Far Eastern University – Nicanor Reyes Medical Foundation

SURGERY B: PRE-OPERATIVE PHYSICAL EXAMINATION OF A Epidermal Cyst Excision

SURGICAL PATIENT – AUGUST 2, 2021 Elliptical incision include the punctum Location: Midback
Dr. Roberto B. Acuña
Mass will reoccur if the
OVERVIEW punctum/capsule is not
Skin excised.
Neck
Head
Chest
Breast
Abdomen Note the complete capsule excision.
Inguinal Area and Genitalia
Anal
Extremities

REMARKS
Catch me if you can. I am an exam question. I’ll ask you the
diagnosis or the diagnostic maneuver.
LIPOMA
DISCLAIMER: Please use at your own risk. - Fat tumor/ Tumor of the subcutaneous tissue
Read carefully - Second most common skin tumor
REFERENCE: - Single largest abnormal cell
o Dr. Acuna’s PPT and lecture - Defect in the lipolysis – the fat can enter the cell but cannot
Skin to Head – Sec X & Y - Skin slides over the mass
Chest and Breast – Sec Z - No redness in the area
Abdomen to Anal – Sec W - Treatment: Lipoma excision
Extremities – Sec W & Z o Mass is lobulated
o Previous years Trans o Specimen should be whole, and capsule should not be broken to
o Books: avoid recurrence of cyst
Harrison’s Principle of Internal Medicine 20th Ed.
Bates’ Guide To Physical Examination 12th Ed.

SKIN
IF THE MASS MOVES WITH SKIN:
o Epidermal cysts
o Skin malignancy
IF THE SKIN GLIDES OVER THE MASS
o Lipomas
o Soft tissue tumors
o Bone tumors

It is Important to differentiate if the mass moves over the skin or the

skin moves over the mass
If the skin moves over the mass, it is not a mass on the skin, a good
test to determine if it is a skin appendage disease or something
deeper than the skin POSSIBLE EXAM QUESTION
If the mass moves with the skin, it is a problem on the skin
If you can pinch the skin over the mass it is more likely a Lipoma is rare in children; based on the picture, what would
subcutaneous tissue or soft tissue mass. be the differential diagnosis?
- Do an ultrasound, to know if this is a femoral hernia
EPIDERMAL CYST - Lipoma usually accumulates over age
- Slowly growing
- Commonly found in oily part of the body (chest, deltoids, back)
o No sebaceous glands in our palm & sole kaya wala tayong
pimples dun
- Sudden enlargement and pain = INFECTION

Started like a blackhead/pimple

Once the pore closes, it will cause
blockage and keratin will start to
accumulate
Kaya kapag tiniris, may lumalabas na
fluid
Punctum – pointed by the arrow
Inborn Lipoma (Single lobulated cell)
NEUROFIBROMA
- Single or multiple masses
- Painless
- Genetic – chromosome 11 & 22
- Precancerous
o They have to be removed or they will be neurofibrosarcoma.
- Defect in peripheral nerves, commonly found in fingers and toes.

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 Differential diagnosis:
Tendon cyst

Take note of th e mass

located in the joint.

Joint has a lot of tendons.

[PICTURES ABOVE LEFT TO RIGHT: Normal Scar, Hypertrophic Scar, Keloid]

SKIN INFECTIONS

ABSCESS CELLULITIS

- Flunctuant area (when - Not flunctuant

you palpate, there is (“maga lang”)
fluid inside) - Flat and swollen
- Mostly Staphylococcal in origin - Commonly Streptococcal in
- Treatment: Incision and origin
drainage - Treatment: Medical
- Make sure that the incision is - No need to operate, it heals
large enough so that you could with medication (antibiotics
drain all the necrotic tissue with gram positive
[PICTURES ABOVE: Neurofibromatosis – “Café Au Lait spots” – it has - Aspiration is not advised, coverage)
Multiple and generalized neurofibroma; has a buttonhole sign) abscess will recur. - Fluid is transudate - watery
- Fluid is exudate – thick and
creamy pus
TENDON CYST (Old name: Ganglion cyst)
- Due to continuous trauma to the tendinous area the sheath (gel-like) CARBUNCLE
will weaken and result to cysts (common to typewriters, call center - Wide, mostly found in back (in diabetic
agent, gamers) patients)
- Indications for surgery - Multibacterial, gram-negative
o Painful - Necrotic (black area), should be removed.
o Greater than 2cm - Treatment: Debridement
- Do not excise if it does not meet the criteria because it might recur.
- Aspiration can also be done, but it is bound to recur if capsule is not
removed.

SKIN CANCER
BASAL CELL CARCINOMA
KELOIDS - “Pinaka-mabait” & most common
- Beyond the wound margins - Treatment: Surgery, You can remove it with a
- Medical narrow margin (1 to 2 mm)
- Keloids are hereditary, - Elevated egdes, waxy borders, necrotic center
common in people with - No chemotherapy, no radiotherapy, excision only.
spanish blood, the darker - Elevated pearly border + necrotic center
the skin color the more (malalim) = parang stuffed crust Pizza
common
- DO NOT OPERATE SQUAMOUS CELL CARCINOMA
- Due to excessive calcium - No lining/ no border
influx - Non-healing wounds more than 2 weeks
- Possible treatment: request for biopsy
o Apply pressure (Silicon pad) - Treatment: Surgery, radiotherapy,
o Steroid/topical chemotherapy
o Intralesion steroid o Most of the time, SqCC is
- Deltoid, chest, sternum, and upper back are prone to keloids chemoresistant

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MELANOMA NECK
- Colored lesion LOCATION
- Suspect melanoma if it has: - Midline
o A – Asymmetrical mass o Thyroglossal duct cyst – upper part
o B – Borders are irregular o Goiter – lower part;
o C – Color veriegation - Lateral
o D – Diameter > 6 mm o Over the SCM
o E – Elevation Branchial cleft cysts (Types I to III)
o “Pinaka-matapang” o Under the SCM
o Treatment: Surgery, radiotherapy, Lymph nodes
chemotherapy Levels of nodes determines the primary site
o Posterior to the SCM
POSSIBLE EXAM QUESTIONS Lymph nodes
When do you suspect a possible melanoma? The lesion is most likely Lymphangioma
___________________.
MIDLINE
IDENTIFY: NECK EXAMINATION
To orient yourself to the neck, identify the thyroid and cricoid cartilages and
Melanoma the trachea below them.

Stand behind when

doing the palpation.

Basal Cell Carcinoma

Inspect the neck for the thyroid gland. Tip the patient’s head slightly
back.
Observe the patient swallowing. Ask the patient to sip some water
and to extend the neck again and swallow. Watch for upward
movement of the thyroid gland, noting its contour and symmetry.
- If the lesion rises, THYROID yun.
Squamous Cell Carcinoma Confirm your visual observations by palpating the gland outlines as
you stand facing the patient.
Palpate the thyroid gland.
- If the tips of your finger cannot palpate the tracheal rings, may
GOITER ka.
Important to determine the pulse rate (NORMAL HR: 60-90)
- Sa IPD/CD, 60-100 hehe.

HEAD THYROGLOSSAL DUCT CYST

SKULL MASSES - If the lesion is above the thyroid cartilage (Adam’s apple)
- Osteoma - Clinical features:
- Metastasis o Commonly, a child is involved but can also be present in adults.
o Thyroid – common in female o When they protrude the tongue, the mass/lesion rises.
o Lung cancer – common in male o If newborn, place a gauze around the tongue and then pull, the
mass will go up
There are 4 cancers that commonly goes to the bones: Thyroid, lung,
breast, and prostate cancer. But in the skull, Thyroid and Lung cancer. The mass on the neck moves during protrusion of the tongue because
of its attachment to the tongue via the tract of thyroid descent (IN
EMBRYOLOGY).
OSTEOMA
- Skin glides over the mass
- Benign

Not a LIPOMA because we don’t have

FATS in our forehead.

When checking fever, we use our

dorsal side of our hand because we
don’t have much fat. [PICTURES ABOVE: SISTRUNK OPERATION]

POSSIBLE EXAM QUESTION

Bone metastasis from
Thyroid cancer Thyroglossal duct cyst
Sistrunk operation is used for _________________________
and usually involves the resection of
______________________.

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GOITER
- Below the thyroid cartilage
- Defined as any enlargement of the thyroid gland, whether
- diagnosed grossly or by ultrasound
[LEFT PICTURE: Diffuse Toxic
Goiter – usually requires
medication & “kulang lang sa
iodine”]
Goiter is related to swallowing (deglutition), because the capsule of
thyroid is related to the trachea. Once the trachea rises, the lump also
rises. If it does not rise, it is lymph node and not goiter.
TGDC – thyroglossal duct cyst
Goiter
Branchial Cleft Cyst
CERVICAL NODES
I – Submandibular
II – Upper Jugular
III – Middle Jugular
IV – Lower Jugular
V – Posterior triangle
VI – Anterior triangle
Importance: drainage of lymph
nodes
PREVIOUS TRANS + LECTURE
There are 6 levels of nodes in the neck. The flow of lymph and venous
blood is one-way, puro pababa towards the heart.
Submandibular nodes (level 1) are the checkpoints for cancer,
viruses, or microbes. It drains the face and anterior 2/3rd of the
mouth.
- If you have acne, rotten teeth or gums, all the lymph will
go to level 1.
- If level 1 is enlarged, check for pathologies in structures
that it drains.
- Eyes drain their lymph toward the preauricular lymph
nodes (near the tragus of the ear).
- Afterwards, it will go to level 1 of the neck.
- Retroauricular lymph nodes (behind the ear) drains the
scalp. It will also go to level 1 of the neck after.
For superior jugular nodes (level 2), look at the tonsils or
oropharynx
Middle jugular nodes (level 3) are found at the middle SCM
aligned to the thyroid cartilage.
- It is a very specific area for thyroid cancer.
- If it’s enlarged, it can possibly be papillary thyroid cancer.
Again!
Follicular thyroid cancer = metastasizes to the bone
Papillary thyroid cancer = metastasizes to the lymph nodes
Inferior jugular nodes (level 4) drain the larynx.
- At the left side of the neck, there’s the thoracic duct which
also drains the abdomen.
- If the patient is cachectic and there is an enlarged lymph
node at the left side of the neck, it’s called the Virchow’s
node.
- It’s a sign of disseminated pancreatic or gastric cancer
Posterior triangle nodes (level 5) are located behind the SCM.
- It drains the nasopharynx.
- If enlarged, it can be a lymphoma or nasopharyngeal
carcinoma.
- If a patient has COVID, level 5 enlarges.
Anterior triangle nodes (level 6) are nonspecific in draining
structures.
Thyroid cancer will not involve level 1 & level 2. Levels 1-4 will not drain
to level 5, but to the superior mediastinum (level 7). Levels 4-6 will drain
to the superior mediastinum (level 7).
[LEFT PICTURE: Cancer of the
Lymph Node/ Lymphoma]
NASOPHARYNGEAL CARCINOMA
- Check LN level 5
- Treatment: Radiotherapy (mostly) &
Chemotherapy (secondary)
Clinical manifestations:
Smoker
Bad breath
Lumps behind the SCM
Weight loss
Differentials:
Lymphoma
Cervical node tuberculosis
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PAROTID TUMOR CHEST
- Behind the ear & goes anteriorly Chest Deformities
- Treatment: Parotidectomy Percussion – Dull
Auscultation
o Breath sound
o Transmission of spoken voice
o Ancillary CT scan or Ultrasound
Beck’s Triad

CHEST DEFORMITIES

PECTUS EXCAVATUM PECTUS CARINATUM

BRANCHIAL CLEFT CYST

CERVICAL NODE TUBERCULOSIS

- Level 3
- 80% of of lymph nodes in the neck of Filipinos is tuberculous in origin
(no correlation with chest TB)
- Lung pathologists are not associated with neck masses - Funnel Chest - Pigeon Chest
- Procedure: - Person's breastbone is sunken - The sternum is displaced
o Order an ultrasound into his or her chest. anteriorly, increasing the AP
o Needle biopsy: discharge is cottage-cheese/ whitish/ matcha - Interfere with the function of diameter.
Due to caseous necrosis the heart and lungs such as - The costal cartilages adjacent
- CT Scan only used for non-resectable lesion diastolic dysfunction, murmur to the protruding sternum are
depressed.

AUSCULTATION + PERCUSSION
Dull, with voice transmission – (+) SOLID
o Consolidation, Tumor, COVID cases
o Do CT Scan
Dull, without voice transmission – (+) FLUID “Which of the
o (+) Blood, Pus, Effusion following will be the
o Do Thoracentesis possible content
Dull, no breath sounds when this ____ is the
LYMPHOMA o Hemothorax, Pleural effusion physical examination
- Black or maitim yung lymph node = Lymphoma finding?”

Did you know why right side

of the chest is a little bigger
than the left? “Right handed
kasi sila mostly.” -Doc

[PICTURE ABOVE: Left – Hemothorax, Thoracostomy;

Right – Pleural Effusion, Thoracentesis;
Both are breast cancer patient]

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 RIGHT PICTURE: Gynecomastia
RIGHT PICTURE: - Symmetric enlargement
- Tympanitic + NO breath sound - Breast enlargement in male due
- Radiolucent – less dense, to estrogen accumulation
appear darker L side of the CXR - Most often associated with liver
- Opaque – right side of the CXR disease or cirrhosis (those who
appears white are alcoholic)
- Right displacement of the heart - Treatment: Stop drinking
(Retrosternal area) & trachea alcohol, liver remedies (estrogen
(presented with DOB) will decrease), Surgeries are for
- Crowding in the R light cosmetic purposes, LIVER TRANSPLANT
- (+) pressure on the left side = Tension Pneumothorax
RIGHT PICTURE: Accessory Breast
Tension pneumothorax must be treated as a medical emergency. If the - Enlargement of fat in axilla with rudimentary nipple
tension in the pleural space is not relieved, the patient is likely to die - But with or without nipple, it is gynecomastia
from inadequate cardiac output or marked hypoxemia. - Responds to the menstrual cycle or breastfeeding ( gets bigger / smaller )
- Accessory nipples (1 out of 5 women have this)
A large-bore needle should be inserted into the pleural space through
the second anterior intercostal space. If large amounts of gas escape
from the needle after insertion, the diagnosis is confirmed. The needle
should be left in place until a thoracostomy tube can be inserted.

Reference: Harrison’s Principle of Internal Medicine 20th Ed.

BECK’S TRIAD
- A collection of three clinical signs associated
with pericardial tamponade which is due to an
excessive accumulation of fluid within the
pericardial sac.
- Pericardial effusion FROM OTHER TRANSES
- Three principal features are: FIBROADENOMA
o Hypotension - Also painless
o Muffled heart sounds - Movable
o Neck vein engorgement/ Jugular - Size is not affected by
venous distention with a prominent x menstruation
(early systolic) descent but an absent y (early diastolic) - Progressive growth
descent. - Common age: 16-25 years old
- Could be due to Pericarditis/ trauma
BREAST CYST VS. FIBROADENOMA
BREAST - A breast cyst is not cancer, it is an
Examining the patient in lying supine position encapsulated structure that
- With an outstretched arm, female breast is best examined on the contains fluid/semi-fluid
first day after menstruation. substances.
o Example: You had your menstruation from Feb 1 to Feb 5 then - Combination of cyst and solid
Feb 6 is the first day after your first menstruation. nodule (COMPLEX CYST)– this is
- Using palmar side of your forefingers (dapat daw dikit-dikit ang what needs to be operated.
fingers), first sweep below the breast and then above Because 1 out of 3 can become
cancer.

fld is black
cystwllamansa
IOOB

bldin nipple
RIGHT PICTURE: Breast cancer
- Breast mass, asymmetry
- Edema of the skin is produced by
lymphatic blockade. It appears as
thickened skin with enlarged pores—
the so-called peau d’orange (orange
peel) sign. It is often seen first in the
lower portion of the breast or areola
- Bloody discharge in the nipple
:[ a
LEFT TO RIGHT PICTURE: Hypoechoic Fibroadenoma, Anechoic,
Complex Cyst
Fibroadenoma – excised if more than 1cm
Breast cyst – not excised even if it is big. Do aspiration.
Complex cyst – must be excised. It is complex because it has both solid
and liquid

FROM OTHER TRANSES: ABDOMEN

non -

healing sarcoma Of
Inspection
wound > LWKS Pectoralis o Globular vs Scaphoid
t major Palpation
squamous
cell ca
o For Pain
o For Masses
o Fluid Wave
Percussion
Left picture: Breast non-healing wound = cancer Auscultation
Right picture: Stage 3 Breast Cancer o For Bowel Sounds

6
 in
colon )
Non prandial ( b4 eating ) → 6- It sounds / min 16-11
-
.

Hyperactive Bs → > 11 pelriumbilical → Obstruction

Hypo active BS → < 6 inflammatory l diverticulitis , etc , prolonged obstruction )
INSPECTION
- Triad of intestinal obstruction:
o I Either distended / collapsed
o 2 Vomiting
Take note the characteristic of the vomitus
Q o 3 Constipation
Normal bowel movement: 3x a day / once after 3 days
Diarrhea – more than 3x a day
Constipation – once every 4 days
Obstipation – complete obstructed bowel
- Both are obstructed
o Could be due to: Cancer / Ulcer in Pylorus, Cancer in
Duodenum
Wala na Kaka PASOK
na air / food Kaya
GLOBULAR SCAPHOID scaphoid Patient is complaining of RLQ pain, what most likely the diagnosis?

TIPS / MUST KNOW

For masses, better to use quadrants
For abdominal pain, use regions
o If due to GI sources, pain ALWAYS start from
Epigastric/ Umbilical/ Hypogastric
Nerve supply: Vagus nerve = Vague pain”
Rectal Cancer Obstructing Esophageal Cancer Order at least an ULTRASOUND kapag may abdominal pain, wag
Large Bowel Obstruction Esophageal Obstruction mo lang basta pauwiin.
(+) Prominent distention (+) Collapsed sikmura
Vomitus would look like the Epigastric pain is due to one of Esophagus, stomach, proximal
Cancer – usually present with chewed food (same color because the derivatives of the FOREGUT duodenum, the liver, the
progressive difficulty in no contact yet in the bile, no foul – supplied by Celiac artery pancreas, and spleen
swallowing (solid lugaw smell because it hasn’t reached Distal duodenum, jejunum,
Umbilical pain due to MIDGUT
saliva) the duodenum) ileum, cecum, appendix,
derivatives – supplied by
ascending colon, and proximal
Superior Mesenteric Artery
2/3 of transverse colon
POSSIBLE EXAM QUESTIONS
If he vomited 1-2 hours after eating and the vomitus is sour and appears Hypogastric pain due to Distal 1/3 of the transverse
partially digested food, where is the obstruction? HINDGUT derivatives – colon, descending colon,
supplied by Inferior Mesenteric sigmoid colon and the upper
Answer: Esophageal
Artery anal canal
If the vomiting occurred 6-8 hours after eating, the vomitus appeared ① Where did pain
green and already a digested food, where is the obstruction? start ? Incessant vomiting “Parang wala ng masuka” = Pancreatitis’
Answer: Small Intestine (Kasi green yung vomit) unique characteristic
② character
of pain?
If the vomitus appears brown and smells like shit, where is the TAKE NOTE OF THE SEQUENCE OF THE SYMPTOMS:
obstruction? Hepatitis has a flu-like symptom (1-2 weeks fever pain
Answer: Large Intestine turns yellow)
Fever for 2 weeks pain = ONLY MEDICAL PROCEDURE
If there is a ruptured appendicitis, what would be the color of o Typhoid Ileitis (Umbilical pain, localizing in RLQ)
the vomitus? o Diverticulitis
Answer: Green (closer to small intestine; near junction of Pain Fever = Needs SURGERICAL PROCEDURE
cecum & ileum) o Classic appendicitis

MUST KNOW ABDOMINAL SIGNS (EPONYMS)

When inspiring iaray !
"

Basic Rule in Surgery: Murphy Sign

Perforators do not bleed (Example: Ruptured Appendicitis) o Inspiratory arrest while palpating
o (+) Murphy sign in the right subcostal area =
Bleeders do not perforate.
Cholecystitis – epigastric pain aggravated by
eating
PALPATION Liver abscess
FLUID WAVE o Gallstone and no thickening: you won’t be able to elicit this
- Ascites / (+) Free fluid in peritoneal cavity (-) Murphy Sign = Cholelithiasis
o Commonly seen in patient with Leptospirosis McBurney Sign
- When one side of the abdomen is pressed, the other side moves as o Referred pain in the epigastrium when pressure is applied
well due to transfer of fluid in it. o In the right lower quadrant (Appendicitis)
- In male commonly due to liver cirrhosis; while in female o In women with PCOS, ectopic pregnancy, pelvic
commonly due to ovarian cancer inflammatory disease

TIPS
When doing the palpation, don’t start in the area that has pain.

CT Scan & Laparoscopy – diagnostic tools

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 Rovsing Sign INGUINAL AREA & GENITALIA
o Pain felt in the right lower abdomen upon palpation of the left INGUINAL EXAMINATION FOR HERNIA
side of the abdomen.
o Press on left side, gas in colon will go to the right, cecum will
Q distend and will elicit pain in appendix.
o Area with pain will be the one to be examined LAST as to not
taint the examination.
Dunphy Sign
o When you cough and then there is pain in the area with
peritonitis, in RLQ, appendicitis.
Blumberg Sign
o Rebound tenderness [PICTURE ABOVE FROM L R: Indirect Inguinal Hernia, Direct Inguinal
Psoas Sign Hernia, Femoral Hernia]
o Happens if the appendix is retrocecal HERNIA – a hernia occurs when an internal organ or other body part
Cullen Sign protrudes through the wall of muscle or tissue that normally contains it;
o Bleeding in the periumbilical area, in the pelvis (ectopic reducible inguinal mass.
pregnancy), in male (pancreatic, liver cancer) Indirect Inguinal Hernia – caused by a persistent opening that does
o Bleeding in retroperitoneol especially for hemorrhagic
pancreatitis it will travel to falciform ligament and go to the
7M IF
:
[not close during fetal development; (+) scrotal enlargemet
Direct Inguinal Hernia – often caused by age-related stress and
bellybutton/”puson” weakened muscles in the inguinal canal; no scrotal enlargement (e.g.
Kehr Sign lifted HEAVY weights, “kapag iri ng iri”)
o Common for motorcycle/bike accident, pain is on the left Femoral Hernia – a bulge in the groin, upper thigh, or labia (common
7- Film
shoulder (referred pain) – Splenic injury DX : nil
in women)

TAKE NOTE: Indirect & Direct Inguinal Hernia – above the inguinal
[PICTURE ABOVE FROM L R: Murphy, Rovsing, Mcburney Signs] ligament; Femoral – below the inguinal ligament.

HYDROPS OF THE GALLBLADDER

- Characteristics we would see in ultrasound:
o Distended gallbladder, Normal common bile duct
o Gallstone in cystic duct impact externally the common
hepatic duct kaya magiging distended
- Murphy Sign
- It makes up the colorless “white bile” (clear and watery content)
- MIRIZZI SYNDROME 1- Dilated hepatic duct
o Jaundice without Common Bile Duct dilatation impinging externally
W/ vascular
On hepatic duct ?
compromise
[PICTURE ABOVE: Incarcerated or Strangulated Inguinal Hernia]
**Incarcerated – means irreducible, should be operated ASAP within 6hrs
nung pagviolet niya; vascular compromised
no vascular compromise

POSSIBLE EXAM QUESTIONS

What are the signs of vascularity?
Change of color (Black Pinkish)
Pulsation
Peristalsis

JAUNDICE
-

- Urine of the patient is also yellow.

- Progressive Jaundice = Cancer (Pancreatic Cancer)

[PICTURE ABOVE: Incarcerated Incisional Hernia s/p open AP – this

patient had an appendectomy before, bumuka yung hiwa ng
appendectomy due to obesity.]

Grey -
aeolic stool

8
 brown
pink
ANAL EXTREMITIES
EXTERNAL VS INTERNAL HEMORRHOIDS
- If the color is pinkish it is ARTERIAL INSUFFICIENCY VENOUS INSUFFICIENCY
INTERNAL because it is the
mucosa, but if the color is
brown, it is EXTERNAL
hemorrhoid, because it is
the perianal skin.
- Bleeding: common for
internal hemorrhoids,
engorgements may bleed (bright-red, arterialized blood), while
external hemorrhoids rarely bleed because there is a blood clot. Pale skin Swollen
- *Vertical yung hiwa – different from prolapse. o (+) Raynaud’s phenomenon Ankle area commonly
– decrease of blood flow affected because this has the
Most common predisposing factor for women: PREGNANCY Thin/ Shrunken legs LEAST blood supply in our
- To avoid having hemorroids, tell the patient to lie/sleep on the Pale/ necrotic black toenails body
left side Cool to touch
Most common predisposing factor for men: PROLONGED SITTING IN
TOILET BOWL lgamer lol )

GRADING FOR INTERNAL HEMORROIDS

Grade 1 Bleeding only (arterialized blood), no mass felt ( no lawit ) ; no surg

/
.

meds ; Grade 2 Bleeding, with mass but when the person stands up the
no surg .
mass goes back (spontaneous reduction)
Grade 3 Bleeding, with mass and needs to be pushed back (manual
reduction)
Grade 4 Bleeding, with mass but even when you push back, it does
not go back anymore, (violet in color)
*Grade 3 and 4 – Surgery

Rectal Prolapse – if circles are the one that hangs

out.
Hemorrhoids – if the furrows are vertical

Differential diagnosis for anal pain (and for

surgery): can't tolerate DRE
Q Hemorrhoids cgrade 4 internal )
Fistula canal fissure )
Perianal abscess

FISTULA-IN-ANO
[PICTURE ABOVE FROM Bates’ Guide To Physical Examination 12th Ed.]

CLINICAL CORRELATION
BUEGER’S DISEASE
- Also known as Thromboangiitis obliterans
- An inflammatory occlusive vascular disorder involving small and
1° opening
medium-size arteries and veins in the distal upper and lower
extremities
- Although the cause of the disease is not known, there is a
20 opening
definite relationship to cigarette smoking in patients with this
- Abnormal communication between rectum and the perianal skin. disorder.
- May nana.
- Usually occurs to those who sit for a long time (bank tellers, medical The clinical features of Bueger’s disease often include a TRIAD of:
students, taxi or cab drivers, call center agents etc.) and also for those I Claudication of the affected extremity

with poor hygiene. 2 Raynaud’s phenomenon,

- Treatment: Fistulotomy 3 Migratory superficial vein

thrombophlebitis

NECROTIZING FASCIITIS Claudication usually is confined to the calves

- This may happen if Fistula-in-Ano is and feet or the forearms and hands because
neglected. this disorder primarily affects distal vessels.
- Discharge is ultra-foul swelling.
o Clostridium, anaerobic In the presence of severe digital ischemia,
infection trophic nail changes, painful ulcerations, and
- Fournier’s Gangrene gangrene may develop at the tips of the fingers
- Scrotal skin should be removed. or toes.
Pus :
buhangin , mail.im , RIGHT PICTURE: 22 years old, (+) ischemic pain “pinupulikat yung pain”,
bad smell
Anaerobe → clostridia usually husband smokes in the same room when they are together

Reference: Harrison’s Principle of Internal Medicine 20th Ed.