - neonates need about 960mL/day - adult variable - but universal formula: 2D (dextrose) 1S (NS) Q8H |
| high risk groups for fluid load and types of fluid | - CHF - elderly - post-op: increased in catecholamines/ADH/aldosterone due to stress - crystalloid: for extravascular deficit, 20-30mins half-life, cheap and few SE - colloid: for intravascular deficit to maintain oncotic pressure (BP), 3-6 hrs half-life, more expensive and SE |
| routes of infection in surgical infection | - necrotizing - abscess - phlegmon with superficial infection - via blood - via lymphatics - sepsis = SIRS + documented source of infection |
| Surgical wound infections | - usually between 5th to 10th day post-op - clean, clean-contaminated, contaminated, dirty - risk factors: abdominal operation, more than 2 hours, 3 pre-existing medical conditions, contaminated operation |
| indication for surgery of lumps and bumps | - malignancy - premalignant lesions - symptomatic - increasing size, progressive - prevent Cx or infection - cosmesis |
| cutaneous hemangioma | - 50% of subglottic hemangioma associated with this - salmon patch: present at birth, regress after age 1 - port wine stain: at birth, no regression but no progression as well - strawberry naevi: at birth, onset 1-3 weeks, regress by 7-8 years, sugary needed if visual field affected |
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