General Surgery-1 Practical PDF

ee General surgery-I General surgery —I Clinical part 162  General surgery-| al —— History Importance: * To be familiar wit...

ee General surgery-I General surgery —I Clinical part 162  General surgery-| al —— History Importance: * To be familiar with your patient ¢ To be reassurance of your patient ¢ To detect the type and degree of risk of: procedures, diseases and its relations. * To decrease errors among patients, (the patient must be identified by more than one method as: name, age, patient no, time of admission) Personal history Include: name, age, living site marital state, occupations, special habits Age: some diseases are common among specific ages such as: RHD and TB are common among pediatric and young patients HTN, CAD, DM and renal diseases are common among old age Ww 7 Ce Bronchogenic carcinoma more common among males Thyroid diseases more common among females Hemophilia is dominant in males and it recessive in females. Occupations: « Anemia and nephropathy more common among lead workers » Bilharziasis common among farmers = Infections and x-ray exposure effects common among medical and Para-medical staffs Address: Filariasis common in el Sharkia lodine deficiency in Oasis and siwa 163  General sur gery-I Special Habits: Smoking: have associated with many Orodental lesions as: o Oral ulceration © Delayed wound healing © Dental caries © Dental abrasion o Teeth staining © Gum disease o Burgers disease Smoking index: ® Mild: 10 cig. / day or 100 box /year @ Moderate: 10-20 cig/ day or 100.-400 box / year @ Heavy smokers: more than 20 cig/day or 400 box /year Alcohol a. Induce the risk of mucosal abrasions, b. Dental erosion c. Cavitary lesions d. Oropharyngeal cancers e. Liver cirrhosis and pancreatitis The above risks increased with alcoholic users by >30 units per day. Socioeconomic history Some diseases are common among high social class as: =» HTN » THD = Oral cancers = Smoking and alcoholic hazards Some diseases common among low social class as e Malnutrition e Infections ¢ Poor oral hygiene diseases 164  General surgery-! aS Menstrual history: » Date start of menarche = Regularity of menstrual cycle « Amount of bleeding in every cycle = Time of every cycle Hazards of contraceptive pills or injections “* Headache % Thromboembolic manifestations “* Breast discomfort “» Hepatic cholestasis “* Hepatic adenoma Family history: Some diseases run commonly in family as familial adenomatous polyposis and hemophilia Size and shape of mouth and facial features Complaint: Written as the patient wards including the onset, course and duration Present history: analyzing the patients complaints in details Past history of: “+ Drugs: antihypertensive drugs, anticoagulant drugs “* Chronic disease: diabetes, IHD + Hospital admissions: cause, time, investigations, and managements ‘Operations: nature of operations, and its complications. “+ Blood transfusion. 165 ———— General surgery-! Common presentations of surgical diseases are pain and or swelling If the pain precedes the swelling: The possible provisional diagnosis will be a growth But if the swelling precedes the pain: The possible provisional diagnosis will be inflammation Pain analysis - S: site - OO: onset: sudden or gradual - C: characters: stitching, colicky, constricting, throuping ----- wen ~ R: radiation: site/s of pain radiation (extent of pain to another sites rather than original site) - A? association: e.g./ tooth ache associated with headache and or fever-- - T: time and treatment: pain may be felt at special time as burning mouth syndrome - E: exacerbation: what increase and what decrease the pain(cold fluid increase the tooth ache) Swelling analysis: > Inspection: *Site *size shape. “Surface *surrounding and overlying area *number *pulsations. *Margin: well, ill-defined ‘Movement with special position as tongue protrusion, swallowing and or respiratory movement ‘impulse on cough especially on abdominal swellings 166  General surgery-| _ —————————— > Palpation: = confirm what do you inspect plus = Temperature: how to detect it? By the hand dorsal surface. Tenderness: you look to the patient face and notice facial expression during examination = Pulsation: felt by the fingers = Reducibility: the swelling reduce in sze or emptying when you press it and return to plug on response to patient effort as coughing and or straining. = Compressibility: the swelling emptying on pressure over it and refill after release of this pressure spontaneously without any effort by the patient as haemangioma. = Consistency: three possibilities: soft as ear pinna, firm as ala of the nose and hard as forehead sensation. = Fluctuations: Paget's test: handling the swelling between the index and thumb of one hand and press the center of swelling by the index of other hand. = Trans illumination test: performed in dark room. A bright light is pointed at swelling Thrill: tap on one side of swelling and feel the percussion wave by another hand = Impulse on cough =» Mobility and fixity: Hold the swelling between your index and thumb and try to move it in all directions in relation to underlying structures Fixity: left up the overlying skin and notes it: lifted or not 167 Se General surgery-I > percussion: It is limited value in swelling examination but: It elicited to detect the nature of swelling content (gas or solid) > Auscultation: for bruits, murmurs or additional sounds by stethoscope. Paget's test Auscultation  General surgery-| SSS Tt General examinations Vital data and all body systems except diseased organ or system Vital data include: * Pulse * Temperature « Blood pressure * Respiratory rate * Built, Decubitus and colors may be added Pulse It is waves transmitted through the blood circulation created by left ventricular contraction It reflect the heart beat Examined by palpation using the middle three fingers Common sites: radial Other sites: Brachial, carotid, femoral, temporal popliteal dorsalis pedis and posterior tibial artery Comment on: rate, regularity, equality on both sides, Volume, blood vessel wall Causes of Unequal pulse Cervical rib Arteritis Thromboembolic obstruction Aneurysmal formation Compression of artery by external factors as tumors, lymphadenopathy A bounding pulse is a strong throbbing felt over one of the arteries in the body. It is due to a forceful heartbeat. 169  General surgery-! ae A bounding pulse and rapid heart rate both occur in the following conditions or events: Abnormal! or rapid heart rhythms Anemia Anxiety Long-term (chronic) kidney disease Fever Heart failure Heart valve problem called aortic regurgitation Heavy exercise Overactive thyroid (hyperthyroidism) Pregnancy, because of increased fluid and blood in the body Hyperkinetic states and pig volume pulse in: Hyperthyroidism Hyperthermia Anemia Arterio-venous fistula Hypoxia superficial temporal artery D> Femoral artery ZA™mMoON Popliteal artery posterior tibial artery Carotid artery brachial artery radial artery dorsalis pedis artery  General surgery-| OE Body Temperature Norma! range: 36.5—-37.4°C Subnormal temp.: 35 —-36.4°C Hypothermia: less than 38°C Fever (pyrexia): 37.5 -40°C Hyperthermia: 40.1-41°C. Malignant hyperthermia more than 41 °C Sites to measure the temp. Oral: as it is. Rectal and tympanic: -0.5°C Axillary: +0.5°C Temperature measured by: Thermometer: Oral and rectal Digital: tympanic, axillary or behind the ear Chemical Infrared NB. Rectal route suitable for comatose patients, infancy and in patients with oral lesions Core temp. : Temperature of deep organ = rectal temperature. Skin temperature: temperature of skin, subcutaneous tissue and fat cell (Affected by environment and not indicate the internal physiology). 171 Se General surgery-I Effect of temperature on other system: Increasing of body temperature by 1 °C leads to: Increase the pulse rate by 10 Increase the respiratory rate by 4c/m, BMR by 7 j. Oxygen consumption by 13%. Types of fever >» Continuous: temperature remains above normal, fluctuant in range of 1 °C /24 hours and do not reach to base temp., as loper pneumonia, TB,, brucellosis, infective endocarditis and sepsis > Remittent: temperature remains above normal, fluctuant more than 2 °C /24 hours and not return to: normal as in typhoid, viral URT, legionella and mycoplasma infection > Intermittent: fever for some hours of day then becoming normal through the rest of day as malaria, Kala Azar and septicemia > Relapsing: high temperature for days and return to normal for other some days as pyogenic infections and Hodgkin lymphoma J ee o  General surgery-| ee ___.._______ ——— Blood pressure Systolic pressure: Pressure during heart contraction ranging from 100 -140 mm/hg Diastolic pressure: Pressure during heart relaxation ranging from 60- 90mmgh Blood pressure measured by: Invasive methods in ICU via arterial canulation Noninvasive methods by sphygmomanometer Sites: arms, forearms and lower limb Position: There is normal variation in blood pressure (standing, semi- position, supine position, upper limbs and lower limbs How to avoid errors during measure of blood pressure Start with plapatory method then auscultatory method and use more accurate device (mercury sphygmomanometer) 173 i General surgery-! eE———————Ee Respiratory rate: One cycle include inspiration and expiration: Normal range: 12-20 c/m. Apnea: zero RR Eupnoea: normal range RR (12-20 c/m in adults) Tachypnea: increasing in RR Bradypnea: decreasing of RR The RR increased with exercise, stress and high temperatures Body weight: BMI = Wt. by Kg/ height my (m)2 18-24 %: normal 25-30%: over weight 30-35 %: high or moderate obesity 35-40 %: very high or sever obesity Above 40 % morbid obesity Above 50 %: super obese Comorbidities with obesity: Obese patients are at risk for developing many medical problems, including insulin resistance and type 2 diabetes mellit us, hypertension, dyslipidemia, cardiovascular disease, stroke, sleep apnea, gallbladder disease, hyperuricemia and gout, and osteoarthritis.  General surgery-I Jaundice Means: Yellowish discoloration of skin, sclera, mucous membrane, palate, associated with itching and color changes in urine and stool Normal Serum bilirubin level: Img/dl Subclinical jaundice :1.1-2.5 mg/dl: (detected laboratory only) Clinicai jaundice :2.5 mg/dl Causes of jaundice: Hepatocellular disease = orange yellow Obstructive cause = lemon yellow Hemolytic cause = olive green Jaundice may be induced with carotene foods and drugs as anti- giardiasis (in this type of jaundice no color change in eyes, urine and mucous membrane) 175 —_—— General surgery-I i Cyanosis: Means: bluish coloration of skin and mucous membrane Its noticed when oxyhemoglobin reduced less than 5 mg/dl and oxygen saturation less than 85% Types: peripheral and central > Central cyanosis: associated with blood hypoxia, all body skin and mucous membrane color changes bluish, not improved by warms and hands warm by vasodilatation It involves the skin, mucous membranes, lips, tongue, and nail beds. > Peripheral cyanosis: not associated with blood hypoxia, Peripheral cyanosis. It involves only the extremities. Affected parts becoming bluish color which improved by warms The most sensitive site for cyanosis is tongue (why) The most specific site is lips ‘Central | Peripheral Mechanism }Dimininshed artenal | Diminished flow of oxygen saturation | blood to the local part SS al Sites On skin and On skin only feereee membranes 8.g. tongue, fips, icheeks etc Clubbing and} Usally associated | Not associated polycythemia ———————— aay —om Temperature | Wann Cold of lhe limb pce ee : = Local heat | Cyanosis remains |Cyanosis abolished Breathing Cyanosis TCyanosis persists pure oxygen decreased hicomNenal corn 176  General surgery-! a Decubitus: position Orthopnea: dyspnea on lying down as in It. sided HF, bronchial asthma, pericardial effusions, massive ascites and morbid obesity. Trepopnea: dyspnea on lateral decubitus position (when lying on healthy side: as in unilateral lung disease Platypnea: Dyspnea occurs on sitting (upright) rather than on lying down position. As left atrial myxoma, left atrial ball valve thrombus, apical lung disease, COPD and hepato-biliary diseases Squatting position: fallout tetralogy Preyring position: pericardial effusion and mediastinal syndrome Opsthtonous: meningitis, tetany and strychnine poisoning Dorsal flexion: abdominal colic, peritonitis and ileo-psoas abscess Sitting leaning forward: position in pancreatitis a « of breath on i as a *, * relieved by baton Dyspnea In Heart Failure a hie ae i PLATYPNEA ets Prone Supine »] =e : Right Lateral Recumbent Fowler's ae ‘ Left Lateral Recumbent Trendelenburg 177 re General surgery-! Head and neck examination You examine the patient in upright position and look straight forward Inspect patients head and neck in all directions Ask the patient to swallow, protrude his tongue while you inspect his neck Also do not forget examination of eyes, oral cavity, lips and the scalp Do not forget head size, neck veins and oral cavity Congested pulsatile neck vein in: = Rt. Sided heart failure = Tension pneumothorax = Pregnancy " Hypervolemia = Hyper dynamic circulation » Early pericarditis and pericardial effusion Congested not pulsatile neck veins: - Asin SVC obstruction - Mediastinal syndrome - Late pericardial effusion and pericarditis Eyes examination: Eye brow: loss of outer third in leprosy, myxedema and artificial Eye balls: bony anomalies or soft tissue swelling as ext. angular dermoid. Exophthalmos: means eye ball protrusion Enophthalmos: means posterior displacement of the eye ball Exophthalmos in thyrotoxicosis, leukemia, depression and congenital Enophthalmos: in dehydration and Horner's disease Eye lid: ptosis in: congenital, hysterical, mechanical, occulo-motor paralysis, Myasthenia graves and thyrotoxicosis 178  General surgery-I Eye lid edema: in angio-neurotic edema, nephrotic syndrome, nephritis and chronic Cough Conjunctiva: Pallor and jaundice, Sub-conjunctival hemorrhage in hypertension, hematological diseases, and trauma Sclera: bluish color in Anklystoma, glaucoma, TB, osteogenisis imperfecta (a genetic bone disease) and Marfan syndrome (a disorder in connective tissue throughout the body), iron deficiency and anemia. Yellow sclera: jaundice Teeth Mobility: Loosening of teeth in: « DM = Osteoporosis =« Trauma Discoloration of teeth in: smoking poor hygiene and lead poisoning Diastema: Gap between the teeth that is wider than0.5mm as acromegaly, Oversized labial frenulum, Missing or undersized teeth, loss of primary teeth Notched teeth as in: congenital syphilis (Hutchinson's Teeth) Hutchinson’s triad: Hutchinson teeth (incisors that are notched or pegged in appearance) Interstitial ocular keratitis Deafness in the eighth nerve (sensory-neural hearing loss) 179 ———— General surgery-I Gums: Bleeding: in liver diseases vit. C deficiency and hematological diseases Hypertrophy: with leukemia, drugs as cyclospores and calcium channel blockers Blue line in: lead poisoning Burton's or Burtonian line, is a clinical sign of chronic lead poisoning. Tongue Color: pallor, cyanosis, and jaundice. Leukoplakia: white, red or combined as in sq. cell carcinoma | Brown in smoking Black in Addison's disease and iron deficiency anemia Strawberry in scarlet fever Micro-glossia and or atrophy in hypo-vitaminosis, iron deficiency anemia, pellagra and congenital Macro-glossia in congenital hypothyroidism, angiomatous malformation and tumors 180  General surgery-I ——— eee How to dress the wound? Washing the wound with normal saline or running water to remove any clotted and or foreign body. Control of bleeding by direct or by proximal tourniquet Washing of the wound with normal saline to remove ail foreign materials Remove lacerated and necrotic tissues Disinfect the wound Control of any bleeding point by gradual release of bleeding control pressure Suturing the wound: Primary or delayed suturing if needed. Dress the wound with sterile gauze Fixate the dressing with blaster How to control of bleeding? Non-surgical methods “* Elevation of injured part above the body level “+ Direct wound compression using gauze or piece of patient clothes + Compress the injuries area by patient hand or by your gloved hands “* Indirect compression: proximal to the injured area.... By tourniquet, or rubber bandage or sphygmomanometer calf “+ Release of pressure gradually to identify the bleeding points and manage it by one the following methods. 181 ——————_— General surgery-I Surgical methods: e Clamping and ligate e Cauterization: using: Electric monopoler or bipolar discharge, or cryo cauterization. Chemical cauterization as silver nitrate. e If bony wound bleeding can be use bone wax ¢ Homeostatic clips ¢ Homeostatic stitches... simple or 8 shaped suture 182  General surgery-I aa Suturing and suture materials Suture is the name for the actual medical device used to repair the wound. The stitching is the technique used by specialist to close the wound. Suturing means: Sewing two structure together using suture materials. Ligaturing: mean staying or encircling a ductal structure such as blood vessel Using suture materials Suture materials: is a synthetic or natural material used to approximate living tissues or sutures together. Tensile strength of suture material: is the ability of suture material to resist breakage or It is the force required to break it when pulling the two ends. It depends on: Type of suture materials, tissue and suture handling and size of suture materials. Elasticity: is the ability of the material to regain its original form or length after deformation. Pliability: is the ability to adjust knot tension & to secure knot. Memory: is the inherent capability of suture to return or maintain original gross shape. Aim of suturing: * Apposition of wound edges ¢ Adequate tension * To fast wound healing * To reduce the risk of infection * To hemostasis * To protect the underlying structure ¢ To give more cosmetic appearance 183  —_—————— General surgery- i ee Ideal characters of suture materials ® Handling easily = Minimal tissue reaction = Smoothness — tend to slide through the tissues = Sterilize easily = Adequate tensile strength " Ease of handling - Minimum memory =" Have a secure Knot ® Cheap Cost = Resistance to infection = Non-allergic = Non-carcinogenic = Non - shrakable High quality stainless steel © Small diameter © Stable in the grasp of needle holder © Sharp enough to penetrate tissues with minimal resistance & trauma | © Sterile & corrosive resistant CLASSIFICATIONS OF SUTURE MATERIALS According to nature: 1. Natural 2. Synthetic 3. Metallic 184  General surgery-I According to structure: 1. Monofilament 2. Multifilament According to absorption 1. Absorbable: Absorbable sutures are stitches made from materials that the body can absorb it over time. Degraded by enzymatic hydrolysis or by phagocytosis 2. Non-absorbable:tend to encapsulated or walled off by fibrosis According to coating: Coated and non-coated Natural Natural Absorbable as * Catgut * Chromic catgut * Collagen * Fascia late * Beef tendon Natural Non-absorbable « Silk ¢ Linen * Cotton 185 —————————————— General surgery-I Synthetic Synthetic Absorbable o Polyglycolic acid oO Polyglactic acid © Polyglactin (vicryl) © Polydioxanone(PDS) Synthetic non-absorbable ‘s) Nylon (polyamide) e) Polypropylene (Prolene) o Polyesters e) polyethylene poly-tetra-fluoro-ethylene (Gore-Tex), poly-vinylidine fluoride (PVDF Metallic non-absorbable SS(stainless steel) Tantalum Silver Gold Aluminum Clips Staples 186  General surgery-I Common used sutures Prolene: non-absorbable synthetic suture material Used in: Repair of tough tissues as sheath Repair of skin Vascular anastomosis Plastic surgery Advantage 1. Don’t loose tensile strength over time. 2.Good knot security. 3. Minimal tissue reaction. 4. High plasticity Disadvantage: 1. Stretched when pulled. 2. Loosens when tissue edema subsides Vicryl It is synthetic, absorbable Monofilament / multifilament and coated /uncoated suture materials. It available in purple color/undyed. Uses: = Intra-oral suturing « Gut anastomoses. = Vascular ligature. = Ophthalmic surgery « Superficial soft tissue approximation of the skin and mucosa 187 av General surgery-I Advantage: 1, Minimal tissue reactivity. 2. Can be used in infected tissues especially monofilament. 3. Stronger than gut: retains strength 3 weeks. Disadvantage: 1-In case of prolong approximation can’t be used 2-Delayed absorption 3-increased inflammation especially with multifilament's, Suture Size: basic size is zero Sized according to diameter with “0” as reference size Numbers alone indicate progressively larger sutures (“1”,*2”, etc.) Numbers followed by a “0” indicate progressively smaller sutures as (2-0, “4.0”, etc.). Packaging...  General surgery-! Needles Needles classified to shape: curved and straight Needles classified to eye: eyed and eyeless needle Needles classified to its tip: round, cutting, triangular, blunt and tapered Taper-Foint (Round) (/ inerrant eSuitedto soft tissue 0 4 Reverse cutting Very sharp Yy oldea! for skin sCuts rather than dilates v - Conventional Cutting Very sharp “/ eCuts rather than ditates Creates weakness allowingsutureteaout Lo — Taper cutting VA : aidealin toughor cakified tissues n & Vascular procedures) Candiaywsedi sMainh (% A 189 SS General surgery-| —————————————————————— ee Technique 1. Needle should be grasped with the needle holder approx. 1/3 distance from the eye & 2/3 from the point. 2. Needle should be placed perpendicular to surface being entered & pushed through tissues following curvature of the needle & rotating the wrist. Needle enters 2-3mm away from the margin of the flap & exists at the GO) same distance on the opposite side. 4. The two ends of the suture are then tied in a knot & cut 0.8cm above the knot. Knot should never lie on incision line. eo ND Never close under tension. The depth of penetration: should be equal on both side of incision line.. The needle always passes from — The movable tissue to fixed tissue. Thinner tissue to thicker tissue. Deeper tissue to superficial tissue. 190  General surgery-l Types stitch Simple interrupted stitch. 7, Continuous stitch Mattress suture stitch Figure of 8 (eight) stitch Sub-cuticular interrupted stitch. Sub-cuticular continuous stitch Simple stitches Uses of Simple interrupted stitch. Single tooth extraction 3" molar extraction Dental implant Biopsies Technique: Suturing is passed through both edges at an equal depth & distance from The incision & knot is tied. Advantage: Rapid and easy to perform Simple Performed in urgent situation Easy to remove Disadvantage: Less support to tissue healing than continuous Inappropriate edge coaptation 191 ——— General surgery-| Continuous stitches: Types: simple Interlocking and Over and over stitch Used in wound approximation perfectly without tension Advantage: Rapid and can be used for swelled up tissue Disadvantage: No chance for free of some stitches Break of smail part of stitch affect in all suture line Cannot be used in areas of existing tension Figure of 8(eight) suture Uses: commonly used for extraction socket closure as well as adaptation of gingival papilla around the tooth. Technique: The needle first inserted into the outer surface of the buccal flap & then the lingual flap. Suturing begins on the buccal surface 3-4 mm from the tip of the papilla Then the needle should be inserted in the same fashion at a horizontal distance & then both ends tied. Advantage: Rapid closure Disadvantage: It is difficult to remove | J It leaves a significant amount of suture threads inside the socket 192  General surgery-I Neen eee ee Surgical Knot Components: 4. Loop- created by knot. 2. Knot- itself which is composed of a number of tight throw. 3. Ears- which are the cut end of the suture. Use the surgical knot: to prevent slippage and loosening of knot Principles of surgical knot Avoid friction or sawing. Avoid excessive tension. Avoid tightness to avoid strangulates the tissues. Placing the final throw at horizontally as possible to keep the knot flat. Maintenance of traction at one end of the suture after the first loop is thrown. Cut the end of suture as short as reasonable to minimize the tissue reaction | Half-hitch Granny 193 i General surgery- Stitch removal The suture material considered as a foreign material produce tissue reaction so, its removed as early as possible: The stitch removed after allows tissue healing The appropriate time to remove the stitches: Face and lips: 3-5 days Oral cavity: 6-8 days Neck : 5-6 days Scalp: 7-10 days Chest, abdomen and legs: 10-14 days How to remove the stitch Clean and disinfect the sutured area Lift up the suture material above the epithelial surface using non-toothed or artery forceps. | Scissor passed through one loop of suture material and cut it close to the epithelial surface Pulled up the suture toward the incision |  General surgery-I sp Reasons for failure of healing with stiches: C Breakage 0 Cuts out C1 Knot slips 1) Extruded suture 0 Resorbs too rapidly 1) Removed too early Possible complications of Jeaving sutures for many days £ Suture abscess CO Scar or stitch mark = Dermoid cyst 195  ———————————————— General surgery-I Alternatives to suture Types | I- Staples: formed from high quality stainless steel Suitable for skin closure only | 2- Tissue adhesives: A sterile, liquid topical skin adhesive materials Reacts with moisture on skin surface (benzoin) to form a strong, flexible bond Only for approx. skin edges of wounds 3- Tape: Steristrips Use of tissue adhesive adjunct Rarely used for primary closure Disadvantage: (Not absolute alternative to mechanical means L] More tissue reaction  General surgery-l CLINICAL EXAMINATION OF SINUS AND FISTULA Inspection Site Location gives the diagnosis in the majority of the cases. Fistulas * Branchial fistula: Anterior border of lower third and upper 2 thirds of steno-mastoid ¢ Parotid: parotid region ¢ Thyroglossal: midline of neck below hyoid Sinuses * Preauricular sinus: Front of root of helix of ear due to failure of fusion of ear tubercles. Direction of the sinus is upwards and backwards « Median mental sinus: symphysis menti *TB- neck. Number Number-can be single or multiple Opening Sprouting with granulation tissue or foreign body. Flushing with skin- TB Discharge White thin caseous-tuberculosis Yellow purulent: staphylococci Faecal: faecal fistula Yellow sulpher: actinomycosis 197 ——_———— General surgery-| Thin mucus discharge: branchial fistula Urine: urinary fistula. Saliva: parotid Bony granules: osteomyelitis Surrounding skin Red, angry (erythematous) looking: inflammatory Bluish discoloration: tuberculosis Pigmentation: chronic sinus Skin excoriation: faecal fistula Palpation * Temperature and tenderness is increased if there is inflammation of the sinus, e.g. pilonidal sinus. * Discharge after application of pressure. It suggests nature of fluid. ¢ Induration is present in chronic fistula, osteomyelitis, etc. * In tubercular sinus, induration is absent. * Fixity: Osteomyelitis sinus is fixed to the bone Median mental sinus may be fixed to the jaw bone. * Probing to know the depth of sinus is not recommended. * Palpation of Deeper plane Enlarged nodes Thickening of mandible or bone Submandibular stone 198  General surgery-I a CLINICAL EXAMINATION OF AN ULCER Inspection * site, size, shape, floor, edge, discharge, surrounding arca. Palpation * Tenderness, local rise of temperature, bleeding on touch, consistency of the ulcer, edge, surrounding area , oedema, mobility. - Regional lymph nodes « Sensations * Pulsations * Function of the joint Systemic examination General examination Pathological examination Inspection Location of the ulcer (sites) ¢ Arterial ulcer: Tip of the toes or dorsum of the foot. - Long saphenous varicosity with ulcer: Medial side of the leg. * Short saphenous varicosity with ulcer: Lateral side of the leg just above the lateral malleolus. - Perforating ulcers: Over the sole at pressure points. ¢ Nonhealing ulcer: Over the shin and lateral malleolus Floor of the ulcer: This is the part of the ulcer which is exposed or seen. * Red granulation tissue: Healing ulcer 199 —_————— General surgery-I * Necrotic tissue, slough: Spreading ulcer * Pale, scanty granulation tissue: Tuberculous ulcer. * Wash-leather slough: Gummatous ulcer * Part of the bone: Neuropathic ulcer * Nodular: Epithelioma * Black tissue: Malignant melanoma Discharge from the ulcer * Serous discharge: Healing ulcer * Purulent discharge: Spreading ulcer * Bloody discharge: Malignant ulcer * Greenish discharge: Pseudomonas infection * Discharge with bony spicules: Osteomyelitis Edge: It represents the areas of maximum cellular activity. If destruction dominates as in spreading ulcers, the edge is inflamed, edematous and angry-looking (extension). If it bluish due to granulation tissue covered with thin epithelium (stage of transition= healing). In a healed ulcer, the outermost part of the edge is whitish due to fibrosis (Stage of repair), Types of edges. * Sloping edge is seen in all healing ulcers such as traumatic and venous ulcers. * Punched out edge is seen in gummatous ulcers and trophic ulcers. Gummatous ulcers have punched out edge due to endarteritis obliterans 200  ee EEE General surgery-l eee Seen caused by syphilitic organisms. Chronic non -healing ulcers may also have punched out edges. « Undermined edge is seen in tuberculous ulcers It is destruction of subcutaneous tissues than the skin. The edge is classically thin and bluish in color. * Raised edge (beaded edge) is seen in rodent ulcers or basal cell carcinoma. - Everted edge (rolled out) is diagnostic of squamous cell carcinoma. The edge grows very rapidly and it occupies the normal skin and thus gets everted. Surrounding area * Thick and pigmented: Varicose ulcer. ¢ Thin and dark: Arterial ulcer. « Red and edematous: Spreading ulcers like diabetic ulcer. ¢ Scar around the ulcer: Marjolin's ulcer Palpation Edge: Induration means : hardness of the edge which caused by extensive fibrosis. ° Some degree of induration can also be seen in chronic ulcers and long- standing, varicose ulcers. ¢ Maximum induration-Squamous cell carcinoma * Minima! induration-Malignant melanoma ¢ Brawny induration-Abscess - Cyanotic induration-Chronic venous congestion as in varicose ulcer 201  ——————— General surgery-I Base: It is the area on which ulcer rests. Pick up the ulcer between thumb and index finger and tissues beneath If the ulcer cannot be lifted up, the base can be tendons, muscles or bone depending upon the site of ulcer. | underlying tissues. Malignant ulcers are usually fixed, whereas benign ulcers are not. Bleeding: Malignant ulcer is friable like a cauliflower and bleed with gentle palpation. Granulation tissue as in a healing ulcer also bleeds Surrounding area: Tenderness and pitting on pressure indicates spreading inflammation surrounding ulcer. Relevant clinical examination 1. Regional lymph nodes * Tender and enlarged: Acute secondary infection * Non-tender and enlarged: Chronic infection * Non-tender and hard: Squamous cel! carcinoma * Non-tender, large, firm, multiple: Malignant melanoma 2. Peripheral vessels: Presence of weak pulses or absent pulses indicate Peripheral vascular disease. 3. Sensations: Loss of vibration sense occurs early in cases of diabetic 202  General surgery-! aaa neuropathy. Later, touch and pain are lost. Totaily anesthetic feet are characteristic of leprosy. 4. Function of the joint: Movements of the involved joint are restricted either due to pain, involvement of the joint or due to infiltration into the joint by malignant ulcers. 5. Varicose veins: If present, it is most probably a varicose ulcer. However, A-V fistula can present as distal ulcers, with arterializations.. Fy eafisrsinge with contonoane murmur Punahed Out Edge Been In Gzahnie. Trophic, Ki Loprmeey, lachemic Artarial ticer. Rated and Pasttly- | Whe Bearded Guage Seen tn Redeni ice. Rolled Out (2 verted} Gdgoe | Typlonily seen in Squamcaus Cell Carolnoma.  General surgery-I _eessssSssSsSsSsSsSsS93”30$3$”:$0aSSsSsSSaSsaa ee QQ ——————— The end With my best wishes Dr. / Hussien ElAnany 204