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.
Micrograph of a BCC, showing the characteristic histomorphologic features
By Nephron – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=22082605
First of all, one should understand the difference between the fat embolism and fat embolism syndrome (FES).
Presence of fat globules in pulmonary and peripheral circulation usually following a long bone fracture or major trauma.
A serious consequence of fat embolism producing a distinct pattern of symptoms and signs.
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.
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.
Since it takes time for this pathological process to occur, symptoms and signs appear within 24-72 hours of the primary injury.
At least 1 major and 4 minor should be present to the diagnosis of fat embolim syndrome.
Urine, sputum, serum (specially pulmonary arterial wedge blood sample) – fat globules
Thyroid examination or the examination of a goiter commonly encountered at Surgical OSCE stations.
Firstly, greet the patient and take consent. Make sure you have enough space behind the patient’s chair before proceeding with the examination.
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
1. Simple colloid goiter.
3. Grave’s disease.
1. Prominent nodule of an MNG.
2. Hemorrhage into a colloid cyst.
3. Thyroid adenoma.
4. Thyroid carcinoma.
5. Foci of thyroiditis.
Thyroid lobectomy and look for the histology to decide on further management. If the histology is malignant, the other lobe is also removed later.
Over the right upper lobe laterally while the patient is holding the breath.
It indicates the increased vascularity of the gland (hyperdynamic circulation) – seen in Grave’s disease.
1. Nocturnal dyspnea and cough.
2. Recent onset dysphagia.
3. Deviated trachea.
4. Displaced carotid pulse.
1. Distended neck veins.
2. Positive Pemberton’s sign.
3. The lower border of the goiter cannot be felt.
4. Retrosternal dullness.
1. Recent rapid enlargement.
2. Recent voice change (Hoarseness).
3. Hard in consistency.
4. Cervical lymphadenopathy.
5. Irregular margins.
6. Multiple attachments.
1. Lid lag.
2. Lid retraction.
It moves upward with deglutition as well as with the protrusion of the tongue when the jaw is fixed. Being in midline differentiates it from goiters.
1. Cosmetically unacceptable.
2. Prone to get infected.
3. May undergo malignant transformation.
Sistrunk procedure (Complete excision of the cyst and its tract together with the middle part of the body of the hyoid bone).
1. Cosmetically unacceptable (Patient’s wish).
2. Compressive symptoms.
3. Secondary thyrotoxicosis.
4. Suspected or proven malignancy.
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.
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.
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.
Method One – 1 cm above the femoral pulse (Easy way).
Method Two – 1 cm above the mid inguinal point (midpoint between the anterior superior iliac spine and pubic symphysis).
No. Once a hernia is repaired, its anatomy is disturbed. So a recurrence of a hernia arises from the weakest part of it. Hence it is neither direct nor indirect.
Yes, it can be.
1. Not enough pressure applied.
2. Finger is not on the deep inguinal ring.
Anyway, this method is just for crude assessment. The direct or indirect nature of a hernia is best identified during the surgery.
It comes from deep inguinal ring, passes obliquely through the inguinal canal and may continue through the superficial inguinal ring to the scrotum. It arises lateral to the inferior epigastric artery. Commonly due to persistent processes vaginalis.
It occurs as a result of weakened posterior wall of the inguinal canal and arise medial to the inferior epigastric artery. So a direct inguinal hernia is not within the spermatic code. It may descend to the scrotum though.
No importance! Management is the same for both.
Inferior epigastric artery.
As early as possible due to the high risk of strangulation.
1. Mesh repair (Gold standard).
2. Darning repair.
3. Bassini repair.
4. Shouldice repair.
Indirect inguinal herniae require both herniotomy (excision of the hernia sac) & herniorrhaphy (hernial repair) while direct inguinal herniae usually only necessitate herniorrhaphy.
1. Chronic cough.
3. Cigarette smoking.
4. Bladder outflow obstruction (BOO)
1. Acute urine retention.
2. Hematoma formation.
5. Ischemic orchitis.
Less than 1%.
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.
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)
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.
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.
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.
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.
It is a break in the continuity of an epithelial surface.
1. Margin – The line of demarcation between normal and affected tissue.
2. Floor – Exposed bottom of the ulcer.
3. Edge – It connects the margin to the floor.
4. Base – The area in which the ulcer rests.
1. Sloping – Venous ulcer.
2. Punched-out – Ischemic ulcer.
3. Undermined – Tuberculous ulcer.
4. Rolled-out – Basal cell CA.
5. Everted – Squamous cell CA.
1. Peripheral vascular disease.
2. Varicose veins.
3. Peripheral neuropathy.
4. Squamous cell carcinoma.
5. Sickle cell disease.
1. Uncontrolled diabetes.
2. Chronic alcoholism.
3. Vitamin B12 deficiency.
1. Painless ulcers.
2. Associated glove & stocking type of sensory loss.
3. Normal surrounding skin.
1. Peripheral neuropathy.
2. Peripheral vascular disease.
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.
1. Site, Size, and Shape (SSS).
2. The skin overlying the lump (Scars, Signs of Inflammation, Punctum).
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.
10. Palpable lymph nodes.
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.
Using the thumb of the examining hand, the skin over the lump is stretched in two directions perpendicular to each other. If the skin is freely movable over the lump, the lump is not attached to the skin.
This method is not accurate as the lump may be attached to the skin at a point other than the site of pinching.
First, the lump should be fixed between the two feeling fingers (the index finger and the thumb) of one hand and press on the lump using the index finger of the other hand. If you can see the feeling fingers moving apart with each press, it is fluctuant. The same technique of examination should be carried out twice in two directions perpendicular to each other, “Cross Fluctuations”.
That means the lump is cystic; in other words, it contains fluid. But lipomas (fat cells) can show pseudofluctuations.
That means the fluid inside is clear and does not absorb light. Some lumps are brilliantly transilluminant.
Lipoma Examination is a basic short case OSCE skill the undergraduates must-have. Firstly, introduce yourself and get consent before you touch the patient.
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
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.
It is a benign tumour that consists of mature fat cells.
It is characterized by multiple painful lipomas.
No. But liposarcoma can occur de novo.
Usually by reassurance. But surgery is offered if the patient complains of pain or if it is cosmetically unacceptable. It is removed by either simple surgical excision under LA. Alternatively, suction lipolysis can be used.