Lump, Bump, Groin Tutorials with Mr Nazli

Try to grab the histological structure of the skin with the appendages. Usually if the pathology occurs within the dermis, the lump or bump should be attached to the skin. For example sebaceous cyst, carbuncle, boil, dermoid (positive transluminance test). Not attached to the skin, you can actually pinch the skin, for example lipoma.

In examining the lesion, As usual we go with inspection, palpation, percussion if needed, auscultation, and some special test in distinguishing the lesions.

LIPOMA

http://www.lipoma.net/wordpress/wp-content/uploads/lipoma4-e1355211534412.jpg

• It is a benign tumor consist of mature fat cells, it is the most common for of soft tissue tumor
• mostly in upperlimbs, chest, neck, shoulder with size smaller than 1 cm commonly. It will have hemispherical or discoid shape, with smooth/ lobulated, may fluctuate with soft of firm in consistency. The edges usually irregular 
• most of the time painless, free mobility of overlying skin with normal temperature
• slips sign test should be positive
• transluminence test usually negative but can be positive if liquified
• it is not a precancerous lesion - less likely to develop into liposarcoma. But if there is liposarcoma, usually it develop de novo ( by its own)
• Prognosis of it 
• 2/3 not growing
• 1/3 growing
• Rx : excision

SEBACEOUS CYST

http://i.ytimg.com/vi/9xKYKyn3oMM/maxresdefault.jpg

http://health.tipsdiscover.com/healme/wp-content/uploads/2013/07/Sebaceous-cyst-%E2%80%93-Causes-Symptoms-Diagnosis-Treatment-and-Ongoing-care.jpg

• arise from hair follicle consisting keratin. If oily, sebum secreted by sebaceous glands.
• Usual sites are the hair bearing sites like scalp, shoulder, neck, scrotum, back
• Usually hemispehrical, with smooth surface, hard and solid, well defines. Attached to the skin hence not mobile
• Usually have one punctum or fistula
• can be complicated with infection, ulceration, calcification, so observe the skin changes suggestive of inflammation
• Rx : excision

DERMOID CYST

http://byebyedoctor.com/wp-content/uploads/2011/05/epidermoid-cyst-3.jpg

• It is "skin lined cyst" deep in the skin in subcutaneous tissue (attached to the skin)
• usually the site is central part of the body 
• shape usually is pherical, smooth surface and may fluctuate, 
• congenital : usually central part of body
• acquired : due to fusion of 2 abnormal layers
• positive transluminance test,
• painless unless infected
• Rx : excision

CARBUNCLE

http://www.millerfamilydermatology.com/wp-content/uploads/2013/05/carbuncle.jpg

• necrotizing infection in the subcutaneous tissue, with pus and slough formation
• multiple punctum
• can be widespread
• lost of skin appendages
• Rx : antibiotic, saucerization(remove layer by l;ayer)
• for saucerization, do dressing for wound healing and prepare blood transfusuion

GANGLION

http://vipplasticsurgery.com/wp-content/uploads/2014/01/ganglion.jpg

Acute Pancreatitis

Patient is 67 years old lady with no known medical illness. She presented with epigastric pain for 7 hours prior to admission with similar episode of pain in October.

The pain was at sudden in onset, constant and pricking in nature. The pain radiated to the back with no specific agrravating or relieving factors. The pain score was described as 7/10. It was associated with vomiting for 3 times already and vomitus consisted of food particles with no biles or blood seen. Oral intake was reduced. She denied chest pain or shortness of breath, no history of yellow discoloration, fever or changes in characteristics of urine and stool. No URTI Ssx.

On further questioning, patient admit that she had an episode of epigastric pain and had seek treatment for the pain. She was prescribed with rastritis medication and she admit she has ingested traditional Chinese herbs to relieve the abdominal pain back in October.

Prior to current admission, she came to Klinik kesihatan to seek medical attention and was referred to hospital as pain was not resolved.


There was no history of scorpion sting, insect bite and not preceded with trauma. She denied a
history of traditional Chinese herbs ingestion in October to relieve abdominal pain. She denied any consumption of alcohol and she is not a smoker. There was no history of eating outside and no similar problem in family. Her elder brother succumbed to cancer but she wasnt sure what type of cancer.

Physical examination, I lost the result. Hmpphhh...

Investigation

CXR erect...no cardiomegaly
no air under the diapghragm
ECG : sinus rhytm
no acute ischemic changes

ABG
FBC
amylase
LFT
RP
AST LDH
Ca
alb
coagulation profile
total bil
UFEME


PRovisional diagnosis
acute pancreatitis

DDxes
gastritis
peptic ulcer disease


Management

• Treat the cause/stop the possible insulting agent
• Resuscitate
• Anticipate complication

IMRIE score

Emergency Trolley

1. Injection : syringe, needle, medication which includes atropine, bla. bla

2. Things tu be used in intubation and torchlight

3. Endotracheal tube, branula, sterile gloves, stopper etc.

4. IV drip, mask

Ward Round

Last week I went to follow ward rounds 3-4 times but i was too lazy for the whole lat week. It wasn't productive at all. *REGRET* I spent most of time watching anime, reading manga and murakami's novel...with thickness of Merck's manual which was impressive. It was all because of the flood and oncall attendance, I had to cancel my plan to go back to taiping for two consecutive weekends, I lost my mood and motivation already. Sounds gedik but honestly I missed my nephew A LOT, that was why.

But yeah, my motivation was recharged now. *But I scrolled through online shoppe with my roomate yesterday. Great*

Lat week there were lots of patients got admitted bacause of lump, hemorrhoid, abcess, So, I got the chance to learn on the management and how to examine these patients with a specialist and some housemen ( Most of them were my seniors, we were in a medic futsal team, owyeahh). I was the only student yang sesat follow another ward round that time, The Heck.

Usually, as a student, it is improtant to be able to describe a lesion be it ulcer, rashes or lump by inspection. One of the HO (futsal teammate) said lump and bump are the common questions which might come up as short notes. Here I'll be focusing on the local examination. But in practice, Don't forget the general examination as well.

1. Site

well, you can actually divide the gluteal part into quadrants just like breast examination but of course there would be no nipple. If you see a patient with nips on the butt, please contact NASA immediately. Or pilonidal cyst can occur just above the gluteal cleft. Would be much better if you can measure the lesion from a bony point, but I was not that good when I got panicked. So I preferred the first option.

2.  size, depth, height

On gluteal, it is recommended that you describe the size by measuring it instead of comparing with size of grape, egg or whatever it is in physical examination. But it is acceptable in history taking. Like in ulcer we can measure the depth...And there was once I saw a doctor presented a case of bump, they even mention the height!!!!

3. shape

I'm not really sure on this, but in browse, it acceptable student want to liken the shape to kidney or pear. Hmm...

4. surface

smooth, bosselated, rough, fungating.

5. color

• erythematous = infection, inflammation
•  purplish = thrombosed, congestion

6. temperature

Assess the skin temperature with the dorsal surfaces of your fingers.

7. tenderness
Is the lump tender? Which parts are tender? Always try to feel the non-tender part before feeling the tender area, and watch the patient’s face for signs of discomfort as you palpate.

8. edge

clearly defined or not.

9 composition

• consistency, hard, firm, soft
• fluctuation
• translucence
• resonance
• pulsatility
• compressibility
• bruit

10. reducibility

11. relation to surrounding structure

Attachment to deeper structures is more difficult

to determine.Underlying muscles must be tensed to

see if this reduces the mobility of an overlying lump

or makes it easier or less easy to feel. The former

indicates that the lump is attached to the fascia covering

the superficial surface of the muscle or to the

muscle itself; the latter that the lump is within or

deep to the muscles. Lumps that are attached to

bone move very little. Lumps that are attached to or

arising from vessels or nerves may be moved from

side to side across the length of the vessel or nerve,

but not up and down along their length. Lumps in

the abdomen that are freely mobile usually arise

from the intestine, its mesentery or the omentum.

-Browse-

12. regional lymph node


13. Discharge is very important.

• pus
• active bleeding
• smell, color
• punctum

There was a patient, there was a swelling measured about 8x4 cm, tender, erythematous margin, fluctuant, warm, with pus discharge from the cente sited at inner quandrant of left gluteal. It was indurated as well. So, the impression was gluteal abcess, and the patient had ultrasound done to rule out any deep seated gluteal abcess. It is acceptable to say that the pus charge is minimal if you can see there is pus seen at the punctum.

And another patient came with on-off puss. he drained it himself at home. It was actually an infected pilonidal sinus with multiple sinus opening. And he was informed on admission that he actually need to undergo surgery to remove it. He was not expecting that. And after the ward round, I went to clerk this patient and asked his permission to look at his file. He said, "boleh je, nak examine yang betul punya pun boleh, panggil lah kawan sorang. " He was a cooperative person. May Allah cure him :)

***

We had a class with Mr Nazli once on Lump, Bump, Groin.  He really stress us to understand the histological structure of the skin that we will be able to understand the pathology hence distinguishing the origin and character of the bumps. Need to do revision on that later.

http://vbil.bioen.illinois.edu/OCT/OCT_content4_clip_image003.jpg

Inguinal hernia

Discussion with Dr Shaiful on my CP last time

Patient was a 57 years old Chinese gentleman electively admitted for surgical management for his underlying bilateral inguinal/ inguinoscrotal mass / swelling.

1. Started noticed suddenly? How he noticed? - during bathing/incidental/wearing cloth/after heavy lifting/return from gym. He described it as bulging in appearance/rounded/about a size of grape/ect..
2. He described it soft on touch. The swelling was localized, not extending to scrotal area
3. On & off or persistent?
4. Resolved when he lie down/massage/
5. Aggravated/prominent upon coughing/standing/heavy weight lifting/straining...
6. Nevertheless, he did not noticed any wound or ulcer, redness on the swelling area.
7. The swelling was associated with pain. If there is pain, describe the pain further.
8. However, it is not associated with pus, fever,  itchiness,penile discharges/swelling or ulcer elsewhere.
9. Not preceded with fall/trauma/insect bite.
10. He had no constituional symptoms such as. He had no history of PTB contact. (WHY?)
11. Not preceded with prolonged constipation/ hard stool/ recurrent cough/SOB/noisy breathing/ lower urinary obstructive symptoms such as hesitancy/poor urinary stream & bla2.(prostatism syndrome) 
12. He had sought medical attention? given medcation? Any investigation done? Blood / imaging done...not done...
13. Was told that it is mostly...?
14. Or he did not sought attention because worry of surgery/or thought it is not dangerous or life threatening..?
15. The swelling was progressively enlarged for past 5years whereby it reach to the size of/ extend to scrotum / unable to be reduced.
16. Nevertheless, there is no worsening pain/nausea/vomiting/abd distension/bla2...
17. 3 months prior to current admission....he noticed another swelling...bla2...similar in character as the 1st swelling...
18. Due to bilateral swelling / swelling unable to be reduced, he sought attn...what been done? Bla2...
19. That's why important u mentioned what been done during sought attention...such as "physical examination was done including per rectal examination and he was told that his prostate was not enlarged"
20. About the constipation....enough u said he had no history of constipation...
21. Unless if he is constipate, then mentioned a bit what contribute to his constipation /reason such as not taking vegetables/sedentary lifestyle....Means no need to explore diet if he had no constipation...

He noticed sudden swelling at right inguinal region 5 years ago when he was defecating. size described as 50 cents coin.
But the swelling only started to progressively increase in size associated with pain when coughing in 1 year, making him decided to retire from his job...lifting cements bag in construction sites since few years back.

And the last 3 monthes, he started to notice small swelling at left inguinal region visible when coughing/sneezing measures about 20 cents coin.
Only 2 months ago, he went to clinic in htaa, referred to surgeon, given date for admission for surgery.

Then i asked him to describe the pain. When coughing, the pain is sudden but gradually but gradually subsided within seconds. The pain was localized to the swelling. Severity is described as 4/10.

He was able to reduce the swelling himself or when lying supine.

He denied any straining in urination, denied nausea, vomiting. No changes in bowel habit.

He has no other underlying disease.

He is non smoker and non drinker.

hemorrhoid

Patient, a 52 years old gentleman with no known medical illness presented in Hospital X 3 days ago with irreducible per rectal mass during defecation. This was a referred case from KK Y.

History went back to about 3 years ago, patient started to notice a soft mass came out on defecation. It was initially reducible digitally and painless. It was also associated with tenesmus and occasional per rectal bleeding especially when he had constipation. He described the blood as bright red, separated from his stool and seen as streak of blood on the stool. Sometimes in few episodes patient claimed to see the blood dripping on the toilet bowl, and bloody residue left on anal. He quantified each episode of bleeding as 2 spoonful of fresh blood. However he denied any itchiness, blood spot on his undergarment and no discharge of mucus. Each episode was not preceded by trauma.

Over these three years, he has been seeking treatment from a private clinic in his town a few times. He was given a few medications, which was told to soften his stool, to increase his Hb, and suppository to stop the bleeding. His blood was taken each visit for investigation and no other investigation was done. Sometimes, he bought medication from local pharmacy as prescribed by GP. He was also advised by the doctor to regularly consume green vegetables, seafoods, meats, and fibres. He was compliant to the prescription and advice. Condition seems to improved after each episode when he used the medication on breakthrough. He reported that the last bleeding was a month ago.

However a day before admission, he started to develop anemic symptoms such as lethargy, dizziness, palpitation and shortness of breath on exertion when he came home. On passing motion, he claimed that the mass was no longer reducible and associated with pain. Pain was described as pricking in nature, intensity 4-5/10. It was not radiating elsewhere, limited to the mass.  It was more painful when touched with no specific relieving factor.

He denied fever, vomiting, nausea and changes in bowel habit: constipation and diarrhea. Normal bowel output. There was no loss of appetite and loss of weight. There was no similar history in his family.

He then went to klinik kesihatan Y with his wife. Blood was taken but he was unsure of the result of investigation. He is then referred to Hospital X for further management and investigation and was transfused with 2 pints of blood on admission.

He is not known to have any medical illness such as HPT, DM, heart or renal failure,or hematological disorder. He was never been hospitalized or undergone any surgery before. Apart from the medications he has been taking over the 3 years, there was no other regular medication.

He is the eldest out of 5 siblings. His father died at the age of 58 due to renal problem and his mother is still alive, diagnosed with HPT. There was no history of malignancy in his family. He is a father of 8 children. He is self-employed married to acook. The total income was claimed to be adequate for basic necesseties. He denied alcohol consumption and do not smoke.

Upon clerking, the patient was lying in left lateral position with the head of the bed propped up to 45 degree. There was a branula attached on to the dorsum of his left hand but upon clerking, patient wasn’t having any intravenous infusion. He was alert and conscious, was not in pain and not tachypneic. Generally, the patient was pale (as seen on his hand and conjunctiva). The haydrational and nutritional status was fair. There was no cyanosis, finger clubbing, angular stomatitis or pitting edema of both legs. No gum bleeding. There was a BCG scar.

The vital signs are as follows:

            Temperature: 37 degree celcius.

            Blood pressure: 130/80 mmHg.

            Heart rate: 80 beats per minute, good volume.

            Respiratory rate: 20 per minute.

There was no parasternal heave or thrill. First and second heart sound were heard with no murmur. Vocal fremitus was equal and normal bilaterally. Percussion note was normal.Vocal resonance was normal and equal bilaterally. Vesicular breath sound was heard. No basal crepitation was heard.

Abdomen was soft and distended. There was no area of tenderness or guarding. The liver or spleen were not palpable. Liver span around 13cm. Kidneys were not ballotable and no palpable mass. Abdominal auscultation revealed normal bowel sounds, occurring 4-5 times in one minute.

On anal examination, there was a purplish mass observed to have prolapsed from within the anus but I couldn’t spescify the position because it looked as if as the whole circumference of anal margin are swollen(edematous) and erythematous. There was no fissure, ulcer, rashes, scratchmark or active bleeding seen from inside the anus, anal margin or the perianal skin. There was no discharge of mucus. On palpation, the mass was warm, tender and irreducible with fingers. Hence I couldn’t proceed with per rectal examination on this patient.

Provisional

1. Hemorrhoid (acute thrombosed hemorrhoid)

Ddxes

1. perianal hematoma

2. anal fissure

3. abcess

4. perianal tumor
5. anal polyp


In understanding hemorrhoid, it is very crucial to grab the anatomy of the anal canal, hence giving a clear picture of pathogenesis behind it together with the complications. I would suggest for more reading from Burkitt and it is important to cover all the common anal symptoms, the classification and priciple of management and the other anal or perianal disorders.

Like in this patient, he presented with acute presentation of complicated hemorrhoid.

Clinical Manifestation in Urolithiasis

History Taking

Factor determining the symptoms

• size of stone
• location of stone
• production of urinary outflow obstruction
• movement of the stone (eg: from renal pelvis to bladder)
• presence of infection

1. Renal stone

• renal colic  (colicky (comes in waves) due to ureteric peristalsis)
• hematuria
• passing out stone
• loin pain
• secondary infection
• urinary tract infection
• sepsis

2. Ureteric stone

• ureteric colic - radiated to the scrotum/labia
• nausea and vomiting

3. Bladder stone

• irritative bladder symptoms
• pain radiated to tip of penis
• obstructive symptoms

4.Uretheric stone

Commonest chief complaints according to percentage

1. pain
2. fever
3. recurrent UTI
4. hematuria
5. palpable mass
6. malaise
7. asymptomatic

Complication of staghorn calculi

1. severe renal deterioration
2. sepsis
3. azotemia
4. death

Urology with Mr. Islah

Today, we had as session with Mr. Islah. He was superb I can say but the problem is the infos was too packed, gushed into my brain that not all them can be digested. But I'll try my best to share what I've got. Sigh, I should have record his session with my phone, I couldn't jot everything, seriously.

The one who was presenting is Maryam. It was a urology case, I missed the history presentation, I was from cafe. Bad student. Haha. So, what I've got is that the patient was an old man. That was it. I was like, "HEY, GUYS! WHY YOU NO LET ME BE INFORMED THAT MR. ISLAH WAS ALREADY THERE? COME ON." but never mind. Hmph!!!

Well, actually I'm not really sure how to organize the input for today. So when after I went to the ward to follow up my patient, then went to send my car for repair, played basketballs with the girls, bought kitten food for Kuro, finished my laundry...I finally I got time to open my lecture notes when I was in BMS. And yes, whatever Mr. islah has taught me this morning, more or less was taught last time. We just need to revise and apply.

In Urological cases, should should master the definition of each spectrum of symptoms and the spectrum of the disease along the urinary tract.

HISTORY TAKING and PHYSICAL EXAMINATION

Urinary tract infection


Actually our urinary tract has its own natural defense mechanism

• normal flora lactobacilli, corynebacteria, streptococci
• urine flush mechanism and urine content itslef (pH)
• bladder has its own immune response  and induced exfoliation 

But any alteration of these defences will actually lead to urinary tract infection or together with some othe urological pathology. The possible alterations are :

• obstruction
• vesicoureteric reflux
• diabetic
• renal papillary necrosis
• HIV
• pregnacy
• neurogenic bladder
• underlying disease
• iatrogenic

1.Look if any of the risk factors of UTI are present

• advanced age
• anatomical abnormalities
• poor nutritional status
• smoking
• immunocompromised
• chronic catheterrization in neurological problem for example
• hospitalization and intrumentation

2. Clinical features which may occur in UTI

• lower urinary tract infection symptoms ( dysuria, urgency, frequency,hematuria)
• fever
• acute urinary retention 
• pain
• loin pain
• suprapubic pain

3. Look also for any symptoms of the complication of UTI to anticipate in management

• painful urinary retention
• LOW /  LOA
• hypoalbunemia (???)
• lethargic
• uremic symptoms

Uremia is a clinical state in which the blood urea nitrogen level, an indicator of nitrogen waste products, is elevated. In uremia, the kidneys’ failure to filter nitrogen waste properly leads to excessively high levels of nitrogen wastes in the bloodstream. Uremia is life-threatening because too much nitrogen in the blood is toxic to the body. Symptoms of uremia include confusion, loss of consciousness, low urine production, dry mouth, fatigue, weakness, pale skin or pallor, bleeding problems, rapid heart rate (tachycardia), edema (swelling), and excessive thirst. Uremia may also be painful.
Uremia is reversible if treated quickly; however, permanent damage to the kidneys may occur. Kidney failure may also result from the underlying processes that cause uremia. -medscape-

• obstructive symptoms ( problem in voiding)
• poor stream
• interminttent stream
• retentio
• irrentetive symptoms (problem in storing)
• frequency
• nocturia
• urgency
• hesitancy
• sequelae of renal failure
• 
  

Signs and symptoms of acute kidney failure may include:

• Decreased urine output, although occasionally urine output remains normal

• Fluid retention, causing swelling in your legs, ankles or feet

• Drowsiness

• Shortness of breath

• Fatigue

• Confusion

• Nausea

• Seizures or coma in severe cases

• Chest pain or pressure

Sometimes acute kidney failure causes no signs or symptoms and is detected through lab tests done for another reason. -mayoclinic-

4. Hence based on these dont forget to aks if the patient has any

•  previous episode
• stone disease
• trauma at
• urinary tract
• spinal cord
• brain
• instrumentation or operation
• includes abdominal patho or procedure
• systemic diseases
• gouty arhthritis
• hyperparathyroidism
• diabetes mellitus

5. Abdominal findings may have

• suprapubic tenderness and warm
• renal punch at renal angle which will be postive for
• renal stone
• pyenephrosis
• pyelonephritis
• renal abcess
• abdominal mass be it from urinary tract or other intraabdominal organs which may compress
• palpable bladder
• ballotable kidney

6. Genitalia examination

• stone in the urethra
• Per Rectal examination...look for any abnormality : eg: prostate (cancer, BPH or inflamed), invasion of cervix cancer, etc.
• urethral caruncle if female

https://edc2.healthtap.com/ht-staging/user_answer

Urethral caruncles are benign, distal urethral lesions that are most commonly found in postmenopausal women, although a case of urethral caruncle has also been described in a male.[1] Urethral caruncles resemble various urethral lesions, including carcinoma. The differential diagnoses of urethral caruncle include urethral diverticulum, urethral prolapse, urethral carcinoma, and periurethral gland abscesses.-medscape-

http://avantgardeurology.com/images/update-edu-3.jpg

7. Check for other related system

8. Symptoms of urinary tract malignancy or urothelial tumor

• painless hematuria
• suprapubic mass
• malignant cystitis
• irritability
• urgency
• dysuria
• metastases diseases
• AUR
• bone pain
• abdominal distension 

Systemic review checklist medical ward