1)Abdominal inspection

The patient has to lie comfortable in a supine position, with a pillow for the head, and relax. His arms
must be kept at the sides; distract the patient with conversation.

Elements to observe: The skin, Umbilicus, The contour of the abdomen, Peristaltis, Pulsations.

2)Abdomen palpation

Light palpation - is helpful in identifying muscular resistance, abdominal tenderness, some superficial
organs and masses.

Involuntary rigidity or spasm of the abdominal muscles indicates peritoneal inflammation!

Deep palpation - is required to delineate abdominal masses. If found, their location, size, shape,
consistency, tenderness, pulsations and mobility must be registered

Abdominal masses - examples

- physiologic: pregnant uterus

inflammatory: diverticulitis of the colon, pseudocyst of the pancreas

vascular: aneurysm of the abdominal aorta

neoplastic: myomatous uterus, carcinoma of the colon or ovary

obstructive: distended bladder, dilated loop of bowel

3)Abdomen percussion

to assess the amount and distribution of gas in the abdomen

to identify possible masses that are solid or fluid filled

to estimate the size of the liver and spleen

is performed in all 9 quadrants to asses the distribution of tympany and dullness.

Tympany: usually predominates because of gas in GI truct

Dullness: in both flanks indicates for ascites( fluid)

4)Abdomen auscultation

Listen to the bowel sounds produced by peristalasis, normally produced at 5 to 10 second intervals.

Absent bowel sound  paralytic ileus, generalaised peritonitis

Excessive bowel sound  diarrhoea, partial obstruction of the bowel

5)THYROID GLANDCLINICAL EXAMINATION(from the lecture)

Hyperthyroidism

Symptoms: palpitation, tiredness, preference for cold, sweating, nervousness, weight loss, good appetite

Signs: palpable thyroid, exophthalmos, finger tremor, hot and moist hands, tachycardia

Palpation:

At the first we start by inspection of the thyroid the we start by palpation and its done by palpating from
behind the patient between the cricoid cartilage and sub sternal notch then we ask the patient to
swallow ( we can offer him a glass of water) while palpating and feeling movement of thyroid gland.
Note the size, shape, tenderness, temperature. Diffuse enlargement called goiter.

6)BREAST examination(from the lecture)

•Palpation–Use the pads of the middle 3 fingers

•Palpation– three methods

–Vertical strips

–Radial spoke pattern

–Circular pattern

•Assessment of the nipple discharge

•Dimpling

•Nipple retraction

•Redness

•Examine the axilla, supraclavicular fossa

7) Preoperative preparation of patients :

1- Patients doesn’t ingest anything 6-8 hours before surgery

2- explain for the patient the procedure

3- consult with the physician and anesthesia to provide for instructions

4- drugs for certain conditions are often allowed with water: cardiac disease, seizures, hypertension.

5- skin preparation - patient shower with antiseptic solution, hair removed by electric clipper

6- patient and family teaching about tubes (drains), vascular access

7-intestinal preparation :enema(laxative).

8)Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity
to obtain ascitic fluid for diagnostic or therapeutic purposes.

Ascitic fluid may be used to help determine the etiology of ascites, as well as to evaluate for infection or
presence of cancer.

Indication:

It is used for a number of reasons:

 to relieve abdominal pressure from ascites

 to diagnose spontaneous bacterial peritonitis and other infections (e.g. abdominal TB)

 to diagnose metastatic cancer

 to diagnose blood in peritoneal space in trauma

Technique : using controlled pressure, insert catheter and stylet perpendicular to the skin along the
anesthetized track using a twisting motion .

Incision site is one third of the way down the umbilicus to the pubic symphysis .

9)An enema, (from google)

also known as a clyster, is an injection of fluid into the lower bowel by way of the rectum. Also,
the word enema can refer to the liquid so injected, as well as to a device for administering such
an injection.  the most frequent uses of enemas are to relieve constipation and for bowel
cleansing before a medical examination or procedure
Indication:
Constipation is a common gastrointestinal condition. It occurs when the colon is unable to
remove waste through the rectum. An enema administration is most commonly used to clean
the lower bowel.
Enemas may also be used before medical examinations of the colon. Your doctor may order an
enema prior to an X-ray of the colon to detect polyps so that they can get a clearer picture. This
procedure may also be done prior to a colonoscopy.
Technique:
Enemas utilize a solution of salt water that is placed into a bag on one side of the tube. The
other portion is lubed and placed directly into the rectum. In order for the solution to reach the
colon properly, hug your knees to your chest while lying on your stomach or on your side.
10) Nasogastric intubation(from google): is a medical process involving the insertion of a
plastic tube (nasogastric tube or NG tube) through the nose, past the throat, and down into the
stomach. Orogastric intubation is a similar process involving the insertion of a plastic tube
(orogastric tube) through the mouth.

Indication
 Gastric decompression, including maintenance of a decompressed state
after  endotracheal intubation, often via the oropharynx. 
 Relief of symptoms and bowel rest in the setting of small-bowel obstruction
 Aspiration of gastric content from recent ingestion of toxic material
 Administration of medication
 Feeding
 Bowel irrigation
 NG tube can be kept following corrosive ingestion for the development of a tract in the
esophagus that subsequently can be used for balloon dilatation

Technique:

1. Gather equipment
2. Don non-sterile gloves
3. Explain the procedure to the patient and show equipment
4. If possible, sit patient upright for optimal neck/stomach alignment
5. Examine nostrils for dobstructions to determine best side for insertion
6. Measure tubing from bridge of nose to earlobe, then to the point halfway between the
end of the sternum and the navel
7. Mark measured length with a marker or note the distance
8. Lubricate 2-4 inches of tube with lubricant (preferably 2% Xylocaine). This procedure is
very uncomfortable for many patients, so a squirt of Xylocaine jelly in the nostril, and a
spray of Xylocaine to the back of the throat will help alleviate the discomfort.
9. Pass tube via either near posteriorly, past the pharynx into the esophagus and
then the stomach.

Instruct the patient to swallow (you may offer ice chips/water) and advance the tube as
the patient swallows. Swallowing of small sips of water may enhance passage of tube
into esophagus.

If resistance is met, rotate tube slowly with downward advancement toward closes ear.
Do not force.

11) stoma types, stoma care (from google)

A stoma is an opening on the front of your abdomen (tummy) which is made using surgery. It
allows feces or urine to be collected in a pouch (bag) on the outside of your body. There are
several reasons why you might need a stoma.
The main types of stoma are:

Ileostomy
An opening from your small bowel, to allow feces to leave your body without passing through
your large bowel. Bowel movements after an ileostomy are usually quite fluid.

Colostomy
An opening from your large bowel, to allow feces to leave your body without passing through
your back passage (anus). Bowel movements after a colostomy are usually quite solid.

Urostomy
An opening from your ureters, to allow urine to leave your body without passing through your
bladder.

12) Abdominal trauma – classification, primary and secondary survey(from the lecture)

1.blunt trauma

Direct blow to the abdomen / fall

2.Penetrating abdominal trauma Classification

* According to mechanism:

•Gunshot

•Stab wound

*According to profoundness:

•non penetrating -Superficial (skin) -deep (fascia)

•penetrating-without / with visceral injury (perforating)

Primary survey

•Airway, with cervical spine precautions

•Breathing

•Circulation

•Disability

•Exposure

Secondary Survey

•General &Systemic-identify all (occult injuries)

•Special attention to back, axilla, perineum

•RT-sphincter tone, bleeding, perforation, peritonitis

•Foley’s catheter-monitor urine output

•Nasogastric tube

AMPLE History A: Allergy M: Medications P: Past medical history L: Last meal E: Event-What
happened

13) SPLENIC INJURY (from the lecture)

•Most common intra-abdominal organ to injured (40-55%)

•20% of splenic injuries due to left lower rib fractures

•Commonly arterial hemorrhage

•Conservative management:

-Hemodynamic stability

-Negative abdominal examination

-Absence of contrast extravasation in CT

-Absence of other indication of laparotomy-Grade 1to 3 (Subcapsular Hematoma ,Laceration <3

cm)

Monitoring

•Serial clinical/US/Haematocritare essential

•Success rate of conservative > 80%

14) liver injury(from the lecture)

•50% liver injury have stop bleeding spontaneously by the time of surgery

Non -Operative

•Hemodynamically Stable

•No other intra-abdominal injury require surgery

•< 2 units of BT required

•Hemoperitoneum <500 ml on CT

•Grade I-III(subcapsular & intr-perenchymal hematoma)

Operative

•Suturing: -Simple suture

-Deep mattress suture

•Laceration: -Mesh hepatorrhaphy

-Omental flap to cover the laceration

-Debridement

•Lobar Resection

•Liver Transplantation

•Ligate or repair damaged blood vessels & bile duct

•Mortality of liver injury is10%

15) Pancreatic Injury(from the lecture)

•Rare 10-20% of all abdominal injury

•Crush, Direct blow to abdo & Seat belt injury

•Associated with abdo. Duodenal injury, Vascular injury & liver injury
•Diagnosis–Difficult, High index of suspicion

•CECT Scan is helpful

•Serum amylase is a poor indicator

•Usually diagnose on Laparotomy

•Distal Pancreatic Injury-Distal resection

•Pancreatojejunostomy–Injury to Ampulla of Vater, Head & Body of Pancreas).

16) renal injury (from the lecture)

Clinically not suspected & frequently overlooked

•Mechanism:

Blunt / Penetrating/ lower ribs or spinous process /Crush abdominal/ Pelvic injury /Direct blow to flank
or back/ Fall /MVA.

Diagnosis

1.History, Clinical examination

2. Presentation: Shock, hematuria & pain

3.Urine: gross or microscopic hematuria

4. x-ray

5. CT scan to abdomen

Classification of Injury

•Grade I: Contusion or Subcapsular Hematoma

•Grade II: Non-Expanding Hematoma, <1cm deep, no extravasation

•Grade III: Laceration >1cm with urinary Extravasation

•Grade IV: Parenchymal Laceration deep to CM Junction

•Grade V: Renovascular injury

17) Diaphragmatic Injury(from lecture)

•Incidence-0.8%-1.6% in BTA

•High index of suspicion required, may be missed.

•40 to 50% are diagnosed immediately

•Presentation may be delayed

•Imaging: Nasogastric tube seen in the thorax, Abdominal contents in the thorax, Elevated
hemidiaphragm (>4 cm Lt vs Rt), Distortion of diaphragmatic margin.

18)Hollow Viscus Injuries (from lecture)

Gastric Injury: Penetrating trauma

Blunt trauma abdomen1%

Causes Penetrating Injury

-Crushing Against the Spine

-CPR

-Vigorous Ventilation with ET Tube in the Esophagus

-Heimlich Maneuver

Diagnosis: X-Ray chest & Abdomen CT scan

Diagnostic Peritoneal Lavage

During Surgical Exploration

Treatment: Expl. Laparotomy with Primary Repair

Isolated Duodenum injury

rare Incidence-3-5%

Cause: - Penetrating injury

- Steering wheel injury

- Assault

- Fall

- Associated with other intra-abdominal injury

Diagnosis: Plan X-ray

Small Intestine& Colonic Injuries

Commonly Injured in Penetrating injury Blunt Trauma

-Incidence 5%-20%

Mechanism: -Crush Injury

-At Fixed point DJ & IC Junction

Rx: Exploratory Laparotomy

19- breast cancer _ risk factors

Sex in men is rare( 1%from all malignant tumors)S ex ratio, women/men= 100:1

Age Ageing is the most important RFR are before 25 years, often after 50 years, maxim at 70years, rare
after 70 years old

Reproductive factors:

• Early age at menarche

•Late age at menopause

Age at first pregnancy Having no children and being older at the time of the first birth both increase the
incidence of breast cancer. Having the first child after 30—35 years will not protect against breast cancer

Inherited risk Up to 10 % of breast cancer in Western countries is due to an inherited factor .It is not yet
known how many breast cancer genes there are, but to date, two specific breast cancer genes have
been identified(BRCA1 and BRCA2).

Previous breast disease Women with certain benign changes in their breasts-severe atypical epithelial
hyperplasia, papilloma.

Radiation Women who received radiation to the chest as a result of repeated X-rays for tuberculosis.
Women with Hodgkin's disease who received radiation therapy to the chest have an excess risk of breast
cancer.

Hormone replacement therapy Among current users of hormone replacement therapy(HRT), there is an
increased risk of breast cancer.

Weight Being overweight is associated with a doubling of the risk of breast cancer in postmenopausal
women

Among premenopausal women obesity is associated with reduced breast cancer incidence.

Hormones contraceptive pill-increased risk while they take the Pill and they remain at risk for 10years
after stopping the drugs.
20- . Breast cancer – investigations

Mammography: Mammograms are a good way of identifying abnormalities in the breast.• Used for
women over the age of 35.•In younger women the breast tissue is more dense, which makes it difficult
to detect any changes on the mammogram

•Breast ultrasound: An ultrasound uses sound waves to build up a picture of the breast
tissue.Ultrasound can often tell whether a lump is solid(made of cells) or a fluid-filled cyst.It can also
often gives the information whether a solid lump is likely to be benign or malignantSigns: Hypo
echogenity, Irregular and unprecise contour of the tumor, presence of Doppler signal

•Core biopsy :

NEEDLE CORE BIOPSYCan allow a breast tissue specimen for histological and immunohistochemistry
exam.Can obtain a preoperative diagnosis resulting in more appropriate decision of therapy.Core
biopsies are often done using ultrasound as guide to the lump.Local anaesthetic is injected into the
area first to numb it

•Open biopsy:

OPEN BIOPSYA biopsy is the only way to tell for sure if cancer is present.An incisional biopsy takes a
sample of a lump or abnormal are abut it but it makes it difficult for the anatomopathologist to measure
the tumor!!!An excisional biopsy takes the entire lump or area.General anaesthesia needed.

Other investigations : • MRI• Chest X Ray• Abdominal ultrasound• Bone scintigraphy.

21-Breast cancer – pathology, staging

Staging of the breast malignant tumour

Stage 0 Ductal carcinoma in situ (DCIS)almost always completely curable. The following stages of
breast cancer are known as invasive breast cancer:

Stage 1The tumour measures less than 2cm. The lymph nodes in the axilla are not affected and there
are no signs that the cancer has spread elsewhere in the body.

Stage 2The tumour measures between 2 and 5cm. or the lymph nodes in the axilla are affected, or
both. However, there are no signs that the cancer has spread further.

•Stage 3The tumour is larger than 5cm. and may be attached to surrounding structures such as the
muscle or skin. The lymph nodes are usually affected.

•Stage 4The tumour is of any size, but the lymph nodes are usually affected and the cancer has spread
to other parts of the body. This is metastatic breast cancer
Hormone receptors

Many breast cancers have receptors for the hormone oestrogen.When oestrogen attaches to these
receptors, it causes the cancer cells to grow.If a breast cancer has a significant number of oestrogen
receptors it is known as being oestrogen-receptor positive ER+If it doesn’t it is known as oestrogen-
receptor negative ER-Knowing whether the tumour has oestrogen receptors or not helps the doctors
to decide on the best treatment

•A tumour that is ER+ is likely to respond to hormone altreatments, whereas a tumour that is ER-will not
respond

.•Some breast cancers have progesterone receptors and are known as progesterone-receptor positive
(PR-positive).

•Usually, cancers that are ER+ will also be PR+.

•Progesterone receptors are less important than oestrogen receptors in predicting the likely response to
hormone treatment.

22-Breast cancer – treatment :

Treatment overview

•The treatment of breast cancer is individual foreach woman

.•The treatment depends on many factors, including:–the stage and grading of the cancer–age–
Receptor status (such as oestrogen) or particular proteins (such as HER2)

T1/T2 primary breast cancers will be treated first with surgery.

Excision: at least 2 cm around the tumor-sectorectomy/quadranectomy

Axillary lymph node dissection

If the whole breast is removed (mastectomy),Breast reconstruction may be carried out, either at the
same time as the initial surgery or later .

T3/T4:chemotherapyorhormonal therapy maybe given to downstage a cancer before surgery-neo-

adjuvant therapy.

•Radiotherapy: before / after surgery.

•Hormonal therapy:before/after surgery, for at least 5 years (for ER, PR positive).

•Further treatment includes hormonal therapies, chemotherapy and/or a drug called Herceptin®.
23. Hernia – definition, types of hernia, clinical presentation

Definition : HERNIA= aprotrusion of an organ through its containing wall “Protrusion of a part or whole
of viscus through an abnormal opening in the wall of the cavity that contains it”

Types :

Common types: Inguinal ,Umbilical , Femoral , Incisional hernia

Less common types: Epigastric ,Spigelian ,Obturator

24- Hernia – risk factors, complications

Risk Factors Of Hernia

• Family history of hernias 

• Age (middle-aged and elderly) 

• Pregnancy 

• Smoking

• Lifting heavy objects for a long period of time

• Overweight

Complications

Irreducibility-bowel obstruction-incarcerated bowel

Strangulation–bowel obstruction +necrotic bowel

Trauma, tumour

25. Inguinal hernia – anatomy, types, physical examination, principles of treatment

An inguinal hernia is located in the inguinal region of the body where the thigh meets the pelvis.

The most common types of inguinal hernias are either direct: Passes through the Hesselbach triangle ,
Posterior to the spematic cord ,Does not pass into the scrotum , Less often associated with strangulation

or indirect : Passes through the deep inguinal ring, down the inguinal canal May extend into the
scrotum , 5 times commoner than direct hernia
and these are found more often by far in men rather than women.

Physical examination : Position-above the inguinal ligament

Tenderness-if strangulated

Shape-“pear-shaped” with the “stalk” at the external inguinal ring

Composition-soft-gut, firm-omentum.

Cough impulse

Reducibility

Principles of treatment :

Enlarging or painful hernias usually require surgery to relieve discomfort and prevent serious
complications.

There are two general types of hernia operations — open hernia repair and laparoscopic repair.

26. Femoral hernia – anatomy, clinical presentation, differential diagnosis, principles of treatment

 femoral hernia usually occurs when fatty tissue or a part of the bowel pokes through into the groin at
the top of the inner thigh.

It pushes through a weak spot in the surrounding muscle wall (abdominal wall) into an area called
the femoral canal

Symptoms;

 severe stomach pain

 sudden groin pain

 nausea

 vomiting

differential diagnosis

physical examination and the presence of /varicocele, lymphadenopathy, lipoma, cyst, abscess,
hematoma, and femoral artery pseudoaneurysm/aneurysm

also we can do CT or ultrasonography.

Treatment

Femoral hernias that are small and asymptomatic may not require specific treatment

We can do a surgery repair

Causes
Chronic cough

Being overweight

Childbirth

Chronic constipation

27. Umbilical hernia

An umbilical hernia occurs when part of the intestine bulges through the opening in the abdominal
muscles near the bellybutton (navel). Umbilical hernias are common and typically harmless.

An umbilical hernia occurs when the opening in the abdominal muscle that allows the umbilical cord to
pass through fails to close completely

Symptoms

Swelling near the umblical region

the baby is in obvious pain

the baby suddenly starts vomiting

the bulge (in both children and adults) is very tender, swollen, or discolored

diagnosis

-see if the hernia can be pushed back into the abdominal cavity (reducible) or if it is trapped in its place
(incarcerated)

-X ray or ultrasound on the abdominal area to check if there any complication

-blood test for infection

Treatment

Surgery when the hernia become painfull, bigger than one half inch in diameter,block the intestine

28. Incisional hernia – definition, etiology, risk factors

Incisional hernia refers to abdominal wall hernia at the site of a previous surgical incision. It is a type
of ventral hernia.

Causes

Incisional hernias are usually caused by a weakness of the surgical wounds, which may be caused
by hematoma, seroma, or infection, all of which result in decreased wound healing. They may also be
caused by increased intra-abdominal pressure due to a chronic cough (as in COPD), constipation, urinary
obstruction,pregnancy
Risk factors of incisional hernia

wound infection-

-existing health conditions, such as renal failure, diabetes, or lung disease

Obesity-

Smoking-

certain medications, including immunosuppressant drugs or steroids-

chemotherapy-

29. Incisional hernia – clinical presentation, complication, principles of repair

Incisional hernia refers to abdominal wall hernia at the site of a previous surgical

Clinical presentation

the characteristic clinical feature of an incisional hernia is a non-pulsatile, reducible, soft and non-

tender swelling at or near the site of a previous surgical wound. 

Complication

The most serious complications of incisional hernias are bowel obstruction and strangulation

Principle of repair

Tension Free Repair-

Incision - Chosen to Provide Good Exposure of the Defect-

Do Not Expose Bowel to Reactive Mesh-

Clear Adequate Margins of the Defect-

Skin Hygiene-

Antibiotic Prophylaxis-

Choice of Anethesia-

30. Abdominal evisceration - definition, etiology, risk factors

Evisceration is the separation of the layers of an abdominal wound before complete healing has taken
place

It occurs when a wound fails to gain sufficient strength to withstand stresses placed upon it. The
separation may occur when overwhelming forces break sutures, when absorbable sutures dissolve too
quickly or when tight sutures cut through tissues
Evisceration is a rare but severe surgical complication where the surgical incision opens (dehiscence) and
the abdominal organs then protrude or come out of the incision

Causes

large wound that extends through the peritoneum, causing a sudden eruption of abdominal contents

risk factors

risk factors for evisceration include age, diabetes, obesity, malnutrition, corticosteroid therapy, and
sepsis. Wound infection is directly associated with over 50% of eviscerations.

 31. Abdominal evisceration – classification, clinical features, prevention and treatment

Classification

Evisceration can range from the less severe, with the organs (usually abdominal) visible and slightly
extending outside of the incision to the very severe, where intestines may spill out of the incision

Prevention and treatment

-Emergency triage—Treatment for shock, assessment and management of secondary injuries, protection
of the exposed abdominal organs, and initiation of antimicrobial therapy

-Wound decontamination—Conversion of the dirty wound into a clean contaminated wound and
temporary closure of the abdomen for surgical prep.

-Post–operative management—Broad spectrum antimicrobial therapy tailored by culture results,

abdominal drainage and/or lavage, fluid and colloid support, pain management, and early refeeding

32. Thyroglossal cyst

A thyroglossal duct cyst is a fluid-filled pocket in the front of the neck, just above the voice box.

 The cyst is usually a painless, soft, round lump in the front center of the neck.

 They will typically move when the person swallows or sticks their tongue out.

 Surgical removal of the cysts helps prevent recurrence and infection

Diagnosis

-blood test

-ultrasound examination

-thyroid scan

- X ray

Symptoms

-difficult of swallow
-readness of the skin around the cyst

-feeling tender

-difficult of breathing

33. Simple goiter

condition that increases the size of your thyroid

the symptoms of a goiter

The primary symptom of a goiter is noticeable swelling neck..

Other symptoms include:

difficulty swallowing or breathing

coughing

hoarseness in your voice

dizziness when you raise your arm above your head

What causes a goiter

Iodine deficiency is the main cause of goiters. Iodine is essential to helping your thyroid produce
thyroid hormones. When you don’t have enough iodine, the thyroid works extra hard to make thyroid
hormone, causing the gland to grow larger.

Other causes include the following:

Graves’ disease.

Hashimoto’s thyroiditis.

Inflammation

Nodules.

Thyroid cancer

Pregnancy

Types of goiters

Colloid goiter (endemic1-

A colloid goiter develops from the lack of iodine, a mineral essential to the production of thyroid
hormones..
Nontoxic goiter (sporadic-2

The cause of a nontoxic goiter is usually unknown, though it may be caused by medications like
lithium. Lithium is used to treat mood disorders such as bipolar disorder.

Toxic nodular or multinodular goiter-3

goiter diagnosed

-Blood tests

Blood tests can detect changes in hormone levels and an increased production of antibodies, which
are produced in response to an infection or injury or overactivity of immune system.

Thyroid scan-

Ultrasound-

Biopsy-

goiter treated

Medications

Surgeries

Surgical removal of your thyroid, known as thyroidectomy, is an option if yours grows too large or
doesn’t respond to medication therapy.

Radioactive iodine

34. Thyroid nodules – clinical assessment, investigations and management

Thyroid nodules are solid or fluid-filled lumps that form within the thyroid

Clinical assessment

— Most patients with a solitary thyroid nodule are euthyroid

— A nodule in a hyperthyroid patient is unlikely to be malignant

— A hard fixed nodule is likely to be malignant

— A very hard nodule- calcified colloid nodule

— Lymphadenopathy- common finding in papillary and medullar carcinoma

— Reccurent laryngeal nerve palsy on the side of a palpable nodule- malignant infiltration

Investigation

— Measurement of T3, T4, TSH

— CXR- tracheal deviation or retrosternal extension

— Isotope scanning- cold or hot nodule

 — Ultrasonography- the structure

— Fine needle aspiration cytology

— Management

— Hyperthyroid-

— FNAC & isotope scan

— Greater than 2 cm.- surgery

— Euthyroid-

— Benign-no pressure sy.-observe, repeat FNAC in 6 months

— Benign- with pressure sy.- surgery

— Suspicious- surgery

— Malignant- surgery

— Inadequate FNAC- repeat

— Cystic benign- observe, review in 6 weeks

Cystic malignant- surgery

42)hyperthyroidism

— Common causes:

- diffuse toxic goitre (Grave’s disease),

- toxic multinodular goitre,

- toxic solitary nodule (Plummer’s disease),

- exogenous thyroid hormone excess,

- thyroiditis

— Rare causes:

- metastatic thyroid carcinoma,

- pituitary tumour secreting TSH

43) primary hyperparathyroidism 

Primary hyperparathyroidism is a condition in which one or more of the parathyroid glands makes too
much PTH. This can lead to the loss of bone tissue.  is usually caused by a tumor within the parathyroid
gland. can cause digestive symptoms, kidney stones, psychiatric abnormalities, and bone disease

Signs and symptoms:

"stones, bones, abdominal groans, thrones and psychiatric overtones

- bones pain

- renal colics

- abdominal pain

- fatigue

- depresion

- memory loss, concentration

`causes

The most common cause of primary hyperparathyroidism is a sporadic, single parathyroid adenoma,

hyperplasia, double adenoma, PT carcinoma

44)Secondry hyperparathyroidism 

 excessive secretion of parathyroid hormone by the parathyroid glands in response to

hypocalcemia with resultant hyperplasia of these glands. This disorder is primarily seen in patients with
chronic kidney failure.

The most common causes of secondary hyperparathyroidism are kidney failure and vitamin D
deficiency. In kidney failure, the kidney is no longer able to make enough vitamin D or remove all of the
phosphorus that is made by the body, which leads to low calcium levels. These low calcium levels
stimulate the parathyroid glands to make more PTH.

Secondary hyperparathyroidism means the parathyroid glands are overproducing parathyroid hormone
in an attempt to help the body increase the amount of calcium in the blood.

diagnosis:

The PTH is elevated due to decreased levels of calcium or 1,25-dihydroxy-vitamin D 3. It is usually seen in
cases of chronic kidney disease or defective calcium receptors on the surface of parathyroid glands.
Sings and symptoms:

Bone and joint pain are common, as are limb deformities. The elevated PTH has also pleiotropic effects
on the blood, immune system, and neurological system.

45) acute mastitis

is usually a bacterial infection and is seen most commonly in the postpartum period

• Bacterial mastitis (acute mastitis) - most common variety.

• Associated with lactation.

• The intermediary – infant harbouring staphylococci in the nasopharynx.

• Ascending infection from a sore and cracked nipple

Acute mastitis-

• Acute galactophoritis

- fever

- painful tension, enlargment of the breast

- Boudin sign

- no lymphadenopathy

• Mammary abscess

- fever

- painful mass and lymphadenopathy

- local inflamatory signs

- distorsion of the breast

Signs and symptoms

 Breast tenderness or warmth to the touch

 General malaise or feeling ill

 Swelling of the breast

 Pain or a burning sensation continuously or while breast-feeding

 Skin redness, often in a wedge-shaped pattern

 Fever of 101 F (38.3 C) or greater[8]

Incision and drainage recommended:

 If the infection did not resolve within 48 hours or

 if after being emptied of milk there was an area of tense induration or

 other evidence of an underlying abscess.

Treatment:

antibiotics: Take acetaminophen or ibuprofen

 Pain relief: A warm compress applied before and after feedings

Chronic:

• Chronic nonspecific abscess

• Galactocel

• Mammary tuberculosis

• Mammary syphilis

• Inadequate drainage

Chronic Intramammary abscess

• Injudicious antibiotic treatment,

• Encapsulated within a thick wall of fibrous tissue the condition cannot be distinguished from a
carcinoma without the histological evidence from a biopsy.

**Chronic mastitis can be a sequela of acute mastitis, or more commonly, associated with duct

ectasia.

46) mondor's disease

• Thrombophlebitis of the superficial veins of the breast and anterior chest wall the arm.

• The absence of injury or infection, the cause is obscure.

• Subcutaneous cord, usually attached to the skin.

• The skin over the breast is stretched by raising the arm,

• A narrow, shallow subcutaneous groove alongside the cord becomes apparent.

Differential diagnosis

• Lymphatic permeation from an occult carcinoma of the breast.

 • Rx - restricted arm movements

• Spontaneous regression a few months without recurrence, complications or deformity.

• Development of malignancy is co incidental.

Signs:

• Young women

• Slow progress

• Acute events (abscesses)

• Painful breast mass, inflamatory signs, retraction of the nipple.

47) fibroadenoma:

• Fibroadenomas are benign tumors

• They are most common in younger women (between the ages of 15 and 35)

• Most fibroadenomas do not increase the risk of breast cancer

• If a fibroadenoma causes discomfort, it may be excised

• Blood flow may be present

• Often followed using ultrasound every six months (up to 1 to 2 years) to track any change in size

• ultrasound-guided core biopsy

48) Galactocele

• Most common benign breast lesion

• Typically occurs in young lactating women

• Is also referred to as a lactocele

• Presents with a painless breast lump occurring over weeks to months 

• Can present as a single or multiple nodule(s)

• Unilateral or bilateral
 • Diagnosis can be done with an aspiration

• Most likely located near the sub-areolar region

• Ultrasound appearances can be widely variable

•  Sonographic characteristics according to one study is as follows:

• cystic / multicystic: ~ 50% 

• mixed (cystic + solid): ~ 37%

• solid: ~ 13%

49) Phyllodes Tumor

• Rare breast tumors that, like fibroadenomas, contain 2 types of breast tissue: stromal
(connective) tissue and glandular (lobule and duct) tissue

• Most commonly found in women in their 30s and 40s, but they may be found in women of any
age

Link to cancer risk

• Not usually cancerous, but in rare cases they may be related

• One third of these tumors are classified as malignant based on how they look under the
microscope, less than 5% of phyllodes tumors overall are clearly true cancers

• Can reappear; close follow-up with frequent breast exams and imaging is usually recommended
after treatment.

Diagnosis:

• Tumors are usually felt as a painless lump, but may be painful

• Capable of growing quickly and can stretch the skin

• Difficult to differentiate from fibroadenomas on imaging tests and by biopsy

• Often the tumor needs to be removed to prove it is a phyllodes tumor

 • Microscopically the main difference between phyllodes tumors and fibroadenomas is the
overgrowth of connective tissue

• Cells that make up the connective tissue part can look abnormal under the microscope

• Histology classifies tumors dependent on the cellular makeup; phyllodes tumors may be
classified as benign (non-cancerous), malignant (cancerous), or borderline (looking more
abnormal than benign tumors, but not quite malignant).

Treatment:

• Phyllodes tumors (even benign ones) can re-grow in the same place if they are removed without
taking enough of the normal tissue around them

• Treated by removing the tumor and at least a 1 cm (a little less than ½ inch) area of normal
breast tissue around the tumor

• Malignant phyllodes tumors are treated by removing them along with a wider margin of normal
tissue, or by mastectomy if necessary

• Malignant phyllodes tumors are different from the more common types of BrCA

• They do not respond to hormone therapy and are less likely than most breast cancers to
respond to RT or chemo

• Phyllodes tumors that have spread to distant areas are often treated more like sarcomas (soft-
tissue cancers) than breast cancers.

50) typical and atypical ductal hyperplasia

• Classification between TDH and ADH is dependent on histological features

• High reproducibility is important classification

• Typical cells appear heterogeneous and atypical are homogeneous in cell type

• ADH is more related to DCIS than typical

• ADH is rare and seen in approx. 4% of symptomatic benign biopsies

• ADH is more commonly linked to sreen-detected benign calcs (31%) and is more commonly an
incidental finding

• Patients are at a 4-5x higher risk of developing BrCA with a h/o ADH

• Risk is even higher if patient has a first degree relative with BrCA
Diagnosis:

1. Pattern

2. Cytology

3. Disease Extent