Basal Cell Carcinoma


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.


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


  • 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)



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

Micrograph of a BCC, showing the characteristic histomorphologic features

By Nephron – Own work, CC BY-SA 3.0,


  • 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
    • The types other than the above-mentioned ones




  • 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



What is Fat Embolism?


What is Fat Embolism?

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


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.


  • 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%


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


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.


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


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


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



  • 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



Basal Cell Carcinoma

Basal Cell Carcinoma (BCC) is a slow-growing locally invasive malignant tumour (malignant [more]


Heart Sounds & Murmurs

Auscultation for heart sounds is mainly done in 4 areas, namely Mitral, Tricuspid, Aortic & [more]


Respiratory Examination (OSCE Guide)

Ideally, the patient should be examined in the sitting position. Position the [more]

Thyroid Examination (OSCE Guide)


Thyroid Examination (OSCE Guide)

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.

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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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. What are the causes of diffuse thyroid enlargement?

1. Simple colloid goiter.
2. Thyroiditis.
3. Grave’s disease.

2. What are the differential diagnosis for a solitary nodule of the thyroid (SNT)?

1. Prominent nodule of an MNG.
2. Hemorrhage into a colloid cyst.
3. Thyroid adenoma.
4. Thyroid carcinoma.
5. Foci of thyroiditis.

3. What would be the next management option, if the histology of an SNT comes as follicular neoplasm?

Thyroid lobectomy and look for the histology to decide on further management. If the histology is malignant, the other lobe is also removed later.

4. Where would you auscultate for a bruit?

Over the right upper lobe laterally while the patient is holding the breath.

5. What is the significance of a thyroid bruit?

It indicates the increased vascularity of the gland (hyperdynamic circulation) – seen in Grave’s disease.

6. What are the compressive features?

1. Nocturnal dyspnea and cough.
2. Recent onset dysphagia.
3. Deviated trachea.
4. Displaced carotid pulse.

7. What are the features of retrosternal extension?

1. Distended neck veins.
2. Positive Pemberton’s sign.
3. The lower border of the goiter cannot be felt.
4. Retrosternal dullness.

8. What are the malignant features?

1. Recent rapid enlargement.
2. Recent voice change (Hoarseness).
3. Hard in consistency.
4. Cervical lymphadenopathy.
5. Irregular margins.
6. Multiple attachments.

9. What are thyroid eye signs?

1. Lid lag.
2. Lid retraction.
3. Exophthalmos.
4. Proptosis.
5. Ophthalmoplegia.

10. How do you identify a thyroglossal cyst?

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.

11. Why do we have to excise thyroglossal cysts?

1. Cosmetically unacceptable.
2. Prone to get infected.
3. May undergo malignant transformation.

12. What is the surgical procedure for a thyroglossal cyst?

Sistrunk procedure (Complete excision of the cyst and its tract together with the middle part of the body of the hyoid bone).

13. What are the indications for thyroidectomy for a multinodular goiter (MNG)?

1. Cosmetically unacceptable (Patient’s wish).
2. Compressive symptoms.
3. Secondary thyrotoxicosis.
4. Suspected or proven malignancy.



Inguinal Hernia (OSCE Guide)


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.


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.


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.


1. How do you locate the deep inguinal ring?

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).

2. If you see a scar of a previous repair, do you still want to locate the deep inguinal ring?

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.

3. If you cannot control the hernia by applying firm pressure over the deep inguinal ring, can it still be an indirect hernia? Why?

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.

4. From where does an indirect inguinal hernia appear?

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.

5. From where does a direct inguinal hernia appear?

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.

6. What is the importance of differentiating direct and indirect inguinal hernia?

No importance! Management is the same for both.

7. What is the landmark to differentiate direct from indirect inguinal hernia during the surgery?

Inferior epigastric artery.

8. At what age, inguinal hernia are operated on children?

As early as possible due to the high risk of strangulation.

9. What are the treatment options?

1. Mesh repair (Gold standard).
2. Darning repair.
3. Bassini repair.
4. Shouldice repair.

10. What is the difference in surgical steps of managing inguinal herniae?

Indirect inguinal herniae require both herniotomy (excision of the hernia sac) & herniorrhaphy (hernial repair) while direct inguinal herniae usually only necessitate herniorrhaphy.

11. What are the aetiological factors?

1. Chronic cough.
2. Constipation.
3. Cigarette smoking.
4. Bladder outflow obstruction (BOO)

12. What are the complications of inguinal herniae?

1. Irreducibility.
2. Obstruction.
3. Strangulation.
4. Incarceration

13. What are the complications of the surgery?

1. Acute urine retention.
2. Hematoma formation.
3. Pain.
4. Infection.
5. Ischemic orchitis.
6. Recurrence.

14. What is the risk of recurrence after a Mesh repair?

Less than 1%.



Examination of a Lump (OSCE Guide)


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.


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.
8. Reducibility.
9. Pulsatility.
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.


1. How do you elicit the skin attachment of a lump?

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.

2. Why “pinching” the skin over the lump is not the ideal way?

This method is not accurate as the lump may be attached to the skin at a point other than the site of pinching.

3. How do you elicit fluctuations?

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”.

4. If it is fluctuant, what does that mean?

That means the lump is cystic; in other words, it contains fluid. But lipomas (fat cells) can show pseudofluctuations.

5. If it is trasilluminant, what does that mean?

That means the fluid inside is clear and does not absorb light. Some lumps are brilliantly transilluminant.


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