8/04/2020

Basal Cell Carcinoma

Basal Cell Carcinoma (BCC) is a slow-growing locally invasive malignant tumour (malignant skin ulcer) arising from basal epidermis and hair follicles – hence affecting the pilosebaceous skin!

90% of the lesions are found on the face above a line from the lobe of the ear to the corner of the mouth.

It rarely metastasize.

EPIDEMIOLOGY

• White people are almost exclusively affected
• Middle-aged and elderly people (40-80 years)
• More in men

RISK FACTORS FOR

• UV light (But 33% arises in parts of the body not exposed to sun)
• Arsenic
• Coal tar
• Aromatic hydrocarbons
• Ionising radiation
• Genetic skin cancer syndromes (Gorlin’s syndrome, Xeroderma pigmentosum)
• Immunosuppression (AIDS)
• Premalignant lesions (Naevus of Jadassohn)

CLASSIFICATION OF BASAL CELL CARCINOMA

BY APPEARANCE

• LOCALIZED
  • Nodular
  • Nodulocystic
  • Cystic
  • Pigmented
  • Naevoid
• GENERALIZED
  • Superficial
  • Infiltrative (morphoeic)

BY PROGNOSIS

• HIGH RISK (The risk of recurrence is high)
  • Located at specific sites – periorbital, nose, perioral, nasolabial folds, pre/post auricular
  • Ill defined margins
  • Histology – morphoeic or infiltrative
  • Those occurring in immunosuppressed
• LOW RISK
  • The types other than the above-mentioned ones

MANAGEMENT OF BASAL CELL CARCINOMA

SURGICAL MANAGEMENT

• Mohs’ Micrographic surgery
• Standard Excisional surgery

NON-SURGICAL MANAGEMENT

• Radiotherapy (for elderly patients)
• Topical chemotherapy (with 5-FU)
• Cryotherapy
• Photodynamic therapy (application of photosensitising agents to the skin that are preferably absorbed by tumour cells

7/04/2020

What is Fat Embolism?

First of all, one should understand the difference between the fat embolism and fat embolism syndrome (FES).

DEFINITIONS

Fat Embolism

Presence of fat globules in pulmonary and peripheral circulation usually following a long bone fracture or major trauma.

Fat Embolism Syndrome (FES)

A serious consequence of fat embolism producing a distinct pattern of symptoms and signs.

CAUSES OF FAT EMBOLISM

• Trauma-related – 95%
  • Fractures and orthopaedic related
    • Long bone fractures – tibia and femur
    • Pelvic fractures
    • Vertebral fractures‣ IM nailing and arthroplasty
  • Non-orthopaedic related
    • Soft tissue trauma
    • Liposuction
    • BM harvesting and transplant
• Non-trauma related – 5%
  • Acute pancreatitis
  • Diabetes Mellitus
  • Sickle cell disease
  • Osteomyelitis
  • Alcoholic liver disease

RISK FACTORS FOR FAT EMBOLISM

• Young age
• Multiple fractures
• Conservative management of long bone fractures
• Overzealous nailing◦ Reaming the medullary cavity
• Increased gap between nail and cortical bone

PATHOGENESIS OF FAT EMBOLISM

Mechanical theory

Following trauma, fat cells in the bone marrow enter into damaged veins and venous sinusoids → reach femoral vein and IVC → reach the pulmonary circulation → obstruct pulmonary capillaries → interstitial haemorrhages and oedema → alveolar collapse → reactive hypoxaemic vasoconstriction → pulmonary symptoms.

Some fat cells reach the systemic circulation through the patent foramen ovale → neurological and dermatological manifestations.

Biochemical theory

Fat globules in the plasma are broken down to FFA by the trauma-related hormonal mechanism → FFA intermediaries form (chylomicrons, VLDL etc.) → CRP causes chylomicrons to coalesce → larger chylomicrons go and obstruct capillaries as above.

When they go and obstruct pulmonary capillaries, FFA induce capillary endothelial damage → ARDS.

The same may happen to cerebral circulation → encephalopathy and neurological deficit.

Sometimes, the capillaries of skin is obstructed, conjunctiva and oral mucosa get obstructed → thin walled capillaries rupture → petechiae.

Fat globules are proinflammatory and prothrombotic → they cause the generation of thrombin and fibrin, platelet aggregation, consumption of coagulative factors → thrombocytopaenia, anaemia and DIC.

CLINICAL FEATURES OF FAT EMBOLISM

Since it takes time for this pathological process to occur, symptoms and signs appear within 24-72 hours of the primary injury.

Respiratory Symptoms (First to Appear)

• Dyspnoea
• Tachypnoea
• Hypoxaemia – Occur in 75%
• ARDS develops – Occur in about 10%

Neurological Symptoms (After Respiratory Symptoms)

• Drowsiness
• Confusion
• Focal neurological signs (hemiplegia, aphasia etc.)

Dermatological Signs

• Petechiae of skin of axilla and upper neck and chest
• Petechiae of Conjunctivae and oral mucosa (emboli shooting from the ‣ aortic arch to non-dependent areas)

Other Signs

• Fever
• Tachycardia
• Retinal changes – Purtscher’s retinopathy, fat globules seen on retina on fundoscopy
• CVS – myocardial depression
• Coagulopathy – mimicking DIC
• Renal – oliguria, lipiduria, haematuria

DIAGNOSIS – GURD’S CRITERIA

At least 1 major and 4 minor should be present to the diagnosis of fat embolim syndrome.

Major Criteria

• Axillary skin and subconjunctival petechiae
• Hypoxaemia – PaO2 <60
• CNS depression disproportionate to hypoxemia
• Pulmonary oedema

Minor Criteria

• Tachycardia
• Fever
• Fat globules in retina on fundoscopy
• Fat globules in urine
• Fat globules in sputum
• FBC – thrombocytopenia, anaemia/drop of haematocrit
• High ESR

INVESTIGATING FAT EMBOLISM

Blood Tests

• FBC – anaemia, thrombocytopenia, low haematocrit
• ESR – high
• Serum Lipase – elevated
• Coagulopathy screening – DIC like picture
• Serum Calcium – hypocalcaemia due to calcium binding to FF

Congo red/oil red O test

Urine, sputum, serum (specially pulmonary arterial wedge blood sample) – fat globules

Pulmonary Tests

• CXR – snowstorm appearance in ARDS
• CT chest – ground glass appearance
• Pulmonary artery wedge pressure – increased → this is an early way to diagnose this condition.

Other Tests

• MRI Brain – at the boundaries of major arterial territories there will be hyperintense punctate diffuse lesions “star ◦ field appearance” – petechiae in the white matter!
• ECG
• Transoesophageal Echocardiogram

MANAGEMENT OF FAT EMBOLISM

Prevention

• Early immobilisation of the fractures
• Early operative fixation of fractures
• When reaming the BM for IM nailing, make sure not to increase the intraosseous pressure

Supportive therapy

• Respiratory support – oxygenation, ventilation
• Neurological support – the aim is to prevent secondary brain damage by maintaining cerebral perfusion and, oxygenation and minimise cerebral oedema
• Renal support – proper fluid management with IP/OP monitoring and renal function assessment
• CVS support – maintain stable haemodynamics, inotropes if necessary

General Measures

• Physiotherapy
• DVT prophylaxis
• Skincare
• Stress ulcer prophylaxis
• Nutrition

Unproven Medication

• Heparin – increases lipase activity and clears the lipaemic serum
• Corticosteroids – limit FFA generation
• Aspirin – prevents gas exchange abnormalities

1/03/2020

Thyroid Examination (OSCE Guide)

Thyroid examination or the examination of a goiter commonly encountered at Surgical OSCE stations.

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THYROID EXAMINATION

Firstly, greet the patient and take consent. Make sure you have enough space behind the patient’s chair before proceeding with the examination.

Examine from front

1. Inspect – Offer a glass of water and ask to swallow on command & look for the lump moving upwards with deglutition. Observe from the side.
2. Only if the lump is small and in the midline, ask the patient to put the tongue out while stabilizing the jaw and look for the lump moving upwards.
3. Look for scars (previous lobectomy scar) and dilated neck veins.
4. Only if the lump is a large one, elicit Pemberton’s sign.

Then go to back of the patient,

1. Palpate the thyroid gland from behind. Examine using one hand at a time while stabilizing the gland from the other. Feel for the consistency and nodularity of the gland.
2. Examine for cervical lymphadenopathy.

After that, come back to front of the patient and look for,

1. Tracheal deviation – Feel along the trachea downwards.
2. Retrosternal extension – Check whether you can feel the lower border of the gland while the patient is asked to swallow. If cannot percuss to elicit retrosternal dullness.
3. Displaced carotid pulsation – Check both carotid pulses, one at a time.
4. Thyroid bruit – Auscultate over the right upper lobe.

Finally, examine for eye signs and hands to complete the thyroid examination

1. Eye Signs – Look for Exophthalmos (See from behind), Lid retraction, Lid lag, and Ophthalmoplegia.
2. Hand signs – Look for sweaty hands, tachycardia (radial pulse), fine tremors.

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THYROID EXAMINATION – PRESENTATION

This patient is having a lump in the anteroinferior aspect of the neck which moves up with deglutition. There are no visible surgical scars in the neck or dilated neck veins and Pemberton’s sign is negative.

The lump is firm in consistency and its surface is nodular with a prominent nodule in the right upper lobe. There is no cervical lymphadenopathy. Its lower border can be felt, trachea is deviated to the left side and the right carotid pulse is deviated posterolaterally. There is no bruit. She is clinically euthyroid and there are no thyroid eye signs.

So, my probable diagnosis is a clinically euthyroid longstanding multinodular goiter (MNG) without retrosternal extension. I would like to investigate her with a thyroid profile, USS neck and FNAC of the prominent nodule to decide on further management

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FREQUENTLY ASKED QUESTIONS

1/03/2020

Inguinal Hernia (OSCE Guide)

Examination of an inguinal hernia is a vital part of surgical examination methods. It is one of the most basics skills that every medical student and doctor should be aware of.

More importantly, differentiating between a femoral and inguinal hernia plays a major role here.

Firstly, introduce yourself and get consent before you proceed to examine the patient.

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INGUINAL HERNIA EXAMINATION

You will be asked to examine the groin area of a patient who is lying supine, but always remember to examine the patient in the erect position as well, at some point in your examination.

1. Get the Consent, cover the area and expose adequately.
2. Look carefully for surgical scars in the groin (Recurrent hernia?).
3. See the shape of the lump in the groin. A direct inguinal hernia is usually globular in shape and an indirect one may be sausage-shaped (inguinoscrotal swellings).
4. Ask the patient to cough,
   • To elicit expansile cough impulse.
   • Inorder to visualize a hernia that cannot be seen.
   • To see the full extent of an already visible hernia.
5. ONLY IF the hernia still cannot be seen, ask the patient where the lump is (It may be a scrotal swelling!!) and ask him to stand up at this point & look for a bulge appearing on the groin area on coughing (Very rare to give invisible ones in an exam setting).
6. Once the hernia is visible, demonstrate the palpable expansile cough impulse.
7. ONLY IF there is no past surgical scar indicating a previous repair, differentiate whether it is direct or indirect hernia.
   • Ask the patient himself to reduce the hernia fully for you.
   • If the patient is unable to do so, ask the examiner whether you may try to reduce it (DO NOT try to reduce without the consent of the examiner)
   • ONLY IF the hernia is reduced,
     1. Locate the deep inguinal ring (2methods can be used).
        • 1 cm above the femoral pulse (Easy way).
        • 1 cm above the mid inguinal point (midpoint between the anterior superior iliac spine and pubic tubercle).
     2. Ask to cough while you are applying firm pressure on deep inguinal ring with your index finger.
     3. If the lump can be controlled by digital pressure over the deep ring, it is an “Indirect inguinal hernia”, if not it is a “Direct inguinal hernia”.
8. Examine the external genitalia to exclude phimosis and coexisting scrotal lump which is very common.
9. If the patient was supine throughout your examination, ask him to stand up before you finish and look for,
   • A coexisting small hernia on the other groin.
   • A coexisting varicocele.

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PRESENTATION

This patient has got a globular shaped lump in the right groin region. It has visible and expansile cough impulse. The hernia can be completely reduced and cannot be controlled by applying firm pressure over the deep inguinal ring. He has got no phimosis and there are no coexisting scrotal lumps. The contralateral groin is normal. So my probable diagnosis is uncomplicated right-sided direct inguinal hernia and I would like to offer him inguinal hernia repair under spinal anesthesia.

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FREQUENTLY ASKED QUESTIONS

1/03/2020

Ulcer Examination (OSCE Guide)

Ulcer Examination is a basic short case OSCE skill for all doctors and medical students.

Firstly, introduce yourself and get consent before you proceed to examine the patient. Examination of an ulcer is more or less similar to an examination of a lump. But some additional features have to be kept in mind.

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ULCER EXAMINATION

Inspection
1. Site.
2. Size (Extent).
3. Margin (Shape) – Regular? Irregular?
4. Edge – Sloping? Punched-out? Undermined? Rolled-out? Everted?
5. Floor – Healthy? Granulation tissue? Slough?
6. Discharge? – Serous? Serosanguinous? Purulent? Amount and smell?

Palpation (With a gloved hand)
1. Palpate the margin and edge.
2. Palpate the base – Muscle? Bone?

Palpation (Without gloves) – depending on the type of suspected ulcer from above
1. Temperature of the surrounding skin.
2. Regional lymphadenopathy.
3. Peripheral pulses.
4. Peripheral sensation and joint position sensations (JPS)

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PRESENTATION

Venous Ulcer
There is an ulcer over the right ankle just above the medial malleolus (Gaiter’s area). It is oval in shape, approximately 2cm x 3cm in size. Its margin is irregular, edge is sloping and the floor contains healthy granulation tissue. There is a serous discharge from the ulcer. The ulcer is superficial and the base contains subcutaneous tissue. The surrounding skin is warmer, pigmented and thickened. There are associated varicose veins. Peripheral pulses and sensation are normal and there is no inguinal lymphadenopathy.

Neuropathic Ulcer
There is an ulcer over the sole of the right foot which is oval in shape, approximately 3cm x 4cm in size. Its margin is regular, edge is punched-out and floor contains healthy granulation tissue. There is no discharge from the ulcer. Ulcer is painless, the base contains flexor tendons of toes, surrounding skin and peripheral pulses are normal. Peripheral sensation to pain is absent up to ankles and joint position sensation is impaired.

Ischemic Ulcer
There is an ulcer over the tip of the 2nd toe of the right foot which is round in shape, approximately 1cm x 1cm in size. Its margin is irregular, edge is punched out and floor contains slough. There is a purulent discharge from the ulcer. The base contains bone of the distal phalanx. The surrounding skin is colder and blackish in colour. Dorsalis pedis and posterior tibial pulses are absent and the femoral pulse is weak on the right side. The peripheral sensations are normal and there is no inguinal lymphadenopathy.

Malignant Ulcer
There is an ulcer over the dorsum of the right foot which is irregular in shape, with a maximum diameter of 6cm. There is a purulent discharge from the ulcer. Its margin is irregular, the edge is raised & everted. Floor is reddish-brown and contains slough. There is hard inguinal lymphadenopathy on the right side. Peripheral pulses and sensation are normal.

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FREQUENTLY ASKED QUESTIONS

1/03/2020

Examination of a Lump (OSCE Guide)

Examination of a lump is a component in almost every surgical clinical examination. Sometimes you may be asked to spot diagnose a lump with just inspection. Given below is a rough guide to the examination of a lump.

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LUMP EXAMINATION

Inspection
1. Site, Size, and Shape (SSS).
2. The skin overlying the lump (Scars, Signs of Inflammation, Punctum).

Palpation
1. Surface (Smooth/ Irregular).
2. Edge (Well or poorly defined).
3. Tissue Plane/ Mobility /Fixity – Skin attachment and attachment to underlying structures.
4. Consistency (Soft, Firm or Hard).
5. Cross Fluctuation (Only if soft to firm).
6. Transillumination (Only if fluctuant).
7. Temperature and Tenderness.
8. Reducibility.
9. Pulsatility.
10. Palpable lymph nodes.

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PRESENTATION

There is a hemispherical shaped lump, over the left lateral aspect of the neck, measuring 5cm x 5cm in size. The overlying skin looks normal. Its surface is smooth and the edge is well defined. It is mobile and not attached to the skin or the underlying structures. It is soft in consistency, fluctuant and transilluminant. It is not reducible or pulsatile and there is no associated lymphadenopathy.

Tip: If you are confident enough, make sure that you give a rational presentation, excluding the possibilities one by one for more marks.

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FREQUENTLY ASKED QUESTIONS

1/03/2020

Lipoma Examination (OSCE Guide)

Lipoma Examination is a basic short case OSCE skill the undergraduates must-have. Firstly, introduce yourself and get consent before you touch the patient.

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LIPOMA EXAMINATION

1. Site – Commonly over the front and back of the chest.
2. Size -Medium to large.
3. Shape – Hemispherical.
4. Skin – Scar? (Recurrence?)
5. Surface – Lobulated.
6. Edge – Well defined.
7. Tissue plane – Freely mobile (Slipping sign). Not attached to skin or underlying muscle. Try to elicit the tissue plane of the lipoma by contracting the underlying muscle. When the muscle is contracted,
✓ If the lump becomes prominent – a subcutaneous lipoma.
✓ If the lump becomes less prominent – an intramural lipoma.
8. Consistency – Soft to firm depending on the nature of fat within it.
9. Fluctuance – Fluctuant (Pseudofluctuant).
10. Transillumination – May be transilluminant

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PRESENTATION

There is a hemispherical shaped lump, measuring 5 cm in diameter, over the right scapula. It is not tender, the surface is lobulated and the edge is well defined. The lump is freely mobile. It is not attached to the skin or the underlying muscle. It is soft in consistency, fluctuant and transilluminant.
So, my probable diagnosis is a lipoma and I would like to offer him surgical excision under LA if it is cosmetically unacceptable.

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FREQUENTLY ASKED QUESTIONS