Physical signsSymptom- what the patient feelsPhysical sign- what the doctor finds at

clinical examination of the patient’s segments.

Symptom is subjectivePhysical sign is objectiveClinical diagnosis = symptoms + signsFinal diagnosis= symptoms + signs +

lab.tests + investigations.

SURFACE LANDMARKS OF THE HEADNasionExternal occipital protuberanceVertexSuperior nuchal lineMastoid process of the temporal boneZygomatic archSuperficial temporal arteryFacial arteryParotid duct

Surface landmarks

Sebaceous cysts

Swelling-cystic mass-cystic tumor-lumpHairy parts of the body- scalpThe mouth of the seb. gland opens into the

hair follicleIf blocked mouth, seb. gland becomes

distended

Seb. Cyst

History- slow growingSymptoms-a lump that gets scratched when

the patient is combing the hairSuch scratches may get infectedIf the cyst becomes infected it enlarges

rapidly and becomes acutely painful

Seb. Cyst- examination-physical signsPosition-hairy parts of the bodyColor- the skin overlying the cyst normal unless it

is infectedTenderness- not tender unless infectedTemperature-normal except when infectedShape- sphericalSize- variable: mm-4-5 cm.Surface- smoothEdge-well definedComposition- hard depending on the pressure in

the cust “cheesy material”

Sebaceous cyst of the scalp

Sebaceous cyst

Surgical treatment- excision

Intact sebaceous cyst-specimen

Cut section- seb.cyst- “cheesy material”-sebum

Lipoma-case report

A 59-year-old woman was admitted with a 10 years' history of a painless swelling at the right thigh. The lesion became ulcerative over the past few months with mild pain.

She had no significant medical and surgical history.

Examination revealed normal vital signs, chest, heart, abdominal and rectal examinations.

LipomaOn local examination, a large mass

occupying the posterior aspect of the lower two thirds of the right thigh was confirmed.

There was an ulcerative lesion at the posteromedial aspect of the mass.

The right popliteal artery was difficult to palpate, but the posterior tibial and dorsalis pedis were normal.

There was no neuronal abnormality.

Lipoma- case reportBlood tests showed normal blood count, liver

function, urea and electrolytes as well as ESR. She had a normal chest and abdominal X-ray.

The X-ray of the right thigh showed a soft tissue shadow and normal bone.

Surgical excision was performed and the findings were consistent with a giant lipoma.

The wound was closed easily as there was redundant skin because of the size of the mass.

The weight of the specimen was 3.2kg.

Lipoma- case report

The patient had an uneventful recovery and was discharged home with a very good condition.

Histology of the specimen reported benign lipoma.

Huge lipoma of the thigh

Ulcerated lipoma on the post-medial thigh

Specimen- 3.2 Kg.

LipomaThis is the external

surface of a lipoma, a benign tumor of adipocyte origin. •The bright yellow color is typical of fat. •Note the lobulated appearance. This is also typical of this lesion. •This particular tumor arose in the subcutaneous fat (note the small strip of skin denoted by the black arrows).

Case Report-lipoma

A 60 year old male presented in out patient clinic with history of progressively increasing swelling in right thigh, which he noticed 3½ years back. Swelling was otherwise asymptomatic except that he had to wear loose fitting trousers.

On examination, right thigh girth was grossly increased as compared to the left thigh.

Lipoma

There were erythema ab agni over the medial aspect of both thighs (as is usual in Kashmiri people because of Kangri – “the fire pot”).

The swelling was firm, non-tender and free from underlying structures.

Lipoma

CT scan of the right thigh was done which revealed a hypodense mass in the posterior compartment of the thigh beneath the hamstring muscles

Lipoma- case reportFNAC of the swelling revealed mature fat cells, suggestive

of lipoma.

The patient was operated on under general anaesthesia, in prone position and the tumour was found beneath the hamstring muscles and was dissected out easily because of the pseudocapsule.

Wound was closed in layers, leaving a suction drain inside the cavity. Healing progressed uneventfully.

Histopathological examination revealed features consistent with lipoma. The tumour removed measured 21x17x14cm in size and weighed 2,95 Kg.

Specimen.Six months after surgery, the patient is symptom free and has no signs of recurrence

LipomaLipoma is one of the commonest benign mesenchymal

tumour in the body composed of mature adipose cells.

It is found in almost all the organs of the body where normally fat exists that is why it is also known as ubiquitous tumour or universal tumour.

Most of the lipomas present as small subcutaneous swellings without any specific symptom.

LipomaGiant lipomas, though rare, can present in thigh,

shoulder or trunk. Clinical features of these giant lipomas are mainly because of their size which includes pain because of stretching of adjacent nerves,(restriction in movements of the part involved or social embarrassment because of mere size of the swelling).

Although definitive diagnosis of giant lipoma can be made only by histopathological examination, but once suspected, other investigations can provide additional information about the tumour.

Lipoma

The characteristics of benign lipoms on ultrasonography, CT and MRI have been well established and even Tc99 DTPA scan have been used to confirm the diagnosis.

LipomaSurgery is the treatment of choice of these giant swellings

due to their tendency to recur and their potential hazard of malignant transformation, other option for treatment of these giant swelling is liposuction.

The dissection of these lipomas is usually easy because of continuous pressure on the surrounding tissue, a well defined pseudocapsule is formed.

Dead space created because of dissection of the giant lipomas is usually drained with the help of a suction drain to avoid collection.

As already mentioned, these tumours have tendency to recur and can have malignant transformation, therefore, should be followed meticulously.

Lipoma

Hemangioma Benign skin lesion consisting of dense, usually

elevated masses of dilated blood vessel. Benign neoplasm characterized by blood vascular

channels. A cavernous hemangioma consists of large vascular

spaces. A capillary hemangioma consists of many small

blood vessels. A collection of dilated small vessels, 3 types: strawberry nevus, port-wine stains, spider nevus

Cavernous hemangioma

Hemangioma Congenital benign tumour made of blood vessels in the skin. Capillary hemangioma , an abnormal mass of capillaries on the

head, neck, or face, is pink to dark bluish-red and even with the skin. Size and shape vary. It becomes less noticeable or disappears with age.

Immature hemangioma (hemangioma simplex, strawberry mark), a reddish nub of dilated small blood vessels, enlarges in the first six months and may become ulcerated but usually recedes after the first year.

Cavernous hemangioma, a rare, red-blue, raised mass of larger blood vessels, can occur in skin or in mucous membranes, the brain, or the viscera. Fully developed at birth, it is rarely malignant. Hemangiomas can often be removed by cosmetic surgery.

Strawberry nevusIntradermal, subdermal collection of dilated

blood vesselsCongenital lesion- present at birthLooks like a strawberryOften regress spontaneously in months/years

after birthRubbed or knocked they may ulcerate and

bleed

Strawberry nevus

Physical examinationPosition- any part of the body- head/neck>Color- bright or dark redShape- protrude from the skin surfaceSize- usually- 1-2 cm.Surface-irregularConsistence- soft, compressible not pulsatileRelations- confined to the skin, freely mobile

over the deep tissues

Port-wine stain-extensive intradermal hemangioma, mostly venous

Cavernous hemangioma on the tongue

This angiogram (an X-ray taken after dye has been injected into the blood stream) shows a mass of blood vessels (hemangioma) in the liver.

Meningocele

Meningocele (MM):Protrusion of the membranes that cover the spine and part of the spinal cord through a bone defect in the vertebral column.

MM is due to failure of closure during embryonic life of bottom end of the neural tube.

The term spina bifida refers specifically to the bony defect in the vertebral column through which the meningeal membrane and cord may protrude (spina bifida cystica) or may not protrude so that the defect remains hidden, covered by skin (spina bifida occulta).

The risk of MM (and all neural tube defects) can be decreased by the mother eating ample folic acid during pregnancy.

A birth defect involving an abnormal opening in the spinal bones (vertebrae) is called spina bifida. The spinal vertebrae have not formed and joined normally, leaving an opening

A defect which also includes a small, moist sac (cyst) protruding through the spinal defect, containing a portion of the spinal cord membrane (meninges), spinal fluid, and a portion of spinal cord and nerves is called a meningocele, myelomeningocele, or meningomyelocele

Surgical treatment is needed to repair the defect and is usually done within 12 to 24 hours after birth to prevent infection, swelling, and further damage.While the baby is deep asleep and pain-free (using general anesthesia), an incision is made in the sac and some of the excess fluid is drained off. The spinal cord is covered with the membranes (meninges) and the skin is closed over the protruding meninges, spinal cord, and nerves.

The long-term result depends on the condition of the spinal cord and nerves. Outcomes range from normal development to paralysis (paraplegia).Infants may require about 2 weeks in the hospital after surgery.

Physical signs in head injuryExamination of a case of recent head injuryThe patient is unconscious

Examine the scalp for a wound or local bruising or hematoma

Examine the nostrils and ears for evidence of blood diluted with CSF

Compare the size of the pupils and test their reaction to light

Make a general survey of the body for other injuriesSearch for paralysisPalpate and percuss the hypogastrium for evidence of an

overfull bladderTemperature, pulse rate, RR-charted every half-hour

Head injuryRadiographs of the skull should be taken at

the first opportunity compatible with safety

Brain injury is more likely in the presence of a skull fracture BUT skull fracture of itself does not indicate brain injury

COMA

Coma is a state of absolute unconsciousness in which the patient does not respond to any stimulus

Reflexes are absent, including the corneal and swallowing reflexes.

Semi-coma- the patient responds only to painful stimuli and reflexes are present

Head injuryThe patient is conscious or semi-consciousPatient with skull fracture – hospital admissionClose observation: PR, BP, RR, pupil size and

reaction/ every ½ h.Signs of neurological deterioration:

Falling pulse rateReduced respiratory rateFalling GCSDilatation of pupilsLoss of light reaction or developing asymmetry

of pupils

Complications of traumatic brain injuryCranial bleedingCerebral hypoxiaInfection

Posttraumatic intracranial bleeding may be:

- extradural

- subdural

- intracerebral

CT of the brain documents the lesions

Local brain compression- focal neurological effects

- raised intracranial pressure

Types of skull fracturesLiniar fractures - involve the skull vault,

- overlying scalp bruising or swelling

Depressed fractures - caused by blunt injuries,

- the scalp is severely bruised

Fractures of the base of the skull- anterior fossa

- middle fossa

- posterior fossa

Fracture of the anterior cranial fossa

Periorbital hematomaSubconjunctival hemorrhageCSF running from the nose

Fracture of the middle cranial fossa

CSF running from the ear or blood escaping from the ear

Bruising behind the ear over the mastoid area

Risk of facial paralysis or deafness

Fracture of the posterior cranial fossa

Deep comaBruising on the posterior wall of the pharynx

SKULL FRACTURESLinear skull fractures, the most common type of skull

fracture, occur in 69% of patients with severe head injury. Usually caused by widely distributed forces.

In rare cases, a linear fracture can develop and lengthen as the brain swells, in what is called a growing fracture.

Diastatic fractures are linear fractures that cause the bones of the skull to separate at the skull sutures in young children whose skull bones have not yet fused. They are usually caused by impact with a wide area such as a wall.

SKULL FRACTURESComminuted skull fractures, those in which a bone is

shattered into many pieces, can result in bits of bone being driven into the brain, lacerating it.

Depressed skull fractures, a very serious type of trauma occurring in 11% of severe head injuries, are comminuted fractures in which broken bones are displaced inward.

This type of fracture carries a high risk of increasing pressure on the brain, crushing the delicate tissue. Complex depressed fractures are those in which the dura mater is torn. Depressed skull fractures may require surgery to lift the bones off the brain if they are causing pressure on it.

Basilar skull fractureBasilar skull fractures, breaks in bones at the base of the

skull, require more force to cause than cranial vault fractures.

Thus they are rare, occurring as the only fracture in only 4% of severe head injury patients.

Basilar fractures have characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes (bruising of the orbits of the eyes that result from blood collecting there as it leaks from the fracture site); and Battle's sign (caused when blood collects behind the ears and causes bruising).

Depressed skull fracture

Subdural hematoma

Intracerebral hematoma

Liniar skull fractures

Epidural hematoma

Liniar skull fracture

TRAUMA

Leading cause of death and disabilityTrauma care involves multidisciplinary teamTrauma care requires both speed and

accuracyIdentification of life threats and emergent

intervention may save life

TRAUMA

1. Prehospital care

2. Primary survey

3. Resuscitation

4. Secondary survey

PREHOSPITAL CARE

Prehospital providers are trained in:

Assessment of the injury scene

Stabilization of the injured patient

Monitoring and transport of critically ill patient

PREHOSPITAL CAREEfficient method for reporting by the

prehospital providers to the trauma team:M I V TM= mechanism of injuryI= injuryV= vital signsT= therapy

MECHANISM OF INJURYCAN PREDICT TYPES OF INJURIES

FRONT-END COLLISION CAR: PATELLA FRACTURE, POST. KNEE DISLOCATION, POPLITEAL ARTERY INJURY, FR. OF THE POST. RIM OF THE ACETABULUM

HIGHT FALLS WITH LANDING ON FEET: CALCIS FR., LOWER EXTREMITIES FR., ACETABULAT FR., SPINE COMPRESSION FR.

PEDESTRIANS STRUCK BY VEHICLES: CALF FR., HEAD INJURY, UPPER EXTREMITY INJURIES

INJURY INVENTORY

A trapped patient- prolonged extrication:RabdomyolisisTraumatic asphyxiaHypothermia

VITAL SIGNS

LEVEL OF CONSCIOUSNESS- GLASGOW’S COMA SCORE

STABLE / UNSTABLE HEMODINAMICALLYRESPIRATION: CYANOSIS

GCSLess than or equal to 8 at 6 h.- 50% dieSevere head injury 3 – 8Moderate head injury 8-13Mild head injury 14-15False- hypothermia, intoxication, sedationImpossible to evaluate- dysphasic, intubated

pts. and with facial or spinal cord injury

THERAPY

AIMED TO STABILIZING THE PATIENT:- SPINE AND EXTREMITY STABILIZATION

- OXYGEN - I.V. FLUIDS

- PREVENTION OF HEAT LOSS

INITIAL EVALUATION AND PRIMARY SURVEY

HISTORY: A M P L E

PRIMARY SURVEY: A B C D E

AIRWAY

ASSURING THE INTEGRITY OF THE AIRWAY IS THE HIGHEST PRIORITY IN THE TRAUMA CARE

LOSS OF AIRWAY FUNCTION- IRREVERSIBLE BRAIN DAMAGE WITHIN MINUTES

AIRWAY

SUCTIONJAW-THRUST MANOEVERGUEDEL PIPETRACHEAL INTUBATIONEMERGENT TRACHEOSTOMY

BREATHINGOnce airway established- give O2Auscultation in the axillae

Absence of BS- SIGNALS PT or HTChest motionsPosition of the tracheaCXRIMMEDIATE DECOMPRESSION- CHEST

DRAINAGE TUBE

CIRCULATIONOnce airway and breathing secured-

assess circulationBP, PR, SKIN PERFUSION- CAPILLARY

REFILL, MENTAL STATUS, URINE FLOWThe most common cause of shok in

trauma is hemorrhage: two venous linesObtain blood for cross-matching, FBC, ABG,

basic biochemistries

CIRCULATIONCARDIAC SHOCK- due to cardiac tamponade

or tension pneumothoraxProeminent jugular venous distensionCool skin, pale, hypoperfused

NEUROGENIC SHOCK following a spinal cord injuryParaplegia, quadriplegiaWarm skin, absence of rectal tonus

DISABILITY

Repeatedly GCSPts. who :

cannot follow a simple “ touch your nose”gross asymmetry of limb motion and pupilsShould be suspected of neurologic injury-Emergent brain CT SCAN

EXPOSURE

Visual inspection of the entire patientInspect the back- logrolling the pt.Inspect the perineum

RESUSCITATION

Monitoring: ECG, BP, UO, PVC, CO, POTo assess the progress of resuscitation

SECONDARY SURVEY

HEADNECKTHORAXABDOMENLIMBS

HEAD

LACERATIONSSTEP-OFFSGCSPUPILSCT

NECK

HARD NECK COLLARSPINE X RAYLOCAL TENDERNESSHEMATOMASSUBCUTANEOUS EMPHYSEMA

THORAX

LACERATIONS, WOUNDSSUBCUT. EMPHYSEMACHEST MOTIONBRUISINGFLAIL CHESTBS

THORAX

CARDIAC TAMPONADENECK VEINSHEART SOUNDSECHOCARDIOGRAPHYPULMONARY CONTUSION-

VENTILATION/PERFUSION MISMATCH

Life threatening condition

ABDOMENBLUNT TRAUMA:

Hemorrhagic abdomen- internal bleedingPeritonitic abdomen

WOUNDS:PenetratingPerforating

Fracture of the pelvic bones

External fixation of the pelvis