Jonny Lenihan
Surgical CT1 NWTD

• Common pathologies
• Examination technique
• Presentation skills
• Background Information
• X-rays
• Summary
• Questions

• Site
• Size
• Shape
• Consistency
• Colour
• Tenderness
• Temperature
• Surface
• Edge
• Pulsatility
• Mobility
• Transillumination
• Auscultation
• Local lymph nodes

• Types of wound prone to these:
– Infection; trauma; burns; tension
• Hypertrophic occur soon after insult; spontaneously regress
• Keloid scars appear months after and continue to grow
• Rx:
– Mechanical pressure dressings with topical agents
– Surgical excision
– Intralesional steroid therapy

Hypertrophic scars
Appearance Confined to wound margins
Site
Keloid Scars
Extend beyond wound margins
Flexor surfaces and skin creases Earlobes, chin, neck, shoulder, chest
Age
Gender
Race
Any age (commonly 8-20)
M=F
Any
Pathology Normal rate of collagen synthesis, but increased rate of collagen breakdown
Puberty to 30
F>M
Black and Hispanic
Increased rate of collagen synthesis and increased rate of collagen breakdown

• Site
• Size
• Shape
• Colour
• Depth
• Discharge
• Tenderness
• Temperature
• Local lymph nodes
• Local tissues
• Edge:
– Sloping = healing ulcer
– Punched out = syphilis, trophic
– Undermined = TB
– Rolled = BCC
– Everted = SCC
• Base:
– Red = granulation tissue
– Grey = slough

• Keep clean and dry
• Antibiotics if infected
• Topical agents
• Dressings:
– 4 layered bandaged technique for venous ulcers

Anterior Triangle
• Pulsatile
– Carotid artery aneurysm
– Tortuous carotid artery
– Carotid body tumour
(Chemodectoma)
• Non-Pulsatile
– Thyroglossal cyst
– Dermoid cyst
– Ectopic thyroid tissue
– Branchial cyst
Posterior Triangle
• Lymph nodes
• Cervical rib
• Cystic hygroma
• Pancoast’s tumour
• Subclavian artery aneurysm

EXAMINATION
1.
Introduction - ?obvious swelling ?scars
2.
HANDS:
– Thyroid acropachy and palmar erythema
– Temperature and pulse
– Fine tremor
3.
EYES:
– Exophthalmos
– Eye movements ?lid lag
– Proptosis (stand behind patient)
4.
Stand in front: ask to swallow
5.
Protrude tongue
6.
Stand behind: palpate each lobe separately; does it move on swallowing?
7.
Palpate for local lymph nodes
8.
?Tracheal deviation
9.
Percuss sternum ?Retrosternal thyroid
10. Listen for bruit (Grave’s disease)
11. Ask patient to stand – proximal myopathy

• Symptoms of hyper/hypo – thyroidism:
– Weight, Appetite, Sweating, Tremor, Palpitations,
Menstrual irregularities, Irritability, Diarrhoea
• Have they noticed a lump
– Change in size over time?
• Change in voice?
• Any pressure symptoms?
– Dyspnoea, Dysphagia
• Diet (deficient in Iodine)
• Any history of radiation exposure?
• Family history

• Biochemistry:
– Thyroid status: T3, T4 and TSH
– FBC, U+Es, Ca 2+ , LFTs and ESR
• Radiology:
– CXR
– Ultrasound (solid, cystic masses)
– CT scan
• Special:
– Fine needle aspirate (not reliable for follicular adenoma/carcinoma)
– Tru-cut biopsy
– Radioisotope scan (Tc 99 )
– Laryngoscopy (?paralysis of vocal chords pre-operatively)

• MEDICAL
– Pharmacological:
– Carbimazole; Propylthiouracil; Propanolol
– Radioiodine (nb: teratogenic)
– >50yrs old, recurrent episodes or post surgery
• SURGERY
– Once medical therapy failed or pressure symptoms
– Sub-total thyroidectomy (after antithyroid drugs)

1. Inclusion dermoids:
– At site of embryological fusion: midline neck, angle of orbit
– Firm, not attached to skin
– Rx = excise
2. Implantation dermoids:
– Subcutaneous swellings after penetrating injury
– Epidermal tissue introduced beneath skin

HOW WOULD YOU TREAT?

WHAT WOULD YOU DO???

WHAT WOULD YOU DO????

WHAT WOULD YOU DO???

• Covered common presentations for Finals
• Examination methods
• Presenting your findings
• Typical XRs in shorts
• Google pathology
• Questions?