Surgery
Surgery
Surgery
1. HISTORY :
A. Age Group: When examining a patient with a neck mass the first consideration
should be the patients age group: pediatric (upto 15 yrs), young adult (16 to 45 yrs) or old
adult (more than 40 yrs). Within each group, the incidence of congenital, inflammatory
and neoplastic diseases fit into one of these three categories. Pediatric patient generally
exhibits inflammatory neck masses more frequently than congenital ones and
developmental more than neoplastic masses. This incidence is similar to that found in
younger adults. In contrast, the first consideration in older adults should always be
neoplasia with a smaller emphasis on inflammatory masses and even less emphasis on
congenital masses.
B. Location of Mass: The next consideration should be the location of the neck mass.
This is particularly important in the differentiation of congenital and development masses
because they usually occur in consistent locations. The location of a mass is both
diagnostically and prognostically significant. The spread of head and neck carcinoma is
similar to inflammatory diseases, generally following an orderly lymphatic spread. The
appearance and location of a metastatic neck mass may be the key to identifying the
primary tumour or source of infection.
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2. CLINICAL EXAMINATION :
The most important diagnostic step is the physical examination of head and neck.
Visualization and palpation are the most important components of the clinical evaluation.
There help determine the location of mass according to anatomic lymphatic drainage
area, the size of lesions and its relationship (fixation or displacement) to surrounding
structures, the consistency of mass, presume of any pulsations or thrills. The physician
should perform an indirect mirror of flexible endoscopics examination of all mucosal
surface of the upper aerodigestive tract. These areas should also be palpated even when
no lesion can be seen specifically the primarily site for lymphatic drainage to the location
area of the mass is question.
Often, even the most thorough physical examination only gives a general
impression of the derivation of mass – vascular, salivary, nodal; inflammatory, congenital
or neoplastic and not a firm diagnosis. At this point a battery of test are available for
help.
3. INVESTIGATION
C. Needle Biopsy:- Gold standard in diagnosis of a neck mass; use small gauge
needle; obtain flow cytometry of lymphoid population.
E. Open Biopsy:- Use only after workup is complete and if diagnosis is not evident;
specimen for histologic frozen section, be prepared to do simultaneous neck dissection.
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F. CT & MRI:- Single most informative test; differentiates cyst from solid lesions;
locates mass within or outside the gland or within a nodal chain mucosal disease
enhancement, provides anatomic relationships.
Micro amounts of tissue obtained by fine needle aspiration have been studied by
flow cytometry for lymphoma diagnosis and polymerase chain reaction (PCR) to identify
the Epstein Barr Virus (EBV) diagnosis of primary nasopharyngeal carcinoma.
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FNA biopsy is needed for staging and planning purpose in a patient of distant
metastasis, to make a tissue diagnosis to initiate non-surgical therapy and in a patient
with unknown mass.
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of lymphatic drainage and manipulation of a metastasis decreases the chances for clean
surgical excision and cure.
In a patient who present with a neck mass and in whom prior routine physical
examination of head and neck is negative, an independent second survey of the less
visible areas of upper aerodiagnostic tracts is the most cost effective diagnostic tool.
Direct endoscopic examination should be performed after T2-weighted MRI because of
its better delineation of submucosal disease.
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National Board of Examinations, Cases Surgery
The neck mass in a patient with a known primary neoplasm of the head and neck
should be managed according to the principles for each primary site. In general clinically
positive cervical lymphnode metastasis are present, a complete cervical
lymphadenectomy should be done alongwith removal of primary tumour.
Thyroid neoplasm, both benign and malignant, are a leading cause of anterior
compartment neck masses in all age groups. In the pediatric group, thyroid-neoplasm
frequently show a male predominance as well as increased incidence of malignant
disease. In contrast, the young adult and older groups show a greater incidence of benign
conditions and a female preponderance. Ultrasound, thyroid function tests, thyroid scans
can be considered for patients having an anterior compartment neck mass. Cystic lesions
of thyroid found on ultrasound should be aspirated. Solid lesion should be managed
according to there activity on nuclear scan. Functioning nodules should be managed by
suppression and all non-functioning cold nodules should be explored with appropriate
concomitant therapeutic measure being taken on the basis of histology and extent of
disease.
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diagnostic test of preference is open biopsy in the form of complete submandibular gland
removal of superficial parotidectomy.
Lipomas are ill defined soft masses that occurs in various neck locations in patient
older than 35 yrs. These are asymptomatic and on CT scan a lipoma appears as a fat air
density. Surgical excision is advised.
Branchial cleft cyst most commonly occur in late childhood or early adulthood.
They frequently follow an upper respiratory tract infection, and they persist as soft,
doughy, variable size masses in anterior triangle of neck, after a course of antibiotic
therapy. Ultrasound scan can be helpful in identifying the lesions as cystic. Aspiration
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of the content yields a milky, mucoid, brownish fluid which often contains cholesterol
crystals. Management involves initial control of local infection followed by surgical
excision of cyst and its entire tract.
Thyroglossal duct cyst are anterior neck, midline structure often appear after an
upper respiratory tract infection. USG can be used to differentiate the persistant mass
from a lymphnode, a dermoid cyst, or thyroid tissue. A pathognomic sign is vertical
motion of the mass with swallowing and tongue protrusism. Radionucleotide scanning
being reserved for cyst in the tongue base, which must be differentiated from
undescended lingual thyroid tissue. The cyst tract should be completely removed,
alongwith the mid portion of the hyoid bone.
Lymphangiomas usually occur at birth or evident within first year of life, located
commonly in posterior triangle of neck. The cervical lymphangioma is a fluctuant,
diffuse, soft, spongy mass, often having indiscrete margin. Its extent is often much
greater than apparent. Transillumination is diagnostic. The lesion should be excised if it
is easily accessible or is affecting vital functions. Sclerotherapy represents as option in
extensive lesions with a high risk of recurrence or complication.
Newer Pulse dye lasers management is being advocated. Local resection of some
lesions is also advocated for better end result cosmesis.
Dermoid cysts occurs most commonly in pediatric patient and young adults,
slowly enlarge because of accumulation of sebaceous content unlike sebaceoun cyst they
lie deep to cervical facia and skin moves freely over them. These cysts are curved by
simple complete excision.
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Lymphadenitis, occurs in nearly every person at some point in life, especially
during the first decade of life. Lymphadenopathy caused by bacterial or viral infection of
the upper respiratory tract, is so common that it is an expected sign.
Granulomatous inflammatory diseases affects specific age group and locations
like tuberculosis, atypical tuberculosis and actinomycosis common in pediatric group.
Excisional biopsy is usually diagnostic and curative. Incisional biopsy should be avoided
due to the sequalate of a chronic draining fistula.
Cervical lymphnode hyperplasia is ubiquitous in human immunodeficiency
virus(HIV) positive patient. Tender enlarging nodes should make one suspicious of
tuberculosis or nocardia species – infection, whereas non tender enlarging head and neck
nodes often indicates ‘Kaposi’s’ sarcoma or Burkitt’s lymphoma.
Sequelae of trauma occasionally present as a neck mass. In pediatric patients.
Haematoma, due to forcep delivery, can result a mass in anterior neck within the
sternomasthoid muscle, which organized later on. Heat massage and observation are
often associated with resolution. Continued growth or increasing torticollis indicate
surgical explorations.
Pseudoaneurysm of major vessels are occasionally associated with blunt trauma neck.
Neuromas are small neck mass that found after surgery, especially radical neck
dissection commonly in post triangle of neck. They occur from sensory nerve ending
commonly from great anvicular nerve (C2 – 3). Neuromas are tender, associated with
sharp shooting pain on palpation, quite slow in growth and require excision.
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National Board of Examinations, Cases Surgery
SPECIALTY : SURGERY
CASE : ASCITES
NAME OF THE EXPERT : Dr. Satinder Singh Kaushal, Prof. & Head,
Medicine, IG Medical College, Shimla.
ASCITES
Healthy men have no intra-peritoneal fluid but woman may normally have as much as
20ml depending on phase of the menstrual cycle.
HISTORY
CLINICAL EXAMINATION
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GENERAL PHYSICAL EXAMINATION
LEVEL OF CONSCIOUSNESS – Drowsy, Stuprosed or Comatosed.
ORIENTAION – Time, place, person.
- JAUNDICE
- SIGN OF LIVER CELL FAILURE – Palmar erythema, Spider Angioma,
Gynecomastia, testicular atrophy, white nails.
SYSTEMIC EXAMINATION
ABDOMEN-
INSPECTION - Distension – fullness in flanks.
UMBLICUS – everted or transversaly stretched, umblical NODULE – firm immobile
mass at umbilicus peritoneal carcinomatosis also knows as SISTER MARY
JOSEPH’S NODULE – Periumblical radiating veins (Caput madusae)
INVESTIGATION
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ABDOMINAL PARACENTESIS & ASCITIC FLUID ANALYSIS
GROSS APPEARANCE
Clear, Straw Colored – Cirrhosis, tuberculosis.
Blood – Malignancy, tuberculosis.
Cloudy – infection, Spontaneous bacterial peritonitis
Chylous, Milky – Lymphatic obstruction.
CYTOLOGY- Normal ascitic fluid has less than 500 leukocytes/ml and less than 250
Polymorphs / ml.
Neutrophils more than 250 Cells/ml Bacterial peritonitis.
Predominance of lymphocytes suggest tubercular or malignancy.
Malignant Cells indicate some malignancy (58-75% sensitive to detect malignant
ascites).
TOTAL PROTEIN-
Earlier terminology of Transudative (Protein < 3 g/dl) and exudative (Protien > 3 g/dl)
has been completely replaced by SAAG.
DIFFERENTIAL DIAGNOSIS
Cirrhosis liver
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Fulmimant Hepatic failure Hypoalbuminemia
Budd-Chiari Syndrome Nephrotic Syndrome
Congestive Heart failure Protein losing enteropathy
Constrictive Pericarditis Diseased Peritoneum
Portal Vein Thrombosis Infections
Hypothyroidism Tuberculosis
HIV associated Peritonitis
Bacterial Peritonitis
Malignant Conditions
Hepatocellular Carcinoma
Pseudo myxoma peritonei
Miscellaneous
Chytous Ascites
Pancreatic ascites
Familial Mediterranean Fever
Vasculitis
Biliary ascites.
ASCITES at times may be confused with
i) Ovarian cyst
ii) Gaseous distension
iii) Obesity
iv) Rarely pregnancy.
MANAGEMENT
DIURETIC THERAPY
Spironolactone (100-400 mg) is drug of choice, since it is powerful aldosterone
antagonist. Some patients may require loop diuretic (Furosemide) starting from 40mg
per day to a maximum of 160 mg/day, in stepwise fashion every 4-5 days.
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The best method of assessing the effectiveness of diuretic therapy is by monitoring body
weight and urinary sodium levels. In general the goal of diuretic treatment should be to
achieve weight loss of 300-500 g/d in patients without edema and 800-1000g/d in
patients with edema. Once ascites has disappeared, diuretic treatment should be adjusted
to maintain the patient free of ascites.
Diuresis is improved if patients are RESTED IN BED while
diuretics are acting, perhaps because renal blood flow in increases in the horizontal
positon.
An indication of the minimum effective dose of spironolachone may be obtained by
monitoring urinary electrolyte concentrations for a rise in sodium and fall in potassium
concentration, reflecting effective competitive inhibition of aldosterone.
PARACENTASIS
Patients with tense ascites esp with respiratory embarrassment require therapeutic
paracentesis.
The removal of 5 Litres of fluid is considered large volume paracentasis. Recent studies
demonstrate that supplementing 5 gm of albumin per each liter over 5 litres decreases
complications of paracentasis such as electrolyte imbalances and increases is serum
creatinine secondary to large shifts of intravascular volume.
Intravenous colloid such as human albumin solution (6-8 gm per litre of ascites removed)
or another plasma expander (dextran) can be used in large volume paracentasis.
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COMPLICATION OF ASCITES
PROGNOSIS
In cirrhosis liver only 10-20% patients survive 5 year from the appearance of ascites.
SPECIALITY :- SURGERY
CASE :-
SALIVARY GLAND TUMOR
NAME OF THE EXPERT :-
DR VIKRAM KATE
D-II/4, JIPMER QUARTERS,
JIPMER, PONDICHERRY- 605006
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History suggestive of trismus indicates infiltration of malignant tumour in the
massetter or pterygoid muscles.
Any other swellings in the neck if present are suggestive of lymph nodal
metastases.
2. Clinical Examination
Examination of the ear lobule. Commonly lifted by parotid tumors.
Physical examination of the swelling- site, size, surface, consistency, mobility
and plane of the swelling. Fixity of submandibular or other salivary tumours
to mandible evaluated.
Intraoral examination
Medial displacement of the lateral oropharyngeal wall and tonsillar
bed for enlargement of deep lobe parotid tumours.
Examination of Stensen’s and Wharton’s duct for inflammation ,
discharge of fluids or stones. Sialadenitis can mimic salivary gland
tumour. Bidigital examination of Stensen’s ducti and palpation of
the Wharton’s duct in the floor of the mouth.
Bidigital examination of the submandibular gland swelling to
differentiate from submandibular lymph nodal enlargement. As
submandibular swelling enlarges on either side of mylohyoid
muscle, it is palpable bidigitally.
Examination of the facial, lingual and hupoglossal verves. Facial
involved with malignant parotid tumour and lingual / hypoglossal
with malignant submandibular gland tumour.
Evaluation of trismus if patient has complained in history.
Examination of the cervical lymph nodes.
3. INVESTIGATIONS
Fine needle aspiration cytology is the investigation of choice
to confirm diagnosis
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CT and MRI are the most useful imaging techniques to
evaluate the extent of the spread of the salivary gland tumours. It also
helps in identifying deep lobe enlargement of the parotid tumours.
Open and true cut needle biopsy is contraindicated as it
leads to tumour seeding. Open biopsy can be done if the tumour has
ulcerated.
4. DIFFERENTIAL DIAGNOSIS
Enlarge lymph nodes, soft tissue tumours and sialadenitis are common
conditions which can simulate the clinical picture of a salivary gland
tumour.
DD of salivary gland tumours :
o Pleomorphic adenoma is the commonest benign tumour.
o Mucoepidermoid carcinoma is the commonest malignant tumour.
o Other benign tumours include Warthin’s tumour (papillary
cystadenoma lymphomatosum) and rarely oncocytoma, lipoma,
hemagioma,
o Other malignant tumours include acinic cell adenocarcinoma,
adenoid cystic carcinoma, squamous cll carcinoma, carcinoma ex-
pleomorphic adenoma.
5. NON-SURGICAL MANAGEMENT
Surgery is the mainstay of treatment for salivary gland
tumours.
Radiotherapy (RT) is indicated for the treatment of malignant
salivary gland tumours. Indications for RT in malignancy include
o Extraglandular disease
o Perineural invasion
o Direct invasion of regional structures
o Regional metastases
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o High grade malignancy
RT may be indicated following excision of recurrent pleomorphic adenoma
to reduce the possibility of further recurrence.
6. SURGICAL MANAGEMENT
Specific parotidectomy is the treatment of choice for bengin parotid gland
tumours of the superficial lobe. Total parotidectomy is done when deep
lobe is involved.
Excision of the submandibular gland, sublingual or minor salivary gland is
the treatment of choice for benign tumours of these organs.
Incisions for the excision of the parotid and submandibular gland-
a. Parotid- lazy S incision, modified Blair incision, Sistrunk’s incision.
b. Submandibular- Incision is 3-4 cm below and parallel to the lower
border of the horizontal ramus of the mandible.
The nerves at risk during salivary gland surgery-
a. Facial with parotid gland surgery. Identification aids for facial
nerve on operation table: Conley’s tragal pointer, posterior belly
of digastric nerve stimulator, retrograde dissection.
b. Marginal mandibular, lingual and hypoglossal with
suybmandibular gland surgery.
Malignant tumours of the parotid-
a. When facial nerve is not infiltrated, superficial
parotidectomy for a superficial lobe tumour and total
conservative parotidectomy is performed when the tumour
extends into the deep lobe. Facial nerve is conserved.
b. With high grade tumoursinfitrating the facial nerve,
radical parotidectomy with elective excision of the facial
nerve is done.
c. If metastases in lymph nodes are present, a modified
radical neck dissection from Level I to Level V is done.
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Malignant tumors of other salivary glands-
a. Radicial excision with en-bloc removal of lymph
nodes if involves
b. When frank infiltration of the lingual or hypoglossal
nerve present, excision of these nerves is done.
Complications of surgery for salivary glands
a. Temporary/permanent facial weakness.
b. Frey,s syndrome.
c. Sialocele.
d. Marginal mandibular/lingual/ hypoglossal nerve
injury.
7. Any other
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National Board of Examinations, Cases Surgery
SPECIALITY: SURGERY
CASE: INGUINO-SCROTAL SWELLINGS
EXPERT: DR. P SAMPATH KUMAR
Inguino-Scrotal Swellings
1. HISTORY
Swelling:
Whether swellings appears on standing or straining like coughing
Swelling disappears on lying down
An existing swelling increases in size on straining
Reducibility:
Reducible either spontaneously or manually by the patient
Reducible easily on lying down (Direct inguinal hernia)
Swelling initially reducible but now-a-days not (Irreducible or
obstructed)
Swelling was never reducible
Pain:
Pain associated with abdominal distension, vomiting and
constipation:
Obstructed or Strangulated hernia.
Precipitating factors:
Cough, attacks of breathlessness:
Brochial asthma, Chronic bronchitis
Straining during micturition
Constipation
2. CLINICAL EXAMINATION
Inspection:
Extent :
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Inguino-Scrotal swelling
Cough impulse
Reducibility on lying down
Palpation:
Inflammatory signs like tenderness, local warmth
Getting above the swelling:
Whether able to get above the swelling (Should be negative)
Expansile cough impulse
Reducibility
Reduces with gurgle (Enterocoele)
Relation to pubic tubercle (differentiate form a femoral hernia)
Internal ring occlusion test
Location of internal inguinal ring
Fluctuation
Transillumination (only if fluctuation is positive)
Testis whether separately felt
Testis enlarged
Tenderness of testis and epididymis
Spermatic cord:
Thickening of Spermatic cord
Opposite side scrotal and groin examination
Abdominal examination:
Abdominal wall tone and Malgaigne’s bulges
Ascitis
Loaded colon
Distended urinary bladder
Genitalia examination:
Phimosis, urethral stricture
Per rectal examination:
Prostate enlargement
Respiratory and Cardiovascular examination
3. INVESTIGATIONS
Ultrasound examination:
Scrotal ultrasound if there is doubt about testicular tumour
X-Ray Chest P.A.
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4. DIFFERENTIAL DIAGNOSIS
5. NON-SURGICAL TREATMENT
6. SURGICAL TREATMENT
7. ANY OTHER
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SPECIALITY: SURGERY
CASE:GENERALISED LYMPHADENOPATHY
EXPERT:DR. V PARI
GENERALISED LYMPHADENOPATHY
(MUST KNOW)
I. HISTORY
3) Others
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III. DIFFERENTIAL DIAGNOSIS
IV. INVESTIGATIONS
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5) Secondaries with known primary
V. MANAGEMENT
1. Non surgical
a) Acute lymphadenitis
- appropriate antibiotics & drainage SOS
b) Tb adenitis –ATT & Drainage SOS
c) Lymphoma-Stage la, IIa- Radiotherapy (RT)
d) Secondaries with unknown primary
Stage. N1, N2a, 2b – curative comprehensive RT
Stage. N2C and N3 – SCC – Palliative RT
Adeno Ca. Palliative Chemo
e) Secondaries with known primary
Early disease - Comprehensive Curative RT to
Both local & Nodal disease
Advanced disease-Palliative RT/Chemo
2. Surgical:
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VI. OTHERS
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SPECIALITY: SURGERY
CASE: HEPATOSPLENOMEGALY
EXPERT: DR. H. S. BHANUSHALI
Hepatosplenomegaly
1. HISTORY
Chief complaints :-
Duration of Complaints
Of Swelling in abdomen
H/o fever with rigors
Pain in ® and (L) hypochondrium
Duration of presence of Ascites
Past History :-
H/o alcoholism
H/o Jaundice
H/o haematemesis
H/o fever with rigors
Loss of appetite
H/o visits to endemic areas (Bihar etc)
Personal History :-
Loss of appetite/Weight
H/o Smoking
Visits to Kala azar area (like Bihar)
H/o Treatment with drugs
2. GENERAL EXAMINATION
Abdominal Examination :-
Supine Position
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Inspection :-
Swelling or distention of Abdomen
Any umbilical veins
Swelling if present – moves with respiration
Hernial Orifices
Testes
Palpation :-
Liver (Enlarged), can not insinuate fingers between costal margins and
liver surface
Moves with respiration (confirmed)
Smooth or nodular surface
Spleen :-
Percussion :-
Grade of Enlargement
To R/o Ascites
Shifting dullness
Examination in knee elbow position
Liver span for upward enlargement
PR/Proctoscopy
4. INVESTIGATIONS
Routine
CBC – Abnormal cells, with Blood for malaria parasites and kala azar
Urine
Blood sugar
Liver Function tests – S. Bilirubin Alb.
S. Protein Globulin
S. Alkaline Phosphotase
SGPT/SGOT/SGGT
Protbrombin time and Index
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Specific :-
Hbs Ag
HCV
USG for Liver, Spleen, Ascites, any other gland or mass
CT Scan with contrast to know any other mass, portal and splenic veins
size
Gastroscopy for oesophageal varices, to R/o any malignancy in
oesophagus
Stomach, duodenum
Spleno portovenogram (Non Invasive) for splenic vein and portal vein
morphology
Bone marrow
Ascitic fluid examination
5. DIFFERENTIAL DIAGNOSIS
6. NON-SURGICAL MANAGEMENT
7. SURGICAL TREATMENT
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III. Resection of Ca upper GI, if operable
SPECIALITY : SURGERY
CASE : BREAST NODULE
NAME OF EXPERT : DR. B.S. GEDAM
127, SUYOGNAGAR NAGPUR
History
- Patient’s Name
- Age
- Duration of lump
- H/o – Pain – Nature, Severity, whether associated with menstruation.
- Fever
- Increase in size
- Cough, expectoration
- Whether received any treatment
Clinical examination :-
- General examination - Pallor
- Jaundice
- Local - Location – quadrant of the breast
- Size
- Overbuying skin
- Prominent veins
- Tethering
- Peau de arange
- Uleration
- Nodule on the skin
Nipple – wheter retracted
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- Whether recent retraction
- Areola
Surface of the hump
- Smooth
- Irregular
Local temp
Tenderness
Consistency
Fixity to - Overbuying skin
- Underlying muscle
Systemic examinaton
- Chest
- Abdomen - Hepatomegaly
- Ascites
Investigations:-
- FNAC
- Biopsy if FNAC in not conclusive.
If Bemign nodule – Pre operative investigations
If Malignant - X Ray chest
- Liver function tests
- USG – abdomen - Liver
- Ascites
- Pelvis - ovaries
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X-Ray of bones, if bony pains
- Bone scan if suspicion of Secondaries.
Differential Diagnosis
Fibroadenoma
Carcinoma of Breast
Simple Cyst
Tuberculosis of breast
Chronic breast abscess
Treatment
Depending upon the final diagnosis.
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National Board of Examinations, Cases Surgery
SPECIALITY : SURGERY
CASE : VARICOSE VEINS &
PERIPHERAL VASCULAR
DISEASE OF LOWER LIMB
NAME OF EXPERT : N.S. HADKE
PROFESSOR OF SURGERY
MAULNA AZAD MEDICAL
COLLEGE, NEW DELHI.
They should ensure that the following key issues are demonstrated/discussed
during long and short case presentation
Aims:
1. Must understand anatomy and physiology of venous system of lower
limb.
2. Must be able to differentiate between primary varicose veins and
secondary varicose veins especially postphlebitic limb.
3. Decide management protocol.
History
1. Must be able to differentiate pain of venous origin from pain of vascular
Insufficiency and other types of pain such as osteoarthritis.
2. Must include history suggestive of secondary varicose veins, especially
history suggestive of deep venous thrombosis.
Clinical examination
1. Must be able to perform Trendlenberg’s test and interpret the results.
2. Must be able to perform three tourniquet test and interpret the results.
3. Must be able to perform Modified Perth’s test and interpret the results.
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National Board of Examinations, Cases Surgery
Investigations
1. Must know the role of Doppler/Duplex scan indications, advantages
and limitations.
2. Must know the types of venographies and their current status in
management of varicose veins.
Nonopereative Management
1. Must know the indications and various aspects of nonoperative
management such as elastic stockings.
2. Must know the indications and contraindications of various operative
procedure such as Trendlenberg’s flush ligation, stripping, Radical
perforator ligations (Open and endoscopic)
3. Must know role of sclerothterapy.
4. Should know principle of management of Postphlebitic limb with
chronic venous insufficiency.
They should ensure that the following key issues are demonstrated/discussed
during long and short case presentation.
Aim:
1. The postgraduate students must be able to differentiate between
Atherosclerosis and thromboangitis obliterans (TAO) as a cause of
ischemia.
2. Reasons for differentiating the two.
3. Decide management protocol.
History:
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National Board of Examinations, Cases Surgery
1. Must include all the differentiating features of atherosclerosis and TAO.
2. Must mention the progression of the disease.
3. Risk factors for the particular disease must be included.
Clinical examination
1. Must be able to identify the type of Gangrene.
2. Must be able to evaluate the evidence of ischemia to skin and
subcutaneous tissue and its proximal extent.
3. Must be able to evaluate ischemia to muscle and its proximal extent.
4. Must be able to evaluate all peripheral pulsations and compare with
opposite side.
Investigations:
1. Must know relevance of ankle – brachial pressure index.
2. Must know about Duplex scan/Doppler evaluation, their advantages
and limitations.
3. Should know about indication for arteriography both invasive and MR
angiography. Their advantages and limitations.
Surgical Management
1. Must know the indications for amputations
2. Must know indications for sympathectomy
3. Should know indications of other surgical modalities to augment
vascularity
4. Must know role of direct arterial manipulations endovascular/Surgical.
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National Board of Examinations, Cases Surgery
SPECIALITY : SURGERY
CASE : SOFT TISSUE TUMOURS OF THE TRUNK
NAME OF EXPERT : DR. Y.E. MISTRY, JUBILEE MISSION MEDICAL
COLLEGE& RESEARCH INSTITUTE, P.B. NO.737,THRISSUR – 680 005
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(4) Excisional Biopsy Tumours 5cms or smaller entire lesion
with margin of clear tissue excised.
Malignant
(1) Melanoma
Squamous cell carcinoma eg. Marjolin ulcer
Sarcomas
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Mixed tumours
MANAGEMENT
(1) Surgery
Local excision
Local excision with wide margins
Local excision with lymph node dissection
Local excision with reconstruction – free flaps
Post OP – compression dressing
Suction drains to prevent seromas which hamper
institution of
radiotherapy
(2) Radiation pre op or post op external beam and radiation, Brachy therapy.
(4) Only radiation in patients who refuse surgery effective in certain sarcomas.
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SPECIALITY : SURGERY
CASE : INGUINOSCROTAL
SWELLINGS
NAME OF EXPERT : DR. DILIP P. AMENKAR,PROFESSOR & HEAD,
DEPARTMENT OF SURGERY, GOA MEDICAL COLLEGE, BAMBOLIM –
GOA.
Write in details about the swelling in first paragraph, details about the pain in the
second paragraph and in the next paragraph write about any straining factor and
any systemic symptoms.
* Patinet was apparently well before he had noticed the swelling in
groin….months/year
back.
* Mode of onset- gradual or acute.
* How did the swelling appear first – following straining or spontaneously.
* Where did the swelling appear first – in the groin or in the scrotum.
* Progress of the swelling-size and extent of the swelling at onset-whether the
swelling
descended from groin to the scrotum or from scrotum to the groin.
* What happens to the swelling when the patient stands up, walks about the
strains.
* What happens to the swelling when the patient lies down.
* Any period of irreducibility of the swelling and abdominal pain.
* Any inguinoscrotal swelling on the opposite side.
In the next paragraph write about the history of pain.
* Site of pain, in the groin or ever the swelling, abdomen.
* Any radiation of pain.
* Character of pain-usually dull aching.
* Relation of pain with straining-usually pain increases with straining.
* How is the pain relieved-usually relieved on lying down.
In 3rd paragraph write about any straining factor.
* History of chronic cough, breathlessness, any histor of chronic bronchial
asthma.
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National Board of Examinations, Cases Surgery
* Bowel habits-whether normal or there is any history of constipation or straining
at stools.
Write in details the usual bowel habit.
* Bladder habit-write in details about bladder habit to exclude any prostatic
enlargement or
Urethral stricture.
- Any dysuria.
- Hesitancy/Urgency/Precipitancy.
- Narrowing of stream.
- Frequency of Micturition, during daytime and nocturnal (ask whether patient
has to wake
up at night to micturate).
- Any history of acute retention of uring/Haematuria-left renal tumor
(Vasicocoele).
- Mention about any other important systemic symptom.
- H/o fever (filariasis).
Past History
Any history of operation. (Inguinal region/Appendix).
Personal history – Type of occupation/smoking habits, Urinary/Bowel.
Treatment history – Whether using truss or net.
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National Board of Examinations, Cases Surgery
CLINICAL EXAMINATION
Local Examination:
SYSTEMIC EXAMINATION:
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National Board of Examinations, Cases Surgery
b) Per rectal Examination:- Prostatic Examination.
c) Palpation of Anterior Urethra – Stricture.
d) Respiratory Tract – Obstructive Pulmonary Diseases.
e) Cardia Vascular System:- Cardiac failure.
DIFFERENT DIAGNOSIS: 1. Inguinal Hernia.
2. Varicocoels.
3. Funiculitis.
4. Lipema of Cord.
5. Infantile/Congenital Hydrocoele/Funicular.
6. LYMPH VARIX.
Candidate must know minimum two clinical signs of each of these above
conditions.
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National Board of Examinations, Cases Surgery
* Surgical treatment of other inguinal scrotal swelling –
varicocoele, hydrocoele, etc.
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National Board of Examinations, Cases Surgery
SPECIALITY : SURGERY
CASE : INGUINO-SCROTAL SWELLINGS
NAME OF EXPERT : DR. P. SAMPATH KUMAR, PROF. OF SURGERY,
KASTURBA MEDICAL COLLEGE, MANIPAL.
Inguino-Scrotal Swellings:
HISTORY
Swelling:
Whether swelling appears on standing or straining like coughing
Swelling disappears on lying down
An existing swelling increases in size on straining
Reducibility:
Reducible either spontaneously or manually by the patient
Reducible easily on lying down (Direct inguinal hernia)
Swelling initially reducible but now-a-days not (Irreducible or
obstructed)
Swelling was never reducible
Infantile hydrocoele
Pain:
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National Board of Examinations, Cases Surgery
Pain associated with abdominal distension, vomiting and
constipation:
Obstructed or Strangulated hernia
Fever: Strangulated hernia
Precipitating factors:
Cough, attacks of breathlessness:
Brochial asthma, Chronic bronchitis
Straining during micturition
Constipation
CLINICAL EXAMINATION:
Inspection:
Extent:
Inguino-Scrotal swelling
Cough impulse
Reducibility on lying down
Palpation:
Inflammatory sign like tenderness, local warmth
Getting above the swelling:
Whether able to get above the swelling (Should be negative)
Expansile cough impulse
Reducibility
Reduces with gurgle (Enterocoele)
Relation to pubic tubercle (differentiate form a femoral hernia)
Internal ring occlusion test
Location of internal inguinal ring
Fluctuation
Transillumination (only if fluctuation is positive)
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National Board of Examinations, Cases Surgery
Testis whether separately felt
Testis enlarged
Tenderness of testis and epididymis
Spermatic cord:
Thickening of Spermatic cord
Opposite side scrotal and groin examination
Abdominal examination:
Abdominal wall tone and Malgaigne’s bulges
Ascitis
Loaded colon
Distended urinary bladder
Genitalia examination:
Phimosis, urethral stricture
Pre rectal examination:
Prostate enlargement
Respiratory and Cardiovascular examination
INVESTIGATIONS:
Ultrasound examination:
Scrotal ultrasound if there is doubt about testicular tumour
X-Ray Chest P.A.
DIFFERENTIAL DIAGNOSIS:
If cough impulse and reducibility positive
Indirect inguinal hernia
Special types and their significance:
Sliding hernia
Maydl’s hernia
Pantaloon’s hernia
Richter’s hernia
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National Board of Examinations, Cases Surgery
Litter’s hernia
Direct Inguinal hernia
If cough impulse is negative and swelling fluctuant
Congenital hydrocoele
Infantile hydrocoele
If cough impulse is negative and fluctuation is negative
Irreducible inguinal hernia
NON-SURGICAL TREATMENT:
Inguinal hernia: No non-surgical treatment
Technique of reduction(taxis), complications
Hydrocoele; No non-surgical treatment
SURGICAL TREATMENT:
Congenital hydrocoele: Herniotomy (reason for herniotomy)
Inguinal hernia: Any of the accepted hernia surgeries
Herniotomy: Indications
Herniorrhaphy: Types
Hernioplasty: Indications, techniques
ANY OTHER:
Complications of inguinal hernia:
Irreducibility
Obstruction
Strangulation
How to diagnose each of them
Treatment:
Pre-operative treatment
Difference in surgical technique in strangulated hernia
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National Board of Examinations, Cases Surgery