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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: At a Glance
- Sprache: Englisch
This new edition of Surgery at a Glance provides a concise and visually-orientated summary of a comprehensive lecture course in surgery. Following the easy-to-use at a Glance format, each topic is presented with clear illustrations and key facts encapsulating all that you need to know.
The book is coherently divided into clinical presentations followed by major surgical conditions. Exploring core principals and important diseases, it is an accessible companion to any surgery core text, and is ideally placed to support the current curriculum.
Surgery at a Glance:
• Features brand new chapters on Orthopaedics and updates on the management of surgical conditions
• Includes more revision-friendly elements for quick reference
• Is fully supported by a resource website at www.testgeneralsurgery.com containing both MCQs and short answer questions
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 282
Veröffentlichungsjahr: 2013
Ähnliche
Table of Contents
Companion website
Title page
Copyright page
Preface
List of abbreviations
Part 1: Clinical presentations at a glance
1 Neck lump
Definition
Differential diagnosis
Important diagnostic features
2 Dysphagia
Definition
Important diagnostic features
3 Haemoptysis
Definition
Important diagnostic features
4 Breast lump
Definition
Differential diagnosis
5 Breast pain
Definition
Important diagnostic features
6 Nipple discharge
Definition
Differential diagnosis
7 Gastrointestinal bleeding/1
Definitions
Upper GI bleeding
Important diagnostic features
Gastrointestinal bleeding/2
Lower GI bleeding
Important diagnostic features
8 Dyspepsia
Definition
Differential diagnosis
9 Vomiting
Definitions
Important diagnostic features
10 Acute abdominal pain
Definitions
Important diagnostic features
11 Chronic abdominal pain
Definition
Important diagnostic features
12 Abdominal swellings (general)
Definition
Important diagnostic features
13 Abdominal swellings (localized) – upper abdominal/1
Abdominal swellings (localized) – upper abdominal/2
14 Abdominal swellings (localized) – lower abdominal
15 Jaundice
Definition
Differential diagnosis
16 Diarrhoea
Definitions
Important diagnostic features
17 Altered bowel habit/constipation
Definitions
Important diagnostic features
18 Groin swellings
Definition
Important diagnostic features
Principles of hernia surgery
19 Claudication
Definition
Differential diagnosis
20 Acute warm painful leg
Definitions
Important diagnostic features
21 Acute ‘cold’ leg
Definition
Important diagnostic features
22 Leg ulceration
Definition
Important diagnostic features
23 Dysuria
Definitions
Important diagnostic features
24 Urinary retention
Definitions
Differential diagnosis
25 Haematuria
Definitions
Important diagnostic features
26 Scrotal swellings
Definition
Differential diagnosis
27 Stomas and incisions
Definitions
Indications for common stomas
Siting and care of a stoma
Features to recognize a stoma
Complications of stomas
Abdominal and thoracic incisions
Part 2: Surgical diseases at a glance
28 Anaesthesia – general
Definitions
Pre-operative assessment
General anaesthesia
Enhanced recovery after surgery (ERAS)
Anaesthesia – regional
Regional anaesthesia
Sedation
Postoperative pain control
29 Hypoxia
Definitions
Classification of hypoxia
Common causes
Clinical features
30 Surgical infection – general
Definitions
Pathophysiology of bacterial infection
Management of surgical infection
Management of established infection
Surgical infection – specific
Specific surgical infections
Post-operative infections
31 Sepsis
Definitions
Epidemiology
Risk factors
Pathophysiology
Prognosis
32 Systemic inflammatory response syndrome
Definitions
Common surgical causes
Pathophysiology
Treatment
33 Shock
Definition
Common causes
Clinical features
Investigations and assessment
Complications
34 Acute renal failure
Definitions
Common causes
Clinical features
Investigations
Prognosis
35 Fractures
Definitions
Common causes
Investigations
Complications
36 Orthopaedics – congenital and childhood disorders
Definitions
Classification
37 Orthopaedics – metabolic and infective disorders
Definitions
Bone loss
Dysplasia
Infections
38 Arthritis
Definitions
Osteoarthritis (OA)
Definition
Aetiology
Pathology
Clinical features
Investigations
Rheumatoid arthritis (RA)
Definition
Aetiology
Pathology
Clinical features
Investigations
Prognosis
Other types of arthritis
Gout
Psoriatic arthritis
Ankylosing spondylitis
Reactive arthritis or Reiter’s syndrome
Haemophillic arthritis
39 Musculoskeletal tumours
Definitions
Epidemiology
Classification of musculoskeletal tumours
Clinical features
Investigations
Specific bone tumours
40 Burns
Definitions
Common causes
Clinical features
Complications
41 Major trauma – basic principles
Definition
Principles of management
Patterns of injury
Timing of death following trauma
42 Traumatic brain injury (head injury)/1
Definitions
Epidemiology
Pathophysiology
Clinical features
Investigations
Traumatic brain injury (head injury)/2
Complications
Prognosis
43 Gastro-oesophageal reflux disease
Definitions
Common causes
Clinical features
Investigations
Complications
Barrett’s oesophagus
44 Oesophageal carcinoma
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
Prognosis
45 Peptic ulcer disease
Definition
Common causes
Clinical features
Investigations
46 Gastric carcinoma
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
Prognosis
47 Malabsorption
Definition
Clinical features
Differential diagnosis
Investigations
48 Crohn’s disease
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
Prognosis
49 Acute appendicitis
Definition
Epidemiology
Pathology
Clinical features
Investigations
Differential diagnosis
Complications
50 Diverticular disease
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
Prognosis
51 Ulcerative colitis
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
Prognosis
52 Colorectal carcinoma
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
Prognosis
53 Benign anal and perianal disorders
Haemorrhoids (‘piles’)
Rectal prolapse
Perianal haematoma
Anal fissure
Perianal abscess
Fistula-in-ano
Pilonidal sinus
54 Intestinal obstruction
Definitions
Common causes
Anatomical classification
Pathophysiology
Clinical features
Investigations
55 Abdominal hernias
Definitions
Types
Pathophysiology
Clinical features
Complications of surgery
56 Gallstone disease/1
Definitions
Epidemiology
Pathogenesis
Pathology
Clinical features
Gallstone disease/2
Investigations
57 Pancreatitis
Definition
Aetiology
Pathology
Clinical features
Complications – acute pancreatitis
Chronic pancreatitis
58 Pancreatic tumours
Definitions
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
Prognosis
Neuroendocrine tumours of the pancreas
59 Benign breast disease
Definition
Abnormalities of development
Abnormalities of cycles
Abnormalities of involution
Other benign conditions
60 Breast cancer
Definition
Epidemiology
Aetiology
Pathology
Screening
Clinical features
Investigations
61 Goitre
Definition
Common causes
Clinical features
62 Thyroid malignancies
Definition
Epidemiology
Pathology
Aetiology
Clinical features
Investigations
Complications of thyroid surgery
63 Parathyroid disease
Hyperparathyroidism
Hypoparathyroidism
64 Pituitary disorders
Definition
Common causes
Clinical features
Investigations
65 Adrenal disorders
Definitions
Common causes
Clinical features
Investigations
66 Skin cancer
Definition
Epidemiology
Malignant melanoma
Squamous cell carcinoma
Basal cell carcinoma
Staging
Investigations
Prognosis
67 Ischaemic heart disease
Definition
Epidemiology
Aetiology
Risk factors
Pathology
Clinical features
Investigations
Complications of MI
68 Valvular heart disease
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
69 Peripheral arterial disease
Definition
Epidemiology
Aetiology
Risk factors
Pathology
Clinical features
Investigations
Prognosis
70 The diabetic foot
Definition
Pathophysiology
Clinical features
Investigations
71 Aneurysms
Definitions
Sites
Aetiology
Risk factors
Pathology
Clinical features of AAA
Investigations
Prognosis
72 Extracranial arterial disease
Definition
Epidemiology
Aetiology
Risk factors
Pathophysiology
Clinical features
Investigations
73 Venous thromboembolism
Definitions
Epidemiology
Aetiology
Diagnosis and investigations
74 Varicose veins
Definition
Epidemiology
Aetiology
Pathophysiology
Clinical features
Investigations
75 Lymphoedema
Definition
Classification of lymphoedema
Clinical features
Clinical grades
Investigations
76 Postoperative pulmonary complications
Definitions
Aetiology/pathophysiology
Clinical features
Investigations
77 Lung cancer
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
Prognosis
78 Urinary tract infection
Definition
Epidemiology
Risk factors
Pathology
Clinical features
Investigations
Complications
79 Benign prostatic hypertrophy
Definition
Epidemiology
Pathophysiology
Clinical features
Investigations
Complications of surgical treatment
Prognosis
80 Renal (urinary) calculi
Definition
Epidemiology
Pathogenesis
Pathology
Clinical features
Investigations
Interventional procedures
Prophylaxis
81 Renal cell carcinoma
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
Prognosis
82 Carcinoma of the bladder
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
83 Carcinoma of the prostate
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
84 Testicular cancer
Definition
Epidemiology
Aetiology
Pathology
Clinical features
Investigations
Prognosis
85 Urinary incontinence
Definition
Epidemiology
Classification
Pathophysiology
Clinical features
Investigations
86 Solid organ transplantation
Definitions
Immunology of transplantation
Graft rejection
Immunosuppression
Graft-versus-host disease
87 Paediatric ‘general’ surgery/1
Infantile hypertrophic pyloric stenosis
Malrotation of the gut
Meckel’s diverticulum
Paediatric ‘general’ surgery/2
Gastro-oesophageal reflux
Intussusception
Inguinoscrotal conditions
Index
This new book is also available as an ebook.
For more details, please see www.wiley.com/buy/9781118272206
or scan this QR code:
Companion website
Includes a companion website at:
www.testgeneralsurgery.com
Featuring:
– MCQs
– Short answer questions.
This edition first published 2013 © 2013 by John Wiley & Sons, Ltd.
Previous editions 1999, 2002, 2006, 2009
Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing.
Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
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Library of Congress Cataloging-in-Publication Data
Grace, P.A. (Pierce A.)
Surgery at a glance / Pierce Grace, Neil R.Borley. – 5th ed.
p. ; cm.
Includes bibliographic references and index.
ISBN 978-1-118-27220-6 (pbk.: alk.paper)
1. Borley, Neil R. 11. Title. [DNLM. 1. Surgical Procedures, Operative–Handbooks. 2. Diagnostic
Techniques and Procedures – Handbooks. WO 39]
617'.9—dc23
2012032718
Cover image: SCIENCE PHOTO LIBRARY © MAURO FERMARIELLO
Cover design by Meaden Creative
A catalogue record for this book is available from the British Library.
Preface
Surgery at a Glance continues to be a very popular text with medical students and others who study surgery. In full colour, the book, in keeping with the At a Glance series in general, has a very user-friendly layout and is easy to read. A key feature of Surgery at a Glance is its division into clinical presentations and surgical diseases. Thus, in one volume is combined the ways that patients present with surgical problems and the surgical diseases that underlie those presentations. Fourteen years on we are delighted to present the revised and updated fifth edition of Surgery at a Glance. The new edition contains some additions. In response to feedback from medical students we have added four new chapters on orthopaedics as well as updating the text and illustrations throughout the book. The book retains its colour profile and beautiful illustrations. We have had lots of help and suggestions from several people in putting this book together. We would like to thank the many medical students and colleagues who have read the book and given us good advice. Students seem to like this book particularly for revision in preparation for exams. We especially thank the publishing team and illustrators at Wiley-Blackwell for their hard work in bringing this beautifully presented book to completion. We believe that the fifth edition of Surgery at a Glance is an excellent book and we hope that this text will continue to help students understand surgery.
Pierce A. GraceNeil R. Borley2013
List of Abbreviations
AAA
abdominal aortic aneurysm
AAT
aspartate amino transferase
ABI
ankle–brachial pressure index
Abs
antibiotics
ACE
angiotensin converting enzyme
Ach
acetylcholine
ACN
acute cortical necrosis
ACS
acute coronary syndrome
ACTH
adrenocorticotrophic hormone
ADH
antidiuretic hormone
AF
atrial fibrillation
AFP
〈-fetoprotein
Ag
antigen
AJCC
American Joint Committee on Cancer
AKI
acute kidney injury
Alb
albumin
ALI
acute lung injury
ALND
axillary lymph node dissection
ANCA
antineutrophil cytoplasmic antibody
ANDI
abnormalities of the normal development and involution (of the breast)
AP
angina pectoris
AP
anteroposterior
APACHE
acute physiology and chronic health evaluation
APTT
activated partial thromboplastin time
ARB
angiotensin receptor blocker
ARDS
adult/acute respiratory distress syndrome
ARF
acute renal failure
ASA
American Society of Anesthesiologists
ASCA
anti-
Saccharomyces cerevisiae
antibodies
ATN
acute tubular necrosis
AV
arteriovenous
BCC
basal cell carcinoma
BCG
bacillus Calmette–Guérin
b.d.
twice daily
BDM
bone mineral density
BE
base excess
BEP
bleomycin, etoposide, cisplatin
BMI
body mass index
BP
blood pressure
BPH
benign prostatic hypertrophy
BS
breath sounds
bx
biopsy
C&S
culture and sensitivity
CABG
coronary artery bypass graft
CAD
coronary artery disease
cAMP
cyclic adenosine monophosphate
CA-MRSA
community-associated methicillin-resistant
Staphylococcus aureus
CAS
carotid angioplasty and stent
CBD
common bile duct
CCF
congestive cardiac failure
CD
Clostridium difficile
CDH
congenital dysplaia of the hip
CDI
central diabetes insipidus
CEA
carcinoembryonic antigen
CEA
carotid endarterectomy
cfu
colony forming units
CgA
chromogranin A
CK
creatinine kinase
CLO
Campylobacter
-like organism
CMV
cisplatin, methotrexate, vinblastine
CMV
cytomegalovirus
CNS
central nervous system
COCP
combined oral contraceptive pill
COPD
chronic obstructive pulmonary disease
COX
cyclo-oxygenase
CPK-MB
creatine phosphokinase (cardiac type)
CRC
colorectal carcinoma
CRF
chronic renal failure
CRP
C-reactive protein
CSF
cerebrospinal fluid
CT
computed tomography
CTA
computed tomographic angiogram
CTCV
congenital talipes calcaneo valgus
CVA
cerebrovascular accident
CVI
chronic venous insufficiency
CVP
central venous pressure
CVS
cardiovascular system
CXR
chest X-ray
D
2
type 2 dopaminergic receptors
DCIS
ductal carcinoma in situ
DDAVP
1-desamino-8-arginine vasopressin (desmopressin)
DDH
developmental dysplaia of the hip
DHEA
dihydroepiandrosterone
DIC
disseminated intravascular coagulation
DM
diabetes mellitus
DMARDs
disease-modifying antirheumatic drugs
DMSA
dimercaptosuccinic acid
DU
duodenal ulcer
DVT
deep venous thrombosis
Dx
diagnosis
DXA
dual energy X-ray absorptiometry
DXT
deep X-ray therapy
EAS
external anal sphincter
EBV
Epstein–Barr virus
ECG
electrocardiogram
EMLA
Eutetic Mixture of Local Anaesthetic
ER
oestrogen receptor
ERCP
endoscopic retrograde cholangio-pancreatograph
ESR
erythrocyte sedimentation rate
ESWL
extracorporeal shock-wave lithotripsy
EUA
examination under anaesthesia
EUS
endoscopic ultrasound
FAP
familial polyposis coli
FBC
full blood count
FCD
fibrocystic disease
FFP
fresh frozen plasma
FHx
family history
FNAC
fine-needle aspiration cytology
FSH
follicle-stimulating hormone
5-FU
5-fluorouracil
gFOBT
guaiac faecal occult blood test
γ-GT
gamma glutamyl transpeptidase
GA
general anaesthetic
GC
gemcitabine, cisplatin
GCS
Glasgow Coma Scale
GFR
glomerular filtration rate
GH
growth hormone
GI
gastrointestinal
GIST
gastrointestinal stromal tumour
Gm+, Gm–
Gram-positive, Gram-negative
GORD
gastro-oesophageal reflux disease
GSF
greater sciatica foramen
GTN
glyceryl trinitrate
GU
gastric ulcer
GU
genito-urinary
GVHD
graft-versus-host disease
HALO
haemorrhoidal artery ligation operation
Hb
haemoglobin
HCG
human chorionic gonadotrophin
β-HCG
beta-human chorionic gonadotrophin
Hct
haematocrit
HCT
hematopoietic cell transplantation
HDL
high density lipoprotein
HDU
high-dependency unit
HER2/neu
human epidermal growth factor receptor 2
HIDA
hepatabiliary imido-diacetic acid
HLA
human leucocyte antigen
HNPCC
hereditary non-polyposis colorectal cancer (Lynch syndrome)
HoLEP
holium laser enucleation of prostate
hPTH
human parathyroid hormone
HRT
hormone replacement therapy
HVA
homovanillic acid
Hx
history
I&D
incision and drainage
IBS
irritable bowel syndrome
ICP
intracranial pressure
ICS
intercostal space
ICU
intensive care unit
IFN-γ
interferon gamma
Ig
immunoglobulin
IGF
insulin-like growth factor
IL
interleukin
iNOS
inducible nitric oxide synthetase
INR
international normalized ratio
IPPV
intermittent positive pressure ventilation
IV
intravenous
IVC
inferior vena cava
IVU
intravenous urogram
JGA
juxtaglomerular apparatus
JVP
jugular venous pulse
KUB
kidney, ureter, bladder
LA
local anaesthetic
LAD
left anterior descending
LATS
long-acting thyroid stimulating (factor)
LBO
large bowel obstruction
LCA
left coronary artery
LDH
lactate dehydrogenase
LDL
low density lipoprotein
LDUH
low dose unfractionated heparin
LFT
liver function test
LH
luteinizing hormone
LHRH
LH-releasing hormone
LIF
left iliac fossa
LMWH
low molecular weight heparin
LOC
loss of consciousness
LOS
lower oesophageal sphincter
LPS
lipopolysaccharide
LRD
living related donor
LSE
left sternal edge
LSF
lesser sciatica foramen
LSV
long saphenous vein
LUQ
left upper quadrant
LURD
living unrelated donor
LUTS
lower urinary tract symptoms
LV
left ventricle
LVF
left ventricular failure
MAG3
mercapto acetyl triglycine
MAP
mean arterial pressure
MCP
metacarpophalangeal
MC+S
microscopy cultures and sensitivity
MDRO
multidrug-resistant organisms
MDT
multidisciplinary team
MEAC
minimum effective analgesic concentration
MEN
multiple endocrine neoplasia
MI
myocardial infarction
MIBG
meta
-iodo-benzyl guanidine
MM
malignant melanoma
MND
motor neurone disease
MODS
multiple organ dysfunction syndrome
MRA
magnetic resonance angiography
MRCP
magnetic resonance cholangio-pancreatography
MRI
magnetic resonance imaging
MRSA
methicillin-resistant
Staphylococcus aureus
MS
multiple sclerosis
MSH
melanocyte-stimulating hormone
MSU
mid-stream urine
MT
major trauma
mTOR
mammalian target of rapamycin
MTP
metatarsophalangeal
MUGA
multiple uptake gated analysis
MVAC
methotrexate, vinblastine, doxorubicin (Adriamycin), cisplatin
N&V
nausea and vomiting
NAdr
noradrenaline/norepinephrine
NDI
nephrogenic diabetes insipidus
NF-κB
nuclear factor-κB
NG
nasogastric
NK
natural killer
NPO
nil
per oram
(nil by mouth)
NSAID
non-steroidal anti-inflammatory drug
NSGCT
non-seminomatous germ cell tumour
NSTEMI
non-ST elevation myocardial infarction
NSU
non-specific urethritis
OA
osteoarthritis
OAB
overactive bladder
o/e
on examination
OGD
oesophago-gastro-duodenoscopy
OGJ
oesophago-gastric junction
PA
posteroanterior
PAD
peripheral arterial disease
PAF
platelet activating factor
PAI-1
plasminogen activator inhibitor
pANCA
perinuclear antineutrophil cytoplasmic antibody
PCA
patient-controlled analgesia
PCI
percutaneous coronary intervention
PCV
packed cell volume
PE
pulmonary embolism
PEEP
positive end expiratory pressure
PEG
percutaneous endoscopic gastrostomy
PET
positron emission tomography
PHPT
primary hyperparathyroidism
PID
pelvic inflammatory disease
PIP
proximal inter phalangeal
PL
prolactin
POP
plaster of Paris
POVD
peripheral occlusive vascular disease
PPI
proton pump inhibitor
PR
per rectum
PSA
prostate-specific antigen
PT
prothrombin time
PTH
parathyroid hormone
PUD
peptic ulcer disease
PUO
pyrexia of unknown origin
PV
per vaginum
PVD
peripheral vascular disease
QoL
quality of life
RA
rheumatoid arthritis
RBC
red blood cell
RCC
renal cell carcinoma
RD
respiratory depression
rhAPC
recombinant human activated protein C
RIA
radioimmunoassay
RIF
right iliac fossa
RLN
recurrent laryngeal nerve
RPLND
retroperitoneal lymph node dissection
RS
respiratory system
RT
radiotherapy
RTA
road traffic accident
RUQ
right upper quadrant
RV
right ventricle
RVF
right ventricular failure
Rx
treatment
SCC
squamous cell carcinoma
SCFE
slipped capital femoral epiphysis
SERM
selective oestrogen receptor modulators
SGCT
seminomatous germ cell tumour
SIADH
syndrome of inappropriate antidiuretic hormone
SIRS
systemic inflammatory response syndrome
SLE
systemic lupus erythematosus
SLN
superior laryngeal nerve
SPECT
sestamibi-single photon emission computed tomography
SRS
somatostatin receptor scintigraphy
SSV
short saphenous vein
STEMI
ST elevation myocardial infarction
SVC
superior vena cava
T
3
tri-iodothyronine
T
4
thyroxine
TAA
thoracic aortic aneurysm
TB
tuberculosis
TCC
transitional cell carcinoma
TED
thrombo-embolic deterrent
TENS
transcutaneous electrical nerve stimulation
tLOSR
transient lower esophageal relaxation
TIA
transient ischaemic attack
TKI
tyrosine kinase inhibitor
TNF
tumour necrosis factor
TNM
tumour, node, metastasis (UICC)
tPA
tissue plasminogen activator
TPHA
treponema pallidum haemagglutination (test)
TPR
temperature, pulse, respiration
TRUS
transrectal ultrasound
TSH
thyroid-stimulating hormone
TURP
transurethral resection of the prostate
TURT
transurethral resection of tumour
TxP
transplantation
UC
ulcerative colitis
UDT
undescended testis
U+E
urea and electrolytes
UI
urinary incontinence
uPA
urokinase plasminogen activator
U/S
ultrasound
UTI
urinary tract infection
VEGF
vascular endothelial growth factor
VEGFR
vascular endothelial growth factor receptor
VF
ventricular fibrillation
VHL
von Hippel–Lindau
VIP
vasoactive intestinal peptide
VMA
vanillyl mandelic acid
V/Q
ventilation–perfusion
VRE
vancomycin-resistant enterococcus
VSD
ventricular septal defect
VV
varicose veins
WBC
white blood cell
WCC
white cell count
ZE
Zollinger Ellison
1
Neck Lump
Definition
A neck lump is any congenital or acquired mass arising in the anterior or posterior triangles of the neck between the clavicles inferiorly and the mandible and base of the skull superiorly.
Differential Diagnosis
50% of neck lumps are thyroid in origin.
40% of neck lumps are caused by malignancy (80% metastatic usually from primary lesion above the clavicle; 20% primary neoplasms: lymphomas, salivary gland tumours).
10% of neck lumps are inflammatory or congenital in origin.
Thyroid
Goitre, cyst, neoplasm.
Neoplasm
Metastatic carcinoma.
Primary lymphoma.
Salivary gland tumour.
Sternocleidomastoid tumour.
Carotid body tumour (rare).
Inflammatory
Acute infective adenopathy.
Collar stud abscess.
Parotitis.
Congenital
Thyroglossal duct cyst.
Dermoid cyst.
Torticollis.
Branchial cyst.
Cystic hygroma.
Vascular
Subclavian or brachiocephalic ectasia (common).
Subclavian aneurysm (rare).
Important Diagnostic Features
Children
Congenital and inflammatory lesions are common.
Cystic hygroma: in infants, base of the neck, brilliant transillumination, ‘come and go’.
Thyroglossal or dermoid cyst: midline, discrete, elevates with tongue protrusion.
Torticollis: rock hard mass, more prominent with head flexed, associated with fixed rotation (a fibrous mass in the sternocleidomastoid muscle).
Branchial cyst (also fistulae or sinus): anterior to the upper third of the sternocleidomastoid.
Viral/bacterial adenitis: usually affects jugular nodes, multiple, tender masses.
Neoplasms are unusual in children (lymphoma most common).
Young Adults
Inflammatory neck masses and thyroid malignancy are common.
Viral (e.g. infectious mononucleosis) or bacterial (tonsillitis/pharyngitis) adenitis.
Papillary thyroid cancer: isolated, non-tender, thyroid mass, possible lymphadenopathy.
Over-40s
Neck lumps are malignant until proven otherwise.
Metastatic lymphadenopathy: multiple, rock hard, non-tender, tendency to be fixed.
75% in primary head and neck (thyroid, nasopharynx, tonsils, larynx, pharynx), 25% from infraclavicular primary (stomach, pancreas, lung).
Primary lymphadenopathy (thyroid, lymphoma): fleshy, matted, rubbery, large size.
Primary neoplasm (thyroid, salivary tumour): firm, non-tender, fixed to tissue of origin.
2
Dysphagia
Definition
Dysphagia literally means difficulty with swallowing, which may be associated with ingestion of solids or liquids or both.
Important Diagnostic Features
Mural Causes
Carcinoma of the oesophagus: progressive course, associated weight loss and anorexia, low-grade anaemia, possible small haematemesis.
Reflux oesophagitis and stricture: preceded by heartburn, progressive course, nocturnal regurgitation (24-hour oesophageal pH monitoring may be indicated).
Achalasia: onset in young adulthood or old age, liquids disproportionately difficult to swallow, frequent regurgitation, recurrent chest infections, long history.
Tracheo-oesophageal fistula: recurrent chest infections, coughing after drinking. Present in infants (congenital) or late adulthood (post trauma, deep X-ray therapy (DXT) or malignant).
Chagas’ disease (
Trypanosoma cruzi
): South American prevalence, associated with dysrhythmias and colonic dysmotility.
Caustic stricture: examination shows corrosive ingestion, chronic dysphagia, onset may be months after ingestion of caustic agent. Long term risk of developing SCC (1–4%).
Scleroderma: slow onset, associated with skin changes, Raynaud’s phenomenon and mild arthritis.
Intraluminal Causes
Foreign body: acute onset, marked retrosternal discomfort, dysphagia even to saliva is characteristic.
Extramural Causes
Pulsion diverticulum (proximal: pharyngo-oesophageal [Zenker’s]; distal: epiphrenic): intermittent symptoms, unexpected regurgitation, halitosis.
External compression: mediastinal lymph nodes, left atrial hypertrophy, bronchial malignancy.
3
Haemoptysis
Definition
Haemoptysis (blood spitting) is the symptom of coughing up blood from the lungs. Blood from the nose, mouth or pharynx that may also be spat out is termed ‘spurious haemoptysis’.
Important Diagnostic Features
The sources, causes and features are listed below.
Spurious Haemoptysis
Mouth and Nose
Blood dyscrasias: associated nose bleeds, spontaneous bruising.
Scurvy (vitamin C deficiency): poor hair/teeth, skin bruising.
Dental caries, trauma, gingivitis.
Oral tumours: painful intraoral mass, discharge, fetor.
Hypertensive/spontaneous: no warning, brief bleed, often recurrent.
Nasal tumours (common in South-East Asia).
True Haemoptysis
Larynx and Trachea
Foreign body: choking, stridor, pain.
Carcinoma: hoarse voice, bovine cough.
Bronchus
Carcinoma: spontaneous haemoptysis, chest infections, weight loss, monophonic wheezing.
Adenoma (e.g. carcinoid): recurrent chest infections, carcinoid syndrome.
Bronchiectasis: chronic chest infections, fetor, blood mixed with copious purulent sputum; physical examination may show TB or severe chest infections.
Foreign body: recurrent chest infections, sudden-onset inexplicable ‘asthma’.
Lung
TB: weight loss, fevers, night sweats, dry or productive cough.
Pneumonia: fever, rigors, cough, myalgia, headache, chest pain, dyspnoea.
Lung abscess: fever, cough, foul-smelling sputum, night sweats, anorexia, gingival disease, clubbing of fingers.
Pulmonary infarct (secondary to PE): pleuritic chest pain, tachypnoea, pleural rub.
Aspergilloma.
Cardiac
Mitral stenosis: frothy pink sputum, recurrent chest infections.
LVF: frothy pink sputum, pulmonary oedema.
4
Breast Lump
Definition
A breast lump is defined as any palpable mass in the breast. A breast lump is the most common presentation of both benign and malignant breast disease. Enlargement of the whole breast can occur either uni- or bilaterally, but this is not strictly a breast lump.
Differential Diagnosis
Swelling of the Whole Breast (Mammoplasia)
Bilateral
Pregnancy, lactation.
Idiopathic hypertrophy.
Drug induced (e.g. diethylstilbestrol, antidepressants).
Gynaecomastia in males.
Unilateral
Enlargement in the newborn.
Puberty.
Gynaecomastia in males.
Localized Swellings in the Breast
Mastitis/Breast Abscess
During lactation: red, hot, tender lump, systemic upset.
Tuberculous abscess: chronic, ‘cold’, recurrent, discharging sinus.
Cysts
Galactocele: more common postpartum, tender but not inflamed, milky contents.
Fibrocystic disease: irregular, ill defined, often tender.
Solid Lumps
Benign include:
Fibroadenoma: discrete, firm, well defined, regular, highly mobile.
Fat necrosis: irregular, ill defined, hard, ?skin tethering.
Lipoma: well defined, soft, non-tender, fairly mobile.
Cystosarcoma phylloides: usually large tumour (5 cm), firm, mobile, well circumscribed, non-tender breast mass. (rare, 1% of breast tumours, 10% are malignant).
Malignant include:
Carcinoma
Swellings Behind the Breast
Rib deformities, chondroma, costochondritis (Tietze’s disease).
5
Breast Pain
Definition
Mastalgia is any pain felt in the breast. Cyclical mastalgia is pain in the breast that varies in association with the menstrual cycle. Non-cyclical mastalgia is pain in the breast that follows no pattern or is intermittent.
Important Diagnostic Features
Non-Breast Conditions
Tietze’s disease (costochondritis): tenderness over medial ends of ribs (typically 2nd/3rd/4th), not limited to the breast area of the chest wall, typically unilateral, relieved by NSAIDs.
Bornholm’s disease (epidemic pleurodynia caused by coxsackie A virus): marked pain with no physical signs in the breast, worse with inspiration, no underlying respiratory disease, relieved with NSAIDs.
Pleurisy: associated respiratory infection, pleural rub, may be bilateral.
Angina: usually atypical angina, may be hard to diagnose, previous history of associated vascular disease.
Mastalgia Due to Breast Pathology
Mastitis/Breast Abscess
During lactation: red hot tender lump, systemic upset.Treatment: aspirate abscess (may need to be repeated), do not stop breastfeeding, oral antibiotics.
Non-lactational abscesses: recurrent, associated with smoking, associated with underlying ductal ectasia:treatment: outpatient aspiration, give oral antibiotics, stop smoking, prophylactic metronidazole for recurrent sepsis, repeat aspiration if necessary.
Infected Sebaceous Cyst
Single lump superficially in the skin of the periareolar region, previous history of painless cystic lump:
Fibrocystic Disease
Common condition. Breast discomfort, dull heavy pain and tenderness. Variable symptoms and intensity, worse premenstrually. Cobblestone consistency to breast on palpation—upper outer quadrants:
Mastalgia without Breast Pathology
Pain often felt throughout the breast, often worse in the axillary tail, moderately tender to examination:
6
Nipple Discharge
Definition
Any fluid (which may be physiological or pathological) emanating from the nipple.
Differential Diagnosis
Physiological Discharges
Milky or Clear
Lactation.
Lactorrhoea in the newborn (‘witches’ milk’).
Lactorrhoea at puberty (may be in either sex).
Pathological Discharges
Serous Yellow-Green
Fibrocystic disease: cyclical, tender, lumpy breasts.
Mammary duct ectasia: usually multiple ducts, intermittent, may be associated with low-grade mastitis.
Bloody
Duct papilloma: single duct, ?retro-areolar, ‘pea-sized’ lump.
Carcinoma: ?palpable lump.
Mammary duct ectasia: usually multiple ducts, intermittent, may be associated with low-grade mastitis.
Pus ± Milk
Acute suppurative mastitis: tender, swollen, hot breast, multiple ducts discharging.
Tuberculous (rare): chronic discharge, periareolar fistulae, ‘sterile’ cultures on normal media.
7
Gastrointestinal Bleeding/1
Definitions
GI bleeding is any blood loss from the GI tract (anywhere from the mouth to the anus), which may present with haematemesis, melaena, rectal bleeding or anaemia. Haematemesis is defined as vomiting blood and is usually caused by upper GI disease. Melaena is the passage PR of a black treacle-like stool that contains altered blood, usually as a result of proximal bowel bleeding. Haematochesia is the presence of undigested blood in the stool usually from lower GI causes.
Upper GI Bleeding
Important Diagnostic Features
Oesophagus
Reflux oesophagitis: small volumes, bright red, associated with regurgitation.
Oesophageal carcinoma: scanty, blood-stained debris, rarely significant volume, associated with weight loss, anergia, dysphagia.
Bleeding varices (oesophageal or gastric): sudden onset, painless, large volumes, dark or bright red blood, history of (alcoholic) liver disease, other features of portal hypertension (ascites, dilated abdominal veins, encephalopathy, reduced platelets or white cells).
Trauma during vomiting (Mallory–Weiss syndrome): bright red bloody vomit usually preceded by several normal but forceful vomiting episodes.
Stomach
Erosive gastritis: small volumes, bright red, may follow alcohol or NSAID intake, history of dyspepsia.
Gastric ulcer: often larger sized bleed, painless, possible preceding (herald) smaller bleeds, accompanied by altered blood (‘coffee grounds’), history of PUD.
Gastric cancer: rarely large bleed, anaemia more common, associated weight loss, anorexia, dyspeptic symptoms.
Gastric leiomyoma (rare): spontaneous-onset moderate-sized bleed.
Dieulafoy’s disease (rare): younger patients, spontaneous large bleed, difficult to diagnose.
Duodenum
Duodenitis: small volumes, bright red, may follow alcohol or NSAID use, history of dyspepsia.
