Tumor in orthopaedic

Approach for orthopaedic tumor PART 1
Teaching Mr. ariff

History and PE : Aim to
1. Differentiate between soft tissue or bone

2. Differentiate between malignancy or benign or benign to maligancy transformation
-benign usually long standing
-malignant usually is fast growing a/w night pain or pain at rest?
-benign to maligant transformation - usually lipoma
Tengok balik buku. Cuba buat table

3. Any symptoms of metastases
-can be to mets from other site (5 tumors commonly mets to bone are lung, breast, thyroid, renal n prostate). So need to rule out those as well. would be useful if we can read the characteristic of those tumor...osteoblastic, osteoclastic or mixed. For example prostate tumor is osteoclastic in nature
-it can also be primarily from bone itself but mets to bone elsewhere.. bone usually mets to lung and other bone which is highly vascularized, which is the cancellous bone. Examples of cancellous bones are proximal girdle,hip, vertebral body, proximal humerus (but can only be seen radiologically once it spread to pedicle giving owl wink sign). Rarely mets to liver, unlike carcinoma. So, ask about any pain elsewhere, hemoptysis, sob...
-note that giant cell tumor (benign) has metastatic characteristic, but only to lungs. It is bacause it gets doslidged from the primary lesion. But unlike a real mets in malignancy, it can't transfer from lung to lung.

4. Anticipate complications  local or systemic
-local compression:
♧nerve - any loss of sensation, numbness
♧vascular - pulse, dilated vein, edema
♧muscle - weakness PNS
♧joint-effusion

- systemic
♧anemic sign n symptoms (ssx)
♧ssx of hypercalcemia (resorption-read more how it occurs)

5. obtain family history of malignancy. Apa tumor yg commonly ada genetic influence. X dpt kawab hari tu sbb x dtg seminar mr goh

6. Syndromic??? X dpt pick up sebab terspace out. Among important keywords : bone tumor boleh develop fibrous dysplasia...monostotic or polyostotic. and syndromes somehow related with endocrine punya features like thyroid pr pituitary. Good to know.

From mr shuk : causes of pain in malignancy
1. Compression to surrounding
2. Central necrosis
3. Stretch of pseudocapsule

Kwashiorkor vs Marasamus

Just sharing from what we hve learnt from dr muhd during bedsite teaching today.

Since today we hve examine ptn at 1yo with kwashiokor, here are some differences between kwashiorkor and marasmus

🐥Kwashiorkor
1.inadequate protein intake , good caloric intake
2.Pitting edema (lower ext > generalized in severe case + moon face)
3.reserved subcutaneous fat, marked atrophy of muscle mass
4.mentality : apathy , disinterest in eating
5.marked skin changes : hyperpigmented hyperkeratosis to macular rash (more common)
6.hair changes : sparse , easily plucked , dull brown/red/yellow white (more common)

🐣Marasmus
1.inadequate calories n nutrients , protein may not deficient
2.edema usually absent
3.loss of subcutaneous fat and muscle mass
4.mentality : irritable
5.skin changes : less common
6.hair changes (as kwashiorkor) : less common

New posting!

Now, it is already my second week of medical posting, the most feared posting. I don't sure how i feel when I started my first week. So many diseases need to be covered and clerking is wayyyy moreeeee detailed in medical posting. But, first, you need to know what are the spectrum of diseases especially the common ones in our setting for each system, and some  MOST diseases have systemic manifestation, everything is interrelated.

But fret not, first, master the PE, try to read through how it is done and possible causes which may lead to a particular complaint. I would suggest you guys to read oxford handbook. Or Talley for throrough reading, my fav so far. LOL. But yes it really is you bible in this posting.

Just got my surgical posting result, it was fine...hmmm....yeah fine. A bit disappointed though with my theory but shouldn't  because it was my own mistake, I procrastinate too much before the exam. But, Thank God, I passed :)

Medical posting is a hectic one, I can't deny that plus the ward is congested most of the time and the current weather was like, phewww...It seems like everyone is hyperthyroid like that. Will be starting to post the cases and discussion here soon. Sharing is caring, if no one is reading, fine, an alien would be interested then. It is for my own revsiion anyway. (-_-')

May Allah ease.

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