GENERAL SURGERY Name:

01. Wound Classifications:

• Simple wounds – only skin is involved.
• Complex wounds – vessels, nerves, tendons or bones are involved.
 Open wounds – Incised wounds, Lacerated wounds ,Crush injuries, Penetrating wounds
 Closed wounds – Contusion, Abrasion, Haematoma
 Others : Clean wound ,Clean contaminated wound ,Contaminated wound, Dirty wound

02. Stages of Wound Healing

A) Stage of inflammation
B) Stage of granulation tissue formation and organisation. Here due to fibroblastic
activity synthesisation of collagen and ground substance occurs.
C) Stage of epithelialisation.
D) Stage of scar formation and resorption
E) Stage of maturation.

03. Primary suturing means suturing the wound immediately within 6 hours. It is done in clean
incised wounds. Delayed primary suturing means suturing the wound in 48 hours to 10
days. It is done in lacerated wounds. This time is allowed for the oedema to subside. It is
done as single layer interrupted deep sutures using monofilament polypropylene or
polyethylene.

04. Secondary suturing means suturing the wound in 10-14 days or later. It is done in infected
wounds. After the control of infection, once healthy granulation tissue appears, secondary
suturing is done.

05. COMPARTMENT SYNDROME :

Common in calf and forearm. Closed injuries causes haematoma leading to increased
pressure, often associated with fracture of the underlying bone causing pallor,
pulselessness, pain, paraesthesia, diffuse swelling and cold limb.
 Problems with the compartment syndrome • Infection, septicaemia and abscess formation •
Renal failure • Gangrene of the limb • Muscle necrosis releases myoglobulin which is
excreted in the urine, damages the kidneys leading into renal failure
 Treatment • Compartment pressure will be persistently more than 30 mm Hg and
fasciotomy. Multiple incisions should be made if needed. Separate incision in each
compartment should be done.
 06. CRUSH SYNDROME :
Crushing of muscles causing extravasation of blood and release of myohaemoglobin into the
circulation leading to acute tubular necrosis and acute renal failure.
 Initially tension increases in the muscle compartment commonly in the limb, which
itself impedes the circulation and increases the ischaemic damage
 Effects of crush syndrome • Renal failure • Toxaemia • Septicaemia • Disability with
extensive tissue loss • Gas gangrene
 Treatment • Tension in the muscle compartment is relieved by placing multiple
parallel deep incisions in the limb so as to prevent further damage.

07. TREATMENT FOR KELOID: (PLS READ 5 DIFFERENCE BETWEEN: KELOID/ HYPERTROPIC
SCAR)
1. Excision and skin grafting
2. Irradiation , or Excision and irradiation
3. Steroid injection—Intrakeloidal triamcinolone, is injected at regular intervals, may be
once in 7-10 days, of 6-8 injections
4. Steroid injection—Excision—Steroid injection, recurrence rate is very high—more than
50%.

08. Callous ulcer: Floor contains pale unhealthy granulation tissue with indurated edge/base. It
lasts for many months to years. Ulcer does not show any tendency to heal. It is due to
callous attitude of the patient

09. Wagner’s grading/classification of ulcer:

Grade 0 – pre ulcerative lesion/healed ulcer
Grade 1 – superficial ulcer
Grade 2 – ulcer deeper to subcutaneous tissue exposing soft tissues or bone
Grade 3 – abscess formation underneath/osteomyelitis
Grade 4 – gangrene of part of the tissues/limb/foot
Grade 5 – gangrene of entire one area/foot

10. Ulcer dressings

 Cotton dressing
 Paraffin dressing
 Polyurethane dressings used in clean wounds
 Type 1 collagen dressings cause haemostasis, proliferation of fibroblasts and improve the blood
supply
 Foam dressings are highly absorbent, decrease the wound maceration, and reduce the
frequency of dressing
• Hydrocolloid dressings help in separation of slough and autolysis of dead tissues
11. TROPHIC ULCER (PRESSURE SORE):
Pressure sore is tissue necrosis and ulceration due to prolonged pressure. Blood flow to the
skin stops once external pressure becomes more than 30 mm Hg causing tissue hypoxia,
necrosis and ulceration. It is due to • Impaired nutrition. • Defective blood supply. •
Neurological deficit.
 Sites : Over the ischial tuberosity. • Sacrum • heel • Buttocks. • Over the shoulder.
• Occiput.
 Due to the presence of neurological deficit, trophic ulcer is also called as neurogenic
ulcer/neuropathic ulcer. Bedsores are trophic ulcers.
 Clinical Features • Occurs in 5% of all hospitalised patients. • Painless ulcer which is
punched out. • Ulcer is nonmobile with base formed by bone
 Management: Nutritional supplementation. • Rest, antibiotics, slough excision,
regular dressings. • Vacuum assisted closure (VAC), Change in position once in 2
hours; lifting the limb upwards for 10 seconds once in 10 minutes; use of water
bed/air bed

12. MARTORELLE’S ULCER :

It is seen in hypertensive patients often with atherosclerosis, in calf.
Often it is bilateral and painful. There is sudden obliteration of the arterioles of the calf skin.
• All peripheral pulses are present.
Treatment: Once ulcer granulates well, skin grafting with lumbar sympathectomy is done

13. TROPICAL ULCER :

• It is an acute ulcerative lesion of the skin observed in tropical regions like Africa, India and
South America.
It is associated with lower socioeconomic group, anaemia, malnutrition and vitamin
deficiency.
• It is commonly caused by Fusobacterium fusiformis (Vincent’s organisms) and Borrelia
vincenti.
• There are abrasions, redness, papule and pustule formation, acute regional lymphadenitis
and severe pain.
• Treatment – improvement in nutrition, penicillin, Eusol dressing, skin grafting at a later

14. DIABETIC ULCER:

 Causes • Increased glucose in the tissue precipitates infection. • Diabetic
microangiopathy Increased glycosylated haemoglobin decreases the oxygen
dissociation, Associated atherosclerosis.
 Sites • Foot-plantar aspect—is the commonest sit, .Leg, Upper limb, back, scrotum,
perineum. • Ulcer is usually spreading and deep.
 Investigations • Blood sugar both random and fasting. • Urine ketone bodies. •
Discharge for culture and sensitivity. • X-ray of the part to see osteomyelitis. •
Arterial Doppler of the limb.
 Treatment • Control of diabetes using insulin. • Antibiotics. • Nutritional
supplements. • Regular cleaning, debridement, dressing , MCR shoes
15. MELENEY’S ULCER (POSTOPERATIVE SYNERGISTIC GANGRENE ) :
It is commonly seen in postoperative wounds in abdomen and chest wall like empyema
drainage or after surgery for peritonitis
 Etiology: streptococci, Staphylococcus aureus and anaerobes.
 Sites • It is common in abdomen and thorax. It begins in wound margin and spreads
rapidly. It can also occur in other areas of skin
 Clinical Features • Features of toxaemia. • Spreading painful ulcer with discharge. •
Abundant granulation tissue with purple and red zones.
 Management • Random blood sugar is checked, if diabetic it has to be controlled. •
Antibiotics. • Blood transfusion, critical care. • Adequate excision of dead tissues
until it bleeds. • Once healthy granulation tissue is formed skin grafting is done.

16. BAZIN’S DISEASE (Erythrocyanosis Frigida) :

Called as Erythema induratum.
• It is localised area of fat necrosis affecting exclusively adolescent girls. • Symmetrical
purple nodules develop in the ankles and calves which eventually break down forming
indolent ulcers with pigmented scars.
• It may be due to tuberculosis.
• Antitubercular drugs and sympathectomy are the treatment.

17. SINUS is a blind track lined by granulation tissue leading from an epithelial surface into the
surrounding tissues. Causes-- Congenital: Pre-auricular sinus. Acquired: Actinomycosis,
tuberculosis, pilonidal sinus, chronic osteomyelitis, median mental sinus.

18. FISTULA is an abnormal communication between the lumen of one viscus to another or the
body surface or between the vessels. Fistula means “flute” or “a pipe or tube.

19. LUDWIG’S ANGINA:

It is cellulitis of upper part of the neck involving submandibular region and floor of the
mouth along the fascial planes. It may be precipitated by tooth extraction, oral cancer,
submandibular gland infection, diabetes mellitus, chemotherapy, etc.
 Clinical Features • Diffuse swelling, redness, tenderness and induration in the floor
of the mouth and submandibular region. • Difficulty in opening of the mouth
(Trismus). • Toxic features like fever, tachycardia and tachypnoea. • Severe
laryngeal oedema (presents with respiratory distress, stridor and cyanosis). •
Dysphagia and putrid halitosis.
 Complications • Septicaemia. • Spread of infection into the parapharyngeal space
leads to thrombosis of internal jugular vein which may extend above into the
sigmoid sinus which may be fatal.
 Treatment: Antibiotics. • Early surgical intervention (decompression) is required
 20. Hilton’s method of draining an abscess: • Initially broad spectrum antibiotics are started
(depending on severity, extent and site of the abscess)
 After cleaning and draping, abscess is aspirated and presence of pus is confirmed. Skin is incised
adequately, in the line parallel to the neurovascular bundle in the most dependent position.
 Next, pyogenic membrane is opened using Sinus forceps and all loculi are broken up. Abscess
cavity is cleared of pus and washed with saline. • A drain (either gauze drain or corrugated
rubber drain) is placed.
 Wound is not closed. Wound is allowed to granulate and heal. Sometimes secondary suturing or
skin grafting is required. • Pus is sent for culture and sensitivity. • Antibiotics are continued.

21. POTT’S PUFFY TUMOUR :

It is formation of diffuse external swelling in the scalp due to subperiosteal pus formation
and scalp oedema.
• It originates commonly in frontal region and may extend into other regions. • Often there
is acute osteomyelitis of frontal bone

22. Swellings which are brilliantly transilluminant:

• Ranula • Cystic hygroma and lymph cyst • Hydrocele • Epididymal cyst (Chinese-lantern
pattern) • Meningocele

23. DERMOIDS
Types.
 Sequestration Dermoids: It occurs at the line of embryonic fusion, due to inclusion of
epithelium beneath the surface which later gets sequestered forming a cystic swelling in the
deeper plane. Common sites are: 1. Forehead, neck, post auricular dermoid. 2. External angular
dermoid. 3. Root of nose. 4. Sublingual dermoid
 Tubulodermoids : It arises from the embryonic tubular structures. Examples include •
Thyroglossal cyst. • Ependymal cyst
 Implantation Dermoid : • Due to minor pricks or trauma, epidermis gets buried into the deeper
subcutaneous tissue which causes reaction and cyst formation
It is common in fingers (common in tailors, gardeners), toes and feet.
Clinical features: Swelling is painless, observed after minor trauma, slowly progressing in fingers
or toes. • It is smooth, soft, mobile, tensely cystic, non transilluminating and is often adherent
to skin. • It contains only squamous epithelium, without hair follicle/sweat or sebaceous glands.
 Teratomatous Dermoid : • It arises from all germinal layers ecto, meso and endoderms. • It
occurs in ovary, testis, retroperitoneum, mediastinum. • It contains hair, teeth, cartilage and
muscle. • It can be benign or malignant.
 Treatment • Excision is done under general anaesthesia
24. SEBACEOUS CYST (WEN, EPIDERMOID CYST) : (PLS READ EPIDIDYMAL CYST)
It is a retention cyst.
It is due to blockage of the duct of sebaceous gland, causing a cystic swelling.
• It is common in face, scalp, scrotum. • It is not seen in palms and soles as there are no
sebaceous glands.
• Sebaceous cyst contains yellowish white cheesy material with fat and epithelium. It has
putty like consistency, with a parasite in the wall of the sebaceous cyst—demodex
folliculorum
• Painless swelling which is smooth, soft, nontender, freely mobile, adherent to skin
nontransilluminating with punctum over the summit
• Punctum is present over the summit in 70% of case
Treatment • Excision including skin adjacent to punctum. • If abscess is formed, then
drainage initially and later excision is done.

25. NEUROFIBROMA:
It is a fusiform swelling which has got horizontal mobility but not longitudinal mobility
(neurilemmoma has got free mobility in all directions)
Café au lait spots signify common neuro-ectodermal origin of nerve sheath and
melanocytes
• Plexiform neurofibromatosis commonly involves trigeminal cranial nerve mainly
ophthalmic division causing paraesthesia, can obstruct the vision when it is large, have
grossly thickened pendulous skin hanging down to various levels
• Calcification, saponification, myxomatous changes, sarcomatous transformation are the
complications
• Intestinal neurofibroma may precipitate intussusception

26. GANGLION :
It is a cystic swelling occurring in relation to tendon sheath or synovial sheath or joint
capsule. It contains clear gel like fluid.
 Common sites- 1. Dorsum of wrist (Near scaphoid-lunate articulation) 2. Flexor
aspect of wrist
 Clinical Features • Well localised swelling which is smooth, soft, cystic, or tensely
cystic, (Paget’s test is +ve), nontender, transilluminant.
 Treatment: Asymptomatic ganglion is better left alone because of high recurrence
rate. •Excision. Usually done under local anaesthesia (lignocaine plain 2%). Patient
should be explained of high recurrence rate (30%). After excision always it should be
sent for histopathology.

27. Swellings which are cross fluctuant

• Psoas abscess • Bilocular hydrocele • Ranula (plunging) • Compound palmar ganglion
28. TPN: Indications : 1. Failure or contraindication for any enteral nutrition. 2. High output
abdominal fistulas, duodenal, biliary, pancreatic fistulas. 3. Major abdominal surgeries of
liver, pancreas, biliary, colonic. 4. Septicaemia, 5. Multiple trauma. 6. Short bowel syndrome
 Components used in TPN • Carbohydrates. • Fat and amino acids. • Vitamins and
trace elements.
 Complications :
 Technical-- 1. Air embolism. 2. Pneumothorax. 3. Bleeding. 4. Catheter
displacement, sepsis, blockage. 5. Infection, thrombosis.
 Biochemical-- 1. Electrolyte imbalance: Hyponatraemia, hypokalaemia,
hypophosphataemia. 2. Hyperosmolarity. 3. Hyperglycaemia. – common. 4.
Dehydration.

29. SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) :

SIRS is body’s systemic response to an infected wound. It causes either
 hyperthermia (>38°C) or hypothermia (< 36°C);
 tachycardia (pulse > 90 / minute);
 tachypnoea (> 20 / minute);
 total white cell count > 12,000 / cu mm

30. Complications of blood transfusion :

1. Congestive cardiac failure
2. Transfusion reactions -- Incompatibility. Major and minor reactions with fever, rigors,
pain, hypotension
3. Infections • Serum hepatitis • HIV infection • Bacterial infection • Malaria transmission •
Epstein barr virus infection • Cytomegalo virus infection • Syphilis, Yersinia • Babesia microti
infection • Trypanosoma cruzi infection
4. Air embolism 5. Thrombophlebitis 6. Coagulation failure • Dilution of clotting factors •
DIC • Dilutional thrombocytopenia occurs in patients with massive blood transfusion
7. Circulatory overload causing heart failure
8. Haemochromatosis in patients with CRF receiving repeated blood transfusions
9. Citrate intoxication causes bradycardia and hypocalcaemia
10. Iron overload

31. Parkland regime: FOR BURNS

Commonly used 4 ml/% burn/kg body weight/24 hours. Maximum percentage considered is
50%. Half the volume is given in first 8 hours, rest given in 16 hours.

32. TERMINAL PULP SPACE INFECTION (FELON)

• It is the second most common hand infection (25%). • Index and thumb are commonly
affected. • Usually by a minor injury like finger prick.
 Bacteria • Staphylococcus commonest. • Streptococcus. • Gram-negative
organisms.
 Clinical Features • Pain, tenderness, swelling in the terminal phalanx. • Fever. •
Tender axillary lymph nodes.
  Investigations • X-ray of the part is required often to rule out osteomyelitis of
terminal phalanx. • Pus for culture and sensitivity
 Treatment • Antibiotics and analgesics. • Drainage of terminal pulp space by an
oblique deep incision

33. DEEP PALMAR SPACE INFECTION:

 Causes-- Trauma. • Spread from infection of finger spaces and web spaces. •
Haematogenous spread. • Spread from tenosynovitis.
 Clinical Features • Pain and tenderness in the palm. • Oedema of dorsum of hand
(frog hand). • Loss of concavity of palm. • Painful movement of
metacarpophalangeal joint • Fever. • Palpable tender axillary lymph nodes
 Treatment • Elevation of the affected limb. • Antibiotics and analgesics. • Drainage
under general anaesthesia
 A horizontal incision is placed on the volar aspect without crossing the palmar
creases and should be extended deep to palmar aponeurosis. A drain is placed. Pus
is sent for culture and sensitivity and appropriate antibiotics are continued.

34. INGROWING TOE NAIL (Onychocryptosis) :

 It is also called as embedded toe nail. • It is due to curling of the side of nail inwards,
causing it to form a lateral spike resulting in repeated irritation and infection of
overhanging tissues in the nail fold.
 Causes • Tight shoes. • Improper cutting of nails
 Treatment • Regular dressing and packing. • Antibiotics

35. PLANTAR FASCIITIS (Policeman’s Heel) :

 It occurs due to friction or tear of the ossified posterior insertion of the plantar
fascia which is common in people who stand or walk for long-time
 Treatment-- Analgesics, rest, steroid injections

36. COMPOUND PALMAR GANGLION :

 It is chronic tenosynovitis of flexor tendon sheaths due to tuberculosis (tuberculous
tenosynovitis) or rheumatoid arthritis.
 Clinical Features • Swelling in the palm and lower forearm which is smooth, soft,
nontender, fluctuant and also cross fluctuant across flexor retinaculum, non
transilluminating.
 Treatment • Start antituberculous drugs: INH, rifampicin, ethambutol and
pyrazinamide for 9 months. • Excision of flexor tendon sheath is done along with
scraping of caseating material.

37. Kanavel signs: seen in acute suppurative tenosynovitis

• Swollen finger held in flexion • Exquisite pain on passive extension • Tenderness precisely
over the tendon sheath. • Area of greatest tenderness over the part of ulnar bursa lying
between transverse palmar creases
 38. Scolicidal agents
• Cetrimide – can cause acidosis
• Alcohol 80% - can cause cholangitis
• Hypertonic saline – hypernatraemia
• Sodium hypochlorite – hypernataraemia
• Hydrogen peroxide

39. INTERMITTENT CLAUDICATION:

Due to arterial occlusion, metabolites like lactic acid and substance P accumulate in the
muscle and cause pain. The site of pain depends on site of arterial occlusion.
• Commonest site is calf muscles. • Pain in the buttock is due to block in the common iliac or
aortoiliac segment, often associated with impotence and is called as Leriche’s syndrome.

40. Claudication :
• Arterial – typically develops after walking for certain distance and resolves rapidly within
5 minutes once walking is stopped
• Neurogenic – pain develops in standing or walking and disappears immediately after
stopping walk; normal feeling pulses without ischaemic changes. It is usually due to narrow
lumbar canal (spinal canal stenosis)

41. Critical Limb Ischaemia :

It is persistently recurring ischaemic rest pain for 2 weeks or ulceration or gangrene of the
foot or toes with an ankle systolic pressure < 50 mmHg or toe systolic pressure < 30 mmHg.

42. Adson’s test (Scalene manoeuvre):

 In a patient sitting on a stool, the radial pulse is felt. The patient is then asked to
take a deep breath and turn the face to same side (to contract scalenus anterior
muscle) so as to narrow the scalene triangle.
 If the radial pulse disappears or become feeble it signifies cervical rib

43. Allen’s test:

 It is done to find out the patency of radial and ulnar arteries. Both the arteries are
compressed near the wrist and allowed to blanch completely in one minute. (In the
mean time patient closes and opens the fist several times for further venous
outflow.)
 Palm appears pale and white. One of the arteries is released and colour of hand is
noted. Normally hand will become pink and flushed in no time; whereas in
obstruction, the area will still remain pale.
 Other artery is also released and looked for changes in hand.

44. Ankle-brachial pressure index: Normally it is 1. If it is less than 0.9, it means ischaemia is
present. If it reaches 0.3 or below then it signifies severe ischaemia with gangrene
45. Seldinger technique: Treatment of TAO
• Arterial cannula is passed into the artery, e.g. femoral artery • Needle is removed and
guide wire is passed through the cannula • Cannula is removed • Dilator is passed over the
guide wire • Dilator is removed and arterial catheter is passed over the guide wire • Guide
wire is removed

46. TAKAYASU’S ARTERITIS (Pulseless disease)

• It is pan-arteritis involving aortic arch and branches arising from aorta • It is common in
young females (85%). • Commonest site is subclavian artery (85%).
Clinical Features • Fever, myalgia, arthralgia. • Visual disturbances. • Upper limb
claudication. • Absence of peripheral pulses. • Hypertension. • Bruit.
Complications • Ischaemia. • Embolism. • Myocardial infarction.
Investigations • DSA. • MR angiography. • Doppler.
Treatment • To suppress immunity. Prednisolone – 50 mg/day. Cyclophosphamide. •
Vascular reconstruction.

47. Coffman criteria for Raynaud’s syndrome –

“episodic attacks of well-demarcated reversible self limiting colour changes for 1–20
minutes on exposure to cold/emotional stimuli and is symmetrical/bilateral lasting for 2
years

48. Causes for Raynaud’s Phenomenon :

1. Raynaud’s disease: It is seen in females, usually bilateral. It occurs in upper limb with
normal peripheral pulses. It is due to upper limb (hand) arteriolar spasm as a result of
abnormal sensitivity to cold. Patient develops blanching, cyanosis and later flushing as in
Raynaud’s syndrome.Symptoms can be precipitated and observed by placing hands in cold
water.
2. Working with vibrating tools: Like pneumatic road drills, chain saws, wood cutting,
fishermen travelling in machine boats.
3. Collagen vascular diseases: Like Scleroderma, Rheumatoid diseases causing vasculitis (all
autoimmune diseases)
4. Other causes: Cervical rib, Buerger’s disease, Scalene syndrome. It is often associated with
CREST syndrome. (Calcinosis cutis, Raynaud’s phenomenon, Esophageal defects,
Sclerodactyly, Telangiectasia).

49. Lumbar sympathectomy: Indications:

• Peripheral vascular disease like TAO. • To promote healing of cutaneous ulcers. • To
change level of amputation and to make flaps to heal better after amputation. • Causalgia of
lower limb (it is common in upper limb). • Hyperhidrosis.

50. CIRSOID ANEURYSM :

• It is a rare variant of capillary haemangioma occurring in skin, beneath which abnormal
artery communicates with the distended veins. • Commonly seen in superficial temporal
artery and its branches
 Clinical Features-- Pulsatile swelling in relation to superficial temporal artery, which is warm,
compressible, with arterialisation of adjacent veins and with bone thickening (due to
erosion). It feels like a ‘pulsating bag of worms’.
 Investigations • Doppler study. • CT scan. • Angiogram. • X-ray of the part.
 Treatment • Ligation of feeding artery and excision of lesion

51. BRANHAM’S sign: seen in AV fistula

If pressure is applied to the artery proximal to the fistula, swelling will reduce in size, thrill
and bruit will disappear, pulse rate and pulse pressure becomes normal. This is called as
Nicoladoni’s sign or Branham’s sign.

52. PERFORATORS: Types • Ankle perforators (May or Kuster) • Lower leg perforators: I, II, III
(of Cockett) • Gastrocnemius perforators (of Boyd) • Mid thigh perforators (Dodd) •
Hunter’s perforator in the thigh

53. Virchow’s triad— a) Stasis b) Hypercoagulability c) Vein wall injury

54. Sclerosants used in varicose veins— • Sodium tetradecyl sulphate 3% (STDS)–commonly

used • Sodium morrhuate • Ethanolamine oleate • Polidocanol

55. Complications of Varicose Veins • Haemorrhage. • Eczema and dermatitis. • Periostitis

causing thickening of periosteum. • Venous ulcer. • Marjolin’s ulcer. • Lipodermatosclerosis.
• Ankylosis of the ankle joint. • Talipes equino varus. • Deep venous thrombosis. •
Calcification. • Thrombophlebitis.

56. Bisgaard method of treating venous ulcer:

• Measures to reduce oedema, increase venous drainage, so as to promote ulcer healing.
• Elevation. • Massage of the indurated area and whole calf.
• Passive and active exercise.
 Pressure bandage (crepe bandage) • Dressing with EUSOL
 Antibiotics depending on culture and sensitivity of the discharge. Once ulcer bed
granulates well, split skin graft (SSG) is placed (Thiersch Graft

57. EUSOL is Edinburgh University solution of lime containing boric acid, sodium hypochlorite,
calcium hydroxide.

58. CHYLOTHORAX : It is accumulation of lymph in the pleural cavity. It is common on right side
because of long course of thoracic duct towards right side.
 Causes • Injury due to trauma/surgeries in neck or chest. Surgical - Tuberculosis,
lymphoma or secondaries in the mediastinum. • Carcinoma lung or oesophagus
 Features • Chest pain, dyspnoea, pleural effusion. • Protein loss and malnutrition •
Pleural tap will show chalky white fluid rich in chylomicrons. • Chest X-ray, CT chest
  Treatment • ICT placement • Fat free protein rich diet • Antibiotics therapy for the
cause.

59. Phalen’s Test (Wrist flexion test)- carpel tunnel syndrome

Flexion of the wrist causes exacerbation of the symptoms within 1 minute and the
symptoms will disappear as the wrist is straightened.

60. Ulnar paradox: In ulnar palsy, higher the lesion, lesser the deformity, lower the lesion more
the deformity. In higher lesion, FDP is also paralysed. In lower lesion FDP is intact and so FDP
causes more flexion (overaction) and so aggravates the claw hand.

61. Trucut Biopsy: It is done using a specialised device wherein gun with Trucut tip is inserted
into the surface tissue / organ and gun is fired to close the punching tip of the needle to
catch and cut adequate tissue. It is done in prostate, breast and surface tumour.

62. Incision Biopsy • It is taken from the edge of the lesion as in ulcer, not from the centre as
there is necrosis. Incision biopsy is contraindicated in a case of melanoma where excision
biopsy is preferred. • In secondaries in lymph nodes, FNAC is preferred.

63. PREMALIGNANT CONDITIONS OF THE SKIN :

• Bowen’s disease of skin, Paget’s disease of nipple • Leukoderma • Senile or solar keratosis
• Albinism • Xeroderma pigmentosa , Chronic lupus vulgaris • Prolonged irritation of skin by
various chemicals like dyes, tar, soot

64. MARJOLIN’S ULCER • It is a well-differentiated squamous cell carcinoma which occurs in

chronic scars like burn scar, scar of venous ulcer
As it develops in a scar due to chronic irritation and there are no lymphatics in scar tissue, it
will not spread to lymph nodes.
Treatment • Wide excision. • In case of large ulcer, amputation is required. • Radiotherapy
should not be given as it may turn into poorly differentiated squamous cell carcinoma

65. MALIGNANT FIBROUS HISTIOCYTOMA (MFH) : It is group of malignant soft tissue tumours
with a fibrohistiocytic appearance. It is the commonest extremity sarcoma (lower > upper).
Myxoid/giant cell/inflammatory/angiomatoid/pleomorphic are the types. It is common in
adults and elderly.

66. Ideal Stump • Should heal adequately. • Should have rounded, gentle contour, with
adequate muscle padding. • Should have sufficient length to bear prosthesis. • For B-K 7.5
(minimum) to 12.5 cm from tibial tuberosity • For above and below elbow 20 cm stump. •
For A-K 23 cm from greater trochanter
67. PARTIAL THICKNESS GRAFT (Split thickness graft—SSG) :
Also called as Thiersch graft, is removal of full epidermis + part of the dermis from the
donor area.
 Pre-requisite 1. Healthy granulation area. 2. B-haemolytic streptococci load less
than 105 per gram of tissue, otherwise graft failure will occur
 Disadvantages of SSG-- 1. Contracture of graft. 2. Seroma and haematoma
formation will prevent graft take up. 3.Infection. 4. Loss of hair growth 5. Dry,
scaling of skin due to nonfunctioning of sebaceous glands

68. FULL THICKNESS GRAFT (Wolfe graft) :

• It includes both epidermis + full dermis. • It is used over the face, eyelid, hands, fingers
and over the joints. • It is removed using scalpel blade. Underlying fat should be cleared off
properly
 Disadvantages -- 1. It can be used only for small areas. 2. Wider donor area has to
be covered with SSG to close the defect. 3. Can not be used to cover ulcers.

 (PLS READ ADVANTAGES FOR BOTH GRAFTS)

69. FLAPS :
 It is transfer of donor tissue with its blood supply to the recipient area.
 Parts of Flaps-- Base, pedicle, tip of flap. Vasculature is usually through the pedicle
in the centre of the flap. Tip is the place where often flap goes for necrosis.
 Indications --1. To cover the wider, deeper defects 2. To cover over bone, tendon,
cartilage
 Disadvantages-- 1. Long-term hospitalisation. 2. Infection. 3. Kinking, rotation and
flap necrosis. 4. Staged procedure

70. CIMINO FISTULA :

It is an arterio-venous fistula created for haemodialysis. Usually at wrist, radial artery is
anastomosed to cephalic vein side-to-side and a created good fistula shows continuous thrill
and bruit.

71. PREAURICULAR SINUS:

• It is due to failure of fusion of anterior tubercles of the auricle creating a sinus. • Often
sinus opening gets sealed forming a preauricular cyst which gets infected forming an
abscess. • Sinus can get infected repeatedly, discharging pus through its opening. • It is
often multiple.
Investigations • Sinusogram. • Discharge study.
72. EPULIS :
 Swelling arising from the mucoperiosteum of gums
 Congenital Epulis- benign condition seen in a newborn ,Well localised swelling from
the gum which is firm and bleeds on touch.
 Fibrous Epulis- seen in the gum, adjacent to the caries tooth. • It is commonest
type. It is fibroma arising from periodontal membrane
 Pregnancy Epulis • It occurs in pregnant women due to inflammatory gingivitis •
Usually during 3rd month of pregnancy
 Myelomatous Epulis • It is seen in leukaemic patients.
 Granulomatous Epulis- It is a mass of granulation tissue in the gum around a caries
tooth
 Giant Cell Epulis- Osteoclastoma causing ulceration and haemorrhage of gum
Carcinomatous Epulis
 Investigations • X-ray jaw. • Orthopantomogram • Biopsy from the lesion.
 Treatment-- Excision with extraction of the adjacent tooth

73. AMELOBLASTOMA (Adamantinoma, Eve’s disease, Multilocular cystic disease of the jaw) :
• It arises from the dental epithelium probably from the enamel/dental lamina, commonly
in mandible or maxilla
• Histologically it is a variant of basal cell carcinoma. • It is a locally malignant tumour. • It
neither spreads through lymph node nor through blood. Hence it is curable.
 Clinical Features • Swelling in the jaw usually in the mandible near the angle which
attains a large size, extending to vertical ramus—Eggshell crackling, Outer table
expansion
 Investigations • Orthopantomogram (OPG) shows multiloculated lesion—Honey
coomb appearance. • Biopsy from the swelling.
 Treatment • Segmental resection of the mandible. OR • Hemimandibulectomy with
reconstruction of the mandible.

74. DENTIGEROUS CYST (Follicular odontome) :

• It is a unilocular cystic swelling arising in relation to the dental epithelium from an
unerupted tooth. • Common in lower jaw, but can also occur in upperjaw. • It occurs over
the crown of unerupted tooth • It causes expansion of outer table of the mandible
 Investigation Orthopantomogram
 Treatment - If it is small, excision of the cyst is done. • If it is large, initial
marsupialisation and later excision is done. • Unerupted tooth should be extracted

75. DENTAL CYST (Radicular cyst, Periapical cyst) :

• It occurs under the root of the chronically infected dead erupted tooth
 Clinical Feature- As a smooth, tender swelling in the jaw in relation to caries tooth
which causes expansion of the jaw bone..
 Investigation Orthopantomogram.
 Treatment • Antibiotics. • Drainage or excision of the cyst with extraction of the
infected tooth is done.
76. RANULA:
Ranula is an extravasation cyst arising from sublingual gland or mucus glands of Nuhn or
glands of Blandin in the floor of the mouth. Initially there is blockage of the duct (of
sublingual gland) causing retention cyst, which causes rupture of the acini due to increased
pressure leading into extravasation cyst.
 Clinical features of ranula • Bluish swelling in the floor of the mouth • Laterally
placed • Nontender • Fluctuant and cross fluctuant (plunging ranula) • Brilliantly
transilluminant
 It extends into the submandibular region through the deeper part of the posterior
margin of mylohyoid muscle and is called as plunging ranula
 Treatment • Marsupialisation

77. CANCRUM ORIS (NOMA) :

It is an infective gangrene, a severe form of Vincent‘s acute ulcerative gingivitis and
stomatitis. • Seen in poorly nourished, ill-child due to Borrelia vincentii and Fusiformis
bacteria.
• It starts in gums, spreads into cheek, bone, soft tissues and skin causing extensive tissue
loss with severe toxaemia. • Extensive necrosis of the mucus membrane of the oral cavity
with destruction of deeper soft tissue and often bone.
Treatment-- 1. Systemic antibiotics, high dose penicillins, metronidazole,

78. LEUKOPLAKIA :
 It is a white patch in the mucosa of the oral cavity that cannot be characterised
clinically or pathologically to any other disease. It is a premalignant condition.
 Types 1. Homogenous. 2. Nodular—more potentially malignant. 3. Speckled—more
potentially malignant–highest.
 Incidence of leukoplakia in those who smoke or chew pan is 20%, whereas incidence
in non-smokers is 1%. • Incidence of its turning into malignancy is 2-4 %
 Histology: Parakeratosis with widening of rete pegs.
 Treatment • Pan chewing and smoking has to be stopped. • Excision, if required
skin grafting has to be done. • Regular follow-up is necessary

79. ERYTHROPLAKIA :
• It is red velvety appearance of the mucosa which cannot characterise any recognised
condition. • It is 17-20 times more potentially malignant than leukoplakia.
• Histologically parakeratosis with severe epithelial dysplasia is the typical feature.
• It can be homogenous/speckled/granular or erythroplakia interspersed with leukoplakia.
• Diagnosis is done by biopsy.
• Treatment: Biopsy and surgical
80. PREMALIGNANT CONDITIONS OF ORAL CAVITY :
High risks – Lesions definite risk of malignant change • Leukoplakia. • Erythroplakia. •
Chronic hyperplastic candidiasis – It is common in commissures of the mouth and tongue. It
is treated by topical or systemic antifungal drugs/surgical excision or laser therapy.
Medium risks – premalignant but not associated with higher incidence of carcinoma • Oral
submucosal fibrosis. • Syhilitic glossitis. • Sideropenic dysphagia
Equivocal risk lesions • Oral lichen planus , Dyskeratosis congenital. • Discoid lupus
erythematosus

81. Structures within the parotid gland from deep to superficial – • External carotid artery,
maxillary artery, superficial temporal artery, posterior auricular artery • Retromandibular
vein (by maxillary and superficial temporal veins) • Facial nerve with its branches

82. Minor Salivary Glands : There are around 450 minor salivary glands which are distributed in
lips, cheeks, palate and floor of the mouth. Glands also may be present in oropharynx,
larynx, trachea and paranasal sinuses.
They contribute to 10% of total salivary volume. Sublingual glands are minor salivary glands
one on each side; located in the anterior aspect of the floor of the mouth in relation to
mucosa.

83. INDICATIONS OF SIALOGRAPHY:

Indications 1. Salivary fistulas. 2. Sialectasis. 3. Congenital conditions. 4. Extraglandular
masses. 5. Parotid duct stones.

84. SALIVARY CALCULUS AND SIALADENITIS • 80% Submandibular. • 80% Radio-opaque. • It is

commonly calcium phosphate and calcium carbonate stones.
• Calculi are more common in submandibular gland, because the gland secretion is viscous,
contains more calcium and also, its drainage is nondependent, causing stasis.
• Secretion from parotid is serous, contains less calcium and so stones are not common.
 Presentation: • Pain, swelling, tenderness is seen in submandibular region and floor
of the mouth. • Duct is inflamed and swollen.
o Investigations • Intra oral X-ray (dental occlusion films) to see radiopaque stones. •
FNAC of the gland to rule out other pathology
o Treatment • If the stone is in the duct, removal of the stone is done intraorally, by
making an incision in the duct. Incised duct is not sutured as it may result in stricture. •
If stone is in the gland, excision of submandibular gland is done

85. PLEOMORPHIC ADENOMA (Mixed salivary tumour) :

• Commonest of the salivary gland tumour. • It is 80% common. • More common in parotids
(80%).
• It is mesenchymal, myoepithelial and duct reserve cell origin
 Grossly it contains cartilages, cystic spaces, solid tissues.
 Histologically it shows: - Epithelial cells - Myoepithelial cells
  Clinical features of parotid tumour • Raised ear lobule • Cannot be moved above
the zygomatic bone— curtain sign • Deviation of uvula and pharyngeal wall towards
midline in case of deep lobe tumour
 Investigations • FNAC is very important and diagnostic. • CT scan to know the status
of deep lobe, local extension and spread. • MRI is better method.
 Treatment • Surgery—First line treatment. • If only superficial lobe is involved, then
superficial parotidectomy is done wherein parotid superficial to facial nerve is
removed.
• If both lobes are involved, then total conservative parotidectomy is done by
retaining facial nerve

86. ADENOLYMPHOMA (Warthin’s Tumour, Papillary Cystadenolymphomatosum) :

• It is a misnomer. It is not malignant, it is not lymphoma.
• It is a benign tumour that occurs only in parotid, usually in the lower pole. • It is said to be
due to trapping of jugular lymph sacs in parotid during developmental period
 Clinical Features • It presents as a slow growing, smooth, soft, cystic, fluctuant
swelling, in the lower pole, often bilateral and is nontender.
 Investigations • Adenolymphoma produces a “hot spot” in 99Technetium
pertechnetate scan—it is diagnostic (Due to high mitochondrial content). • FNAC.
 Adenolymphoma does not turn into malignancy.
 Treatment -- Superficial parotidectomy

87. MUCOEPIDERMOID TUMOUR :

• It is the commonest malignant salivary gland tumour (in major salivary glands).
 Types • Low grade—mucus cells mainly. • High grade—epidermoid cells mainly.
Facial nerve involvement is late in mucoepidermoid carcinoma of parotid
 Clinical Features • Swelling in the salivary (parotid or submandibular) region, slowly
increasing in size, eventually attaining a large size, which is hard, nodular, often with
involvement of skin and lymph nodes

88. THORACIC OUTLET SYNDROME (TOS) :

 It is syndrome complex due to neurovascular bundle compression in the thoracic
outlet.
 Causes • Cervical rib. • Long C7 transverse process. • Anomalous insertion of
scalene muscles. • Scalene muscle hypertrophy. • Scalene minimus. • Abnormal
bands and ligaments. • Fracture clavicle or first rib
 Clinical Features -- Neurological • Paraesthesia. • Pain in shoulder, arm, forearm
and fingers. • Vascular-- Claudication, ischaemic ulcers, gangrene.
 Signs • Scalene muscle tenderness. • Pulsatile swelling in supraclavicular region with
thrill and bruit (25%). • Bony mass above clavicle. • Adson’s test.
 Treatment • Conservative. • Surgical.-- Transaxillary (ROOS)—mainly for first rib
excision and also cervical rib • Supraclavicular approach for cervical rib and soft
tissue excision.
89. BRANCHIAL CYST :
It arises from the remnants of second branchial cleft. Normally 2nd, 3rd, 4th clefts
disappear to form a smooth neck. Persistent 2nd cleft is called as cervical sinus which
eventually gets sequestered to form branchial cyst.
 Features • Swelling in the neck beneath the anterior border of upper third of the
sternomastoid muscle. It is smooth, soft, fluctuant, often transilluminant with a
sensation of ‘Half-filled double hot water bottle
 FNAC shows cholesterol crystals
 Treatment: Excision under G/A

90. BRANCHIAL FISTULA:

It is a persistent second branchial cleft with a communication outside to the exterior
. It is commonly a congenital fistula. Occasionally, the condition is secondary to incised,
infected branchial cyst
• External orifice of the fistula is situated in the lower third of the neck near the anterior
border of the sternomastoid muscle.
• Internal orifice is located on the anterior aspect of the posterior pillar of the fauces, just
behind the tonsils.
• Track is lined by ciliated columnar epithelium with patches of lymphoid tissues beneath it,
causing recurrent inflammation.
• Discharge is mucoid or mucopurulent
• Investigations: Discharge study, fistulogram.
• Treatment: Always surgery

91. CYSTIC HYGROMA (Cavernous lymphangioma):

• It is a cystic swelling due to sequestration of a portion of jugular lymph sac from the
lymphatic system, during the developmental period in utero.
• Present at birth and so may cause obstructed labour. Occasionally present in early
infancy. • It is also called as hydrocele of the neck.
Clinical Features 1. Swelling is present at birth in the posterior triangle of neck causing
obstructed labour. 2. Swelling is smooth, soft, fluctuant (cystic), compressible, brilliantly
transilluminant
Swelling may rapidly increase in size causing respiratory obstruction—dangerous sign. 4. It
may get infected forming an abscess

Treatment 1. Aspiration of the contents. Later once the sac or capsule gets thickened by
fibrous tissue, it is excised. 2. When it causes respiratory obstruction, aspiration and
tracheostomy is done

92. CAROTID BODY TUMOUR (Potato tumour, Chemodectoma, Non-chromaffin para-

ganglioma)
• It arises from the carotid body, which is located at the bifurcation of the common carotid
artery. • The tumour is situated in the adventitia of the artery.
• They are benign or locally malignant tumours
  Clinical feature: Swelling in the carotid region of the neck which is smooth, firm,
pulsatile (transmitted pulsation—due to pulsatile carotid vessel overlying its surface)
and moves only side to side but not in vertical direction
 Investigations • Doppler. • Angiogram to see the ‘tumour blush’—DSA.
Widening/splaying of the carotid artery with tumour blush in an angiogram is called
as Lyre sign. • CT scan, MRI
 Treatment • If it is small, it can be excised easily as the tumour is situated in the
adventitia. • When it is large, as commonly observed, complete excision has to be
done followed by placing a vascular graft.

93. Stages of tuberculous lymphadenitis :

1. Stage of infection, and lymphadenitis 2. Stage of periadenitis with matting 3. Stage of
caseating necrosis and cold abscess formation 4. Stage of formation of collar stud
abscess 5. Stage of formation of sinus which discharges yellowish caseating material

94. Cold abscess –

• Deep to deep fascia • No evidence of signs of inflammation • Not warm, non tender,
smooth, soft and fluctuant, non-transilluminating
• Not adherent to skin (skin is free); no redness • Contains cheesy caseating material
• It may form collar stud abscess and later sinus
• FNAC, AFB, culture are useful investigations
• Differential diagnosis are branchial cyst, lymph cyst
• Treated by – Antituberculous drugs – ‘Zig - zag’ aspiration by wide bore needle in
nondependent area to prevent sinus formation – Drainage using nondependent incision

95. Commando operation: (Combined mandibular dissection and neck dissection) It is en-block
removal, which includes wide excision of primary tumour with hemimandibulectomy and
neck block dissection, e.g. in tongue.

96. CERVICAL RIB :

Definition • It is an extension of costal element (anterior part) of transverse process of C7
vertebra more than 2.5 cm (normal). • Syndrome caused by it is called as cervical rib
syndrome, thoracic-inlet syndrome, thoracic-outlet syndrome, scalene syndrome.

97. LINGUAL THYROID:

It is a thyroid swelling in the posterior third of tongue, at the foramen caecum, presenting
as rounded swelling.
It causes— a. Dysphagia. b. Speech impairment. c. Respiratory obstruction. d. Haemorrhage
Diagnosis • Radioisotope study shows the uptake of iodine by the lingual thyroid and also
shows the status of the thyroid in normal fossa. • U/S neck has to be done to see the
absence of thyroid in normal location.
Treatment • L-Thyroxine is given daily orally. • Often requires surgical excision
98. THYROGLOSSAL CYST :
• Thyroglossal cyst is a swelling occurring in the neck in any part along the line of
thyroglossal tract.
 Possible sites for thyroglossal cyst: a.Beneath the foramen caecum b. In the floor of
mouth c. Suprahyoid d. Subhyoid—commonest site e. On the thyroid cartilage
 Clinical Features -- a. Swelling in the midline, towards the left. b. Moves with
deglutition as well as with the protrusion of tongue, c. Swelling is smooth, soft,
fluctuant (cystic), nontender, mobile, often transilluminant. d. Thyroid fossa is
empty, if there is no thyroid in normal location
 Investigations -- a. Radioisotope study. b. U/S neck. c. FNAC from the cyst.
 Treatment --a. Sistrunk operation: Excision of cyst and also full tract upto the
foramen caecum is done along with removal of central part of the hyoid bone, as
the tract passes through it.

99. THYROGLOSSAL FISTULA:

• It is not a congenital condition.
• It either follows infection of thyroglossal cyst which bursts open or after inadequate
removal of the cyst. • It is lined by columnar epithelium, discharges mucus and is a seat of
recurrent inflammation. “Hood sign” is characteristic
• Investigations: Radioisotope study and fistulogram. • Treatment: Sistrunk operation.

100. SOLITARY THYROID NODULE :

It is a single palpable nodule in thyroid on clinical examination, in an otherwise normal
gland.
Causes - 1. Thyroid adenomas a. Follicular – colloid (commonest). 2. Papillary carcinoma of
thyroid. 3. Thyroid cyst.
Based on radioisotope study: • Hot—Means autonomous toxic nodule. • Warm—Normally
functioning nodule. • Cold—Nonfunctioning nodule; may be malignant
Features • Single nodule palpable in one or other lobes of the thyroid which is usually
smooth and firm
Rapid enlargement of thyroid nodule can be malignant. • Tracheal deviation towards
opposite side is common– confirmed by trail sign, three-finger test, auscultation and X-ray
neck
TREATMENT:
IF nontoxic nodule due to any cause, hemithyroidectomy with complete removal of lateral
lobe and whole of the isthmus is done.
• If it is papillary carcinoma thyroid, then near total thyroidectomy is done along with
suppressive dose of L-thyroxine given 0.3 mg OD daily.
If FNAC report says follicular adenoma, then hemithyroidectomy is done. If histology report
says follicular carcinoma (capsular and vascular invasion) then completion total
thyroidectomy
101. ALL THYROID PROBLEMS—INVESTIGATION:
Investigations :
• U/S neck (very useful).
• FNAC.
•T 3, T4, TSH.
• Radioisotope study. (I123/I131/99mTc). • CT scan or MRI neck is not done routinely, but
only in selected cases. Large swelling/to see vascularity/ retrosternal extension are the
indications.
• X-ray neck to see tracheal deviation.

102. RETROSTERNAL GOITRE :

Retrosternal goitre is defined as having > 50% goitre below the suprasternal notch.
types:
1. Substernal type: Part of the nodule is palpable in the lower neck.
2. Plunging goitre: An intrathoracic goitre is occasionally forced into the neck by increased
intrathoracic pressure.
3. Intrathoracic goitre itself. Neck is normal
Clinical Features • Dyspnoea at night during lying down or neck extended. • Cough and
stridor (stridor is harsh sound on inspiration). • Dysphagia. • Engorgement of neck veins and
superficial veins on the chest wall.
• Lower border is not seen on inspection and not felt on palpation.
• Pemberton’s sign is positive. The patient is asked to raise the arm above the shoulder
level. Dilated veins are seen over neck and upper part of chest wall. Stridor and rarely
dysphagia may occur
Treatment • Surgical removal of retrosternal thyroid is done.

103. Order of appearance of signs -- HYPERTHYROIDISM

1. Stellwag’s sign — Mild; first sign to appear 2. von Graefe’s sign — Mild 3. Joffroy’s sign
— Moderate 4. Moebius sign — Severe

104. TOXIC NODULE:

• Is a solitary overactive nodule.
• There is an autonomous hypertrophy and hyperplasia of a part of the gland where there is
a nodule
• There is high levels of circulating thyroid hormones suppress TSH secretion and so, normal
thyroid tissue surrounding the nodule is itself suppressed and inactive.
• Once patient becomes euthyroid by drugs, surgery (hemithyroidectomy) or radioactive
iodine therapy I131 in a therapeutic dose of 5 m curie is given orally.
 Before the age of 45, surgery is preferred. • After 45 years age, radioiodine therapy
is used
 105. HASHIMOTO’S THYROIDITIS (Struma lymphomatosa) :
• Also called as diffuse non-goitrous thyroiditis.
• It is an autoimmune thyroiditis—common in women (15 times more common). • There is
hyperplasia initially, then fibrosis, eventually infiltration with plasma cells and lymphocytic
cells. • Askanazy cells are typical (like Hurthle cells)
Features • Painful, diffuse, enlargement of usually both lobes of thyroid which is firm,
rubbery, tender and smooth (occasionally one lobe is involved).
• Initially they present with toxic features but later, they manifest with features of
hypothyroidism.
Hyperplasia → Hyperthyroid – Hashitoxicosis → Euthyroid.
Fibrosis → Hypothyroid.
Treatment 1. L-thyroxine therapy. 2. Steroid therapy often is helpful.

106. DE-QUERVAIN’S SUBACUTE GRANULOMATOUS THYROIDITIS :

 It is due to viral aetiology either mumps or coxsackie viruses causing inflammatory response
with infiltration of lymphocytes, neutrophils, multinucleated giant cells.
 Clinical Features • Painful diffuse, swelling in thyroid which is tender • Commonly seen in
females. • Initially there is transient hyperthyroidism with high T3 and T4 but poor radioiodine
uptake.
 FNAC is done. • It is usually a self limiting disease. • Prednisolone 20 mg for 7 days helps

107. RIEDEL’S THYROIDITIS (0.5% common) :

• A very rare benign entity wherein thyroid tissue is replaced by fibrous tissue which
interestingly infiltrates the capsule into surrounding muscles, paratracheal tissues, carotid
sheath.
Clinical Features • Hard, fixed, swelling with stridor, often Berry’s sign may be positive, i.e.
absence of carotid pulsation.
Treatment -- Isthmectomy is done to relieve compression on the airway. They require L-
thyroxine replacement later, as hypothyroidism is common.

108. Remember : GOITRE

• Goitre is enlargement of the thyroid gland
• Solitary nodule is single palpable nodule on clinical examination without palpable rest of
the gland
• Dominant nodule is single nodule with palpable enlargement of the remaining thyroid
gland
• Thyroid swelling is confirmed by its movement with deglutition due to attachment of
enclosed pretracheal fascia to inferior constrictor muscle which is attached to trachea and
cricoid cartilage and so moves with deglutition
U/S neck, FNAC, estimation of T3, T4, TSH are essential investigations
109. Complications of Thyroidectomy :
1. Haemorrhage: May be due to slipping of ligatures either of superior thyroid artery or
other pedicles or small veins.
2. Respiratory obstruction: It may be due to haematoma (if it is so, the haematoma has to
be evacuated), or due to laryngeal oedema, or due to tracheomalacia or bilateral RLN
palsy
3. Recurrent laryngeal nerve palsy: It can be transient or permanent
4. Hypoparathyroidism is rare 0.5% common
5. Thyrotoxic crisis (Thyroid storm): Occurs in a thyrotoxic patient inadequately prepared
for thyroidectomy
6. Treatment of thyrotoxic crisis
• Injection hydrocortisone high dose—500-1000 mg IV
• Rehydration with adequate IV fluids to control circulatory collapse
• Injection sodium iodide IV – 1 gram
• Injection propranolol – 2 mg
• Oral iodides - Lugol’s iodine
• Oral antithyroid drugs • Tepid sponging
• Fluid and electrolyte management
• ICU care, ventilator support and cardiac monitor

110. MEN SYNDROME (MEA SYNDROME) :

• Commonly inherited as an autosomal dominant. • Cells involved has got common
features of APUD cells (APUDomas). APUD—Amine Precursor Uptake Decarboxylation
 Type—I: Parathyroid hyperplasia or adenomas; pituitary tumour; pancreatic tumour
[Endocrine— Insulinoma, gastrinoma, glucagonoma, vipoma]. It is also called as
Werner’s syndrome.
Here the defect is in chromosome 11.
• Type—II: Also called as Sipple’s disease.
1. II a includes medullary carcinoma of thyroid+ phaeochromocytoma + parathyroid
hyperplasia (50%). Here the defect is in chromosome 10.
2. II b includes medullary carcinoma of thyroid + phaeochromocytoma mucosal neuromas in
lips and eyelids with bumpy-lumpy lesions, with marfanoid face, megacolon.

111. Phaeochromocytoma is rarely malignant in MEN II • Phaeochromocytoma under 40

years of age suspect MEN 2A, VHL
• Beta-blocker is given only after patient is fully alpha blocked with phenoxybenzamine or
doxazocin
• Alpha-blocker is given 4 weeks prior to surgery to control hypetension and beta-blocker is
given one week before surgery to control tachycardia and arrhythmias

112. EXTRADURAL HAEMATOMA :

• It is collection of blood in the extradural space between the dura and skull.
• Most common site is temporo-parietal region. • Middle meningeal veins • Anterior branch
of middle meningeal artery • Posterior branch of middle meningeal artery
  Clinical Features • History of transient loss of consciousness following a H/o blow or
fall. • Patient soon regains consciousness and again after 6-12 hr starts deteriorating
(Lucid interval).
 Hutchinsonian pupils, Features of raised intracranial pressure like high blood
pressure, bradycardia, vomiting is also seen. Occasionally convulsions may be
present.
 Investigations • X-ray skull may show fracture of temporal bone. • Electrolyte
estimation. • CT scan head is diagnostic. Extradural haematoma shows biconvex
lesion.
 Treatment: Craniotomy is done and cranial flaps are raised, Antibiotics and
anticonvulsants are given postoperatively.

113. Indications for thoracotomy :

• Haemothorax more than 1500 ml found when ICT is placed or hourly collection in ICT is
200300 ml • ICT placed shows persistent drainage of blood • Diaphragmatic injury • When
associated with liver and spleen injuries • Bronchus and major vessel injuries •
Haemopericardium • Oesophageal and thoracic duct injuries

114. FLAIL CHEST AND STOVE IN CHEST :

• It is fracture of two or more consecutive ribs, with each rib having two or more fracture
sites. Such segment is called as flail segment.
• Stove in chest is depression of a portion of chest wall due to severe chest injury, otherwise
features and management are like flail chest
Clinical features : paradoxical respiration,Mediastinal flutter: Movement of mediastinum
during different phases of respiration occurs, often causing kinking of great vessels and
sudden cardiac arrest.
• Pendular movement of air from one lung to other, hypoventilation: carbon dioxide
retention and respiratory failure.
Investigations • Chest X-ray—to identify the fracture segment. • Blood grouping. • Arterial
PO2 and PCO2 and serum electrolytes.
Treatment • Intercostal tube drainage. • Applying clips to fracture ribs and fixing above and
below to normal ribs. • Antibiotics like penicillins, cefotaxime. • Blood transfusion, IV fluids.
• Bronchodilators, steroids.
Ventilator support with IPPV—IPPV is treatment of choice

115. TENSION PNEUMOTHORAX :

Causes • Trauma. • Postoperative: pulmonary, cardiac, oesophageal surgeries, cervical
sympathectomy, leak from CVP monitor line. • Tumours of lung, mediastinum, pleura. •
Leaking aneurysms. • Spontaneous
Clinical features • Tachypnoea and tachycardia • Decreased/absent breath sounds •
Resonant on percussion with severe mediastinal/ tracheal shift • Cyanosis hypotension
Management • Once clinically diagnosed, a wide bore needle is immediately placed in the
second intercostal space in midclavicular line.
Nasal o2, antibiotics, IPPV if required
116. HAEMOTHORAX :
It is blood in pleural cavity. It causes pain, shock, as it is very irritant to pleural cavity.
Clinical features • Pain in the chest, tenderness • Difficulty in breathing, dullness on
percusion diminished breath sounds • Features of shock
Chest X-ray. • Aspiration (pleural tap). • Chest CT scan.
Treatment 1.ICT placement in the mid-axillary line in the 6th intercostal space. 2.
Antibiotics, bronchodilators. 3.Thoracotomy

117. Beck’s triad • Hypotension • Muffled heart sounds • Raised jugular venous
pressure

118. ABERRATION OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI) OF THE

BREAST ANDI includes variety of benign breast disorders occurring at different periods
of reproductive periods in females—early, matured and involution phase of
reproductive age group
In early reproductive age group (15-25 years):
• Normal lobule formation may cause aberration as fibroadenoma. If it is more than 5 cm it
is called as giant fibroadenoma
In mature reproductive age group (25-40 years):
• Normal cyclical hormonal effects on glands and stroma get exaggerated by aberration
causing generalized enlargement. Its diseased status is cyclical mastalgia with nodularity
also called as fibrocystadenosis.
Involution age group (40-55 years):
• Lobular involution with microcysts, fibrosis, adenosis, apocrine metaplasia and eventual
aberrations as macrocysts and cystic disease of breast.
• Ductal involution may cause ductal dilatation and nipple discharge as aberration. Later
disease status develops with periductal mastitis, bacterial infection, non-lactational breast
abscess and mammary duct fistula

119. Quadrantectomy as part of therapy — QUART (VERONESI): Entire segment of

the involved breast is removed along with axillary dissection (done through a separate
incision in the axilla, level I and II removal) and radiotherapy.
There is a higher rate of local recurrence after conservative QUART therapy especially in
younger patient and in high grade tumours.

120. EMPYEMA THORACIS:

Causes of empyema is never primary. Secondary causes are: • From chest wall: Wounds,
osteomyelitis of ribs. • From lung: Pneumonia, abscess, bronchiectasis, tuberculosis, growth.
• Postoperative: After thoracotomy. • From oesophagus: Perforations, carcinoma. • From
below diaphragm: Subphrenic abscess. Tuberculosis and pneumonia are common causes in
developing countries
Clinical Features • Pain in the chest, tenderness, fever. • Difficulty in breathing. • Features
of toxicity in acute type of empyema. • Dullness on percussion, absence of breath sounds. •
Decreased chest wall movement.
Investigations • Chest X-ray, ESR. • Peripheral smear. • Diagnostic aspiration. • Pus C/S,
AFB. • Bronchoscopy. • CT scan and MRI for carcinoma bronchus
Treatment: Antibiotics. • Repeated aspirations. • Intercostal tube drainage. •
Antituberculous drugs., ICT drainage, Decortication is very useful and favourable method

121. EMPYEMA NECESSITANS :

It is a complication of empyema thoracis, wherein empyema which is not drained
perforates through the chest wall presenting as subcutaneous collection of pus
communicating directly or often with a tortuous route with the pleural cavity.
Treatment • Antibiotics. • Empyema is drained by placing an ICT. Pus is sent for C/S and
AFB. • If it is tuberculous, antitubercular drugs are started

122. INHALATION INJURY :

It occurs after major fire burns. It is due to: • Inhalation of heat. • Noxious gases and
incomplete products of combustion.
• At the site of fire, oxygen concentration is less than 2% which can cause death in 45
seconds due to hypoxia.
• Inhaled carbon monoxide binds with Hb immediately to form carboxyhaemoglobin
causing severe anoxia and death.
• Symptoms of carbon monoxide intoxication– headache, disorientation, visual changes,
fatigue, vomiting, hallucinations, shock and cardiac arrest.
• Smoke contains hydrocyanide which causes tissue hypoxia and profound acidosis. •
Laryngeal oedema and laryngospasm. • Bronchial oedema and bronchospasm.
 Management • Replacing the patient from the site earliest. • Ventilator support. •
Antibiotics. • Bronchoscopy. • Tracheostomy whenever required

123. AMPUTATION:
Indications • Gangrene due to atherosclerosis, embolism, TAO, diabetes, ergots. • Trauma:
To save life in crush injuries. • Neoplasms: Osteosarcomas, Marjolin’s ulcer, melanomas. •
Gas gangrene. • Severe sepsis.
Types I. • Non end bearing/side bearing. • End bearing/cone bearing.
II. • Weight bearing. • Non weight bearing.
Types of flaps • Long posterior flap in below-knee amputation. • Equal flaps in above-knee
amputation.

I didn’t cover BREAST.., so pls READ!!

ALL THE BEST!!!

Dr.Yogesh.S
Reg. No: 107015