HYSTORY
CLINICAL EXAMINATION
LAB.TESTS
IMAGISTIC INVESTIGATIONS
 Symptom- what the patient feels
 Physical sign- what the doctor finds at
clinical examination of the patient’s
segments.
 Symptom is subjective
 Physical sign is objective
 Clinical diagnosis = symptoms + signs
 Final diagnosis= symptoms + signs +
lab.tests + investigations.
SURFACE LANDMARKS OF THE HEAD
 Nasion
 External occipital protuberance
 Vertex
 Superior nuchal line
 Mastoid process of the temporal bone
 Zygomatic arch
 Superficial temporal artery
 Facial artery
 Parotid duct
Surface landmarks
Sebaceous cysts
 Swelling - cystic mass - cystic tumor - lump
 Hairy parts of the body- scalp
 The mouth of the seb. gland opens into the hair follicle
 If blocked mouth, seb. gland becomes distended
Seb. Cyst
 History- slow growing
 Symptoms-a lump that gets scratched when the
patient is combing the hair
 Such scratches may get infected
 If the cyst becomes infected it enlarges rapidly and
becomes acutely painful
Seb. Cyst- examination-physical signs
 Position-hairy parts of the body
 Color- the skin overlying the cyst normal unless it is
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infected
Tenderness- not tender unless infected
Temperature-normal except when infected
Shape- spherical
Size- variable: mm-4-5 cm.
Surface- smooth
Edge-well defined
Composition- hard depending on the pressure in the cust
“cheesy material”
Seb. cyst of the scalp
Parietal region
Seb. cyst- lateral view
Seb. cyst of the scalp
Seb. cyst of the scalp
Surgical treatment- excision
Intact sebaceous cyst-specimen
Cut section- seb.cyst- “cheesy
material”-sebum
Lipoma-case report
 A 59-year-old woman was admitted with a 10 years'
history of a painless swelling at the right thigh.
The lesion became ulcerative over the past few
months with mild pain.
 She had no significant medical and surgical
history.
 Examination revealed normal vital signs, chest,
heart, abdominal and rectal examinations.
Lipoma
 On local examination, a large mass occupying the
posterior aspect of the lower two thirds of the right
thigh was confirmed.
 There was an ulcerative lesion at the
posteromedial aspect of the mass.
 The right popliteal artery was difficult to palpate,
but the posterior tibial and dorsalis pedis were
normal.
 There was no neuronal abnormality.
Lipoma- case report
 Blood tests showed normal blood count, liver
function, urea and electrolytes as well as ESR.
 She had a normal chest and abdominal X-ray.
 The X-ray of the right thigh showed a soft tissue
shadow and normal bone.
 Surgical excision was performed and the findings
were consistent with a giant lipoma.
 The wound was closed easily as there was redundant
skin because of the size of the mass.
 The weight of the specimen was 3.2kg.
Lipoma- case report
 The patient had an uneventful recovery and was
discharged home with a very good condition.
 Histology of the specimen reported benign
lipoma.
Huge lipoma of the thigh
Ulcerated lipoma on the postmedial thigh
Specimen- 3.2 Kg.
Lipoma
 Lipoma - a benign tumor
of adipocyte origin.
•The bright yellow color is
typical of fat.
•Note the lobulated
appearance - typical of this
lesion.
•This particular tumor
arose in the subcutaneous
fat (note the small strip of
skin ).
Case Report-lipoma
 A 60 year old male presented in out patient clinic with
history of progressively increasing swelling in right
thigh, which he noticed 3½ years back. Swelling was
otherwise asymptomatic except that he had to wear
loose fitting trousers.
 On examination, right thigh girth was grossly
increased as compared to the left thigh.
Lipoma
 There were erythema ab agni over the medial aspect of
both thighs (as is usual in Kashmiri people because of
Kangri – “the fire pot”).
 The swelling was firm, non-tender and free from
underlying structures.
Lipoma
CT scan of the right thigh was done which revealed a
hypodense mass in the posterior compartment of the
thigh beneath the hamstring muscles
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Lipoma- case report
 FNAC of the swelling revealed mature fat cells, suggestive of
lipoma.
 The patient was operated on under general anaesthesia, in
prone position and the tumour was found beneath the
hamstring muscles and was dissected out easily because of
the capsule.
 Wound was closed in layers, leaving a suction drain inside
the cavity. Healing progressed uneventfully.
 Histopathological examination revealed features consistent
with lipoma.
 The tumour removed measured 21x17x14cm in size and
weighed 2,95 Kg.
Specimen.
Six months after surgery, the patient is symptom
free and has no signs of recurrence
Lipoma
 Lipoma is one of the commonest benign
mesenchymal tumour in the body composed of
mature adipose cells.
 It is found in almost all the organs of the body
where normally fat exists.
 Most of the lipomas present as small subcutaneous
swellings without any specific symptom.
Lipoma
 Giant lipomas, though rare, can present in thigh,
shoulder or trunk.
 Clinical features of these giant lipomas are mainly
because of their size which includes pain because of
stretching of adjacent nerves,(restriction in
movements of the part involved or social
embarrassment because of mere size of the swelling).
 Definitive diagnosis of giant lipoma can be made only
by histopathological examination.
Lipoma
 Surgery is the treatment of choice
 The dissection of these lipomas is usually easy
because of a well defined capsule.
 Dead space created because of dissection of the
giant lipomas is usually drained with the help of a
suction drain to avoid collection.
LIPOMA
Surgical specimen
Hemangioma
 Benign skin lesion consisting of dense, usually
elevated masses of dilated blood vessel.
 Benign neoplasm characterized by blood vascular
channels.
 A cavernous hemangioma consists of large vascular
spaces.
 A capillary hemangioma consists of many small blood
vessels. A collection of dilated small vessels, 3 types:
 strawberry nevus,
 port-wine stains,
 spider nevus
Cavernous hemangioma
Hemangioma
 Congenital benign tumour made of blood vessels in the skin.
 Capillary hemangioma , an abnormal mass of capillaries on the
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head, neck, or face, is pink to dark bluish-red and even with the
skin.
Size and shape vary. It becomes less noticeable or disappears with
age.
Hemangioma simplex/strawberry mark, a reddish nub of dilated
small blood vessels, enlarges in the first six months and may
become ulcerated but usually recedes after the first year.
Cavernous hemangioma, a rare, red-blue, raised mass of larger
blood vessels, can occur in skin or in mucous membranes, the
brain, or the viscera.
Hemangiomas can often be removed by cosmetic surgery.
Strawberry hemangioma
 Intradermal, subdermal collection of dilated blood
vessels
 Congenital lesion- present at birth
 Looks like a strawberry
 Often regress spontaneously in months/years after
birth
 Rubbed or knocked they may ulcerate and bleed
Strawberry hemangioma
Physical examination
 Position- any part of the body- head/neck>
 Color- bright or dark red
 Shape- protrude from the skin surface
 Size- usually- 1-2 cm.
 Surface-irregular
 Consistence- soft, compressible not pulsatile
 Relations- confined to the skin, freely mobile over the
deep tissues
Port-wine stain-extensive intradermal
hemangioma, mostly venous
PORT-WINE STAIN
Cavernous hemangioma on the
tongue
Meningocele
 Meningocele (MM):Protrusion of the membranes that cover the
spine and part of the spinal cord through a bone defect in the
vertebral column.
 MM is due to failure of closure during embryonic life of bottom
end of the neural tube.
 The term spina bifida refers specifically to the bony defect in the
vertebral column through which the meningeal membrane and
cord may protrude (spina bifida cystica) or may not protrude so
that the defect remains hidden, covered by skin (spina bifida
occulta).
 The risk of MM (and all neural tube defects) can be decreased by
the mother eating ample folic acid during pregnancy.
A birth defect involving an abnormal opening in the
spinal bones (vertebrae) is called spina bifida.
The spinal vertebrae have not formed and joined
normally, leaving an opening
A defect which also includes a small, moist sac (cyst) protruding
through the spinal defect, containing a portion of the spinal cord
membrane (meninges), spinal fluid, and a portion of spinal cord
and nerves is called a meningocele, myelomeningocele, or
meningomyelocele
Surgical treatment is needed to repair the defect and is usually done within 12 to
24 hours after birth to prevent infection, swelling, and further damage.
Under general anesthesia, an incision is made in the sac and some of the excess
fluid is drained off. The spinal cord is covered with the membranes (meninges) and
the skin is closed over the protruding meninges, spinal cord, and nerves.
The long-term result depends on the condition of the spinal cord
and nerves. Outcomes range from normal development to paralysis
(paraplegia).
Infants may require about 2 weeks in the hospital after surgery.
Physical signs in head injury
Examination of a case of recent head injury
 The patient is unconscious
 Examine the scalp for a wound or local bruising or
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hematoma
Examine the nostrils and ears for evidence of blood
diluted with CSF
Compare the size of the pupils and test their reaction to
light
Make a general survey of the body for other injuries
Search for paralysis
Palpate and percuss the hypogastrium for evidence of an
overfull bladder
Temperature, pulse rate, RR-charted every half-hour
Head injury
 Radiographs of the skull should be taken at the first
opportunity compatible with safety
 Brain injury is more likely in the presence of a skull
fracture BUT skull fracture of itself does not indicate
brain injury
COMA
 Coma is a state of absolute unconsciousness in which
the patient does not respond to any stimulus
 Reflexes are absent, including the corneal and
swallowing reflexes.
 Semi-coma- the patient responds only to painful
stimuli and reflexes are present
Head injury
The patient is conscious or semi-conscious
 Patient with skull fracture – hospital admission
 Close observation: PR, BP, RR, pupil size and reaction/
every ½ h.
 Signs of neurological deterioration:
 Falling pulse rate
 Reduced respiratory rate
 Falling GCS
 Dilatation of pupils
 Loss of light reaction or developing asymmetry of pupils
Complications of traumatic brain injury
 Cranial bleeding
 Cerebral hypoxia
 Infection
Posttraumatic intracranial bleeding may be:
- extradural
- subdural
- intracerebral
CT of the brain documents the lesions
Local brain compression- focal neurological effects
- raised intracranial pressure
Types of skull fractures
 Liniar fractures - involve the skull vault,
- overlying scalp bruising or swelling
 Depressed fractures - caused by blunt injuries,
- the scalp is severely bruised
 Fractures of the base of the skull- anterior fossa
- middle fossa
- posterior fossa
Basilar skull fractures
 a fracture of the base of the skull - the
temporal, occipital, sphenoid and ethmoid
bones.
 Such fractures can cause tears in the cerebral
meninges - leakage of the cerebrospinal (CSF),
hematoma formation and meningitis
Physical signs - pathognomonic for basilar skull
fracture.
1. Otorrhea – leakage of CSF from the auditory canal
2. Leakage of CSF into the nasopharynx via the eustachian tube, causing a
salty taste.
3. Rhinorrhea – leakage of CSF from the nasal passages
4. Hematoma presentation surrounding the orbits and ears as blood is
flushed to the surface of the facial tissues.
5. Bleeding from the nose and ears
6. Deafness, nistagmus, vomitus
7. Battle’s sign is bruising over the mastoid sinus and is a delayed physical
finding associated with basilar skull fractures.
8. Hemotympanum (blood behind the ear drum)
9. Periorbital bruising “raccoon eyes”
Fracture of the anterior cranial fossa
 Periorbital hematoma
 Subconjunctival hemorrhage
 CSF or blood running from the nose
Fracture of the middle cranial fossa
 CSF running from the ear or blood escaping from the
ear
 Bruising behind the ear over the mastoid area
 Risk of facial paralysis or deafness
Fracture of the posterior cranial fossa
 Deep coma
 Bruising on the posterior wall of the pharynx
Raccoon eyes are always bilateral in closed-head trauma and
appear in 2-3 days
Black eyes associated with facial trauma can affect one or both
eyes and appear within hours from injury
Raccoon: medium-sized mammal
native to North America
Battle sign
Patients are prone to meningitis due to CSF leakage and
meningeal trauma increasing the microbial portal of entry and
menigeal integrity.
Basilar skull fracture
 Basilar skull fractures, breaks in bones at the base
of the skull, require more force to cause than
cranial vault fractures.
 Thus they are rare, occurring as the only fracture in
only 4% of severe head injury patients.
SKULL VAULT FRACTURES
 Linear skull fractures, the most common type of skull
fracture, occur in 69% of patients with severe head injury.
Usually caused by widely distributed forces.
 In rare cases, a linear fracture can develop and lengthen as
the brain swells, in what is called a growing fracture.
 Diastatic fractures are linear fractures that cause the
bones of the skull to separate at the skull sutures in young
children whose skull bones have not yet fused. They are
usually caused by impact with a wide area such as a wall.
SKULL FRACTURES
 Comminuted skull fractures, those in which a bone is
shattered into many pieces, can result in bits of bone being
driven into the brain, lacerating it.
 Depressed skull fractures, a very serious type of trauma
are comminuted fractures in which broken bones are
displaced inward.
 This type of fracture carries a high risk of increasing pressure
on the brain, crushing the delicate tissue. Complex depressed
fractures are those in which the dura mater is torn. Depressed
skull fractures may require surgery to lift the bones off the
brain if they are causing pressure on it.
Depressed skull fracture
Liniar skull fractures
Liniar skull fracture
Epidural hematoma
Subdural hematoma
Intracerebral hematoma
TRAUMA
 1. Prehospital care
 2. Primary survey
 3. Resuscitation
 4. Secondary survey
PREHOSPITAL CARE
 Prehospital providers- tasks:
 Assessment of the injury scene
 Stabilization of the injured patient
 Monitoring and transport of critically ill patient
 Efficient method for reporting by the prehospital
providers to the trauma team on arrival in A&E Unit:
 MIVT
 M= mechanism of injury
 I= injury
 V= vital signs
 T= therapy
VITAL SIGNS
 LEVEL OF CONSCIOUSNESS- GLASGOW’S COMA
SCORE
 STABLE / UNSTABLE HEMODINAMICALLY
 RESPIRATION- spontaneous or ventilated
GCS
 Less than or equal to 8 at 6 h.- 50% die
 Severe head injury 3 – 8
 Moderate head injury 8-13
 Mild head injury
14-15
False- hypothermia, intoxication, sedation
Impossible to evaluate- dysphasic, intubated pts. and
with facial or spinal cord injury
INITIAL EVALUATION AND PRIMARY SURVEY
 HISTORY: A M P L E
 PRIMARY SURVEY: A B C D E
HEAD
 LACERATIONS
 STEP-OFFS
 GCS
 PUPILS
 CT
NECK
 HARD NECK COLLAR
 SPINE X RAY
 LOCAL TENDERNESS
 HEMATOMAS
 SUBCUTANEOUS EMPHYSEMA