SURGERY B – Physical Examination of Surgical Patient

Doc Acuna
(PRELIMS)

OBJECTIVES Lipoma
By region
• Skin • Single cell
• Head • Defect in lipolysis
• Neck • Skin glides over the mass
• Chest
• Breast From doc:
• Abdomen • Eto ung most common na nakikita sa clinic
• Inguinal area and genitalia • It is the largest single pathologic cell in the body (single
• Anal largest normal cell in the body= ovum)
Pathology • Single cell: that very big mass is just ONE CELL
• Congenital
• Ang problem dito is that yung fat nakakapasok sa
• Tumors
adipose tissue tapos hindi sya nakakalabas so it doesn’t
o Benign
o Malignant participate in lipolysis and gluconeogenesis kaya sya
• Inflammatory diseases naipon and lumalaki din
• Skin glides over the mass: It is a defect in the
subcutaneous tissue; you can pinch the skin over the
SKIN mass
• Mass moves with skin • Liposuction is a valid option for removal
o Epidermal cysts • Usually seen in adults but also has rare cases in infants
o Skin malignancy (congenital lipoma)

• Skin glides over the mass

o Lipomas
o Soft tissue tumors
o Bone tumors
From doc:
• Madali sa skin masses para malaman if ito ba ay galing
sa skin o sa structures underneath the skin (ex: fats,
bones, muscles).
• If you can move the skin over the mass, it is NOT a skin
appendage tumor. Ibig sabihin hindi sya galing sa skin
Epidermal Cyst
• Punctum
• Slowly growing mass
• Sudden enlargement and pain=Infection
From doc:
• Most common benign skin tumor
• Used to be “sebaceous cyst” “epidermal cyst” since it’s
not the sebaceous gland that’s involved
• Punctum: a central, dark comedone opening; makikita
mo na may maitim
• Slowly growing: Basically it is a blackhead tapos nagbara
yung production ng lining epithelium ay maiipon so palaki
sya nang palaki everyday
o Usually na tinitiris ng mga px na may
mabahong lumalabas
• Management: Antibiotics muna then excise after 2-3
days para lumiit na kaoonti
• Epidermal Cyst Excision, Midback
o 1st step- Elliptical incision, include the punctum
o If di mo sinami ung punctum & the mass should be
removed whole, the cyst will just recur
Neurofibroma
• Single or multiple masses
• Painless
• Genetic
• Precancerous
From doc:
• Painless pero lumalaki din kaya lang pag tumubo na sa
daliri di na nila maigagalaw young daliri
• Genetic: women are usually the carriers (fibroma gene)
& the males are affected
• Precancerous: it has to be excised and removed; lahat
na tutubo sa balat dapat tanggalin
Neurofibromatosis
• These patches are the precursors of neurofibromatosis-
“cafe au lait spots” (coffee with milk)
• During surgery: parang “sago” ang itsura
• Just like lipoma, this is not a skin tumor so the incision is
LINEAR hindi kailangan na elliptical
Tendon Cyst
• Indications for surgery
o Pain
o >2 cm
From doc:
• Sa litid yan doon ang most common
• When tendon and tendon sheaths are subjected to work
or irritation
• CYST: any encapsulated with a fluid or semi-fluid
substance & kabaliktaran nya is “solid nodule”
• Old treatment: aspirate- pero intact pa din dito ang
capsule
• As long as the capsule is still intact, it will recur.

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SURGERY B – Physical Examination of Surgical Patient
Doc Acuna
(PRELIMS)

• Pain: this is the area of the ulnar nerve so it has to be • Cellulitis

removed kahit na maliit lang na may pain na or malaki >2 o Cellulitis = Streptococcus cellulitis
cm otherwise medical lang ang treatment (massage the ▪ Ung 7 groups of antibiotics, any of
area) those ay may effect so kahit alin
• At risk: doon gagaling ung patient
o Gamers o Medical yan hindi ito inoopera
o Call center agents • Carbuncle
o Bank tellers o Most severe
o Usually found in the back and nape (doon sa
makakapal na skin)
o This CANNOT be treated with incision &
Keloids drainage since it is a very big cavity of necrosis
inside and they are usually all interconnected
• Beyond the wound margins
so binibiak sya na malaki (lahat nung nakikita
• Medical
na discolored ay tatanggalin) & you let it heal
• Avoid surgery
via Secondary intention
From doc:
• Collagen type I- has a disarray of collagen.
• Dapat may orientation ang hiwa para di sya mag scar Non-Melanoma Skin Cancers
• Hypertrophic Scar
• Kasi mali ung orientation nung hiwa kasi dapat • Basal Cell Carcinoma
PERPENDICULAR to the muscle • Squamous Cell Carcinoma
• Normal scar is flat; hypertrophic pag elevated ng konti; in
keloids the collagen will go beyond the line of incision. From doc:
• 2 kinds of skin cancers: Melanoma (colored) & Non-
• Those that are of Mediterrenean descent (mga Kastilain) Melanoma (non-colored lesion)
& American-Black are prone to keloids; it is genetic so • Basal Cell Carcinoma
namamana sya o The most common & is pinaka mabait din
Keloids o It only needs MINOR surgery with an ellipse
• Surgery- you connect the deltoid to the other deltoid, the incision (korteng itlog na hiwa)
front and back o NO chemotherapy & radiotherapy
• You do NOT operate on keloids; the more you operate o You will notice that the edges are elevated &
on keloids, the larger they become waxy (waxy edges); parang pearly waxy
• Old treatment for keloids- steroids • Squamous Cell Carcinoma
• Ultimate treatment- pressure (apply pressure, any o It needs surgery
means) o Sometimes chemotherapy but often
• Modern treatment- Calcium channel blockers radiotherapy
o According to research, ang problem pala sa o Treatment - madalas ay surgery followed by
keloids ay excessive calcium influx bale ung radiation & then occasionally chemotherapy
collagen kumukuha syang madaming calcium (eto ung malaking difference nya from Basal
o Keloids are assoc with calcium supplements Cell Carcinoma)
so the more calcium that you take in you are
more prone to keloids
Melanoma

Skin Infections • Asymmetrical mass

• Borders are irregular
• Abscess • Color variegation
• Cellulitis • Diameter >6 mm
• Carbuncle • Elevation

From doc:
From doc:
• Abscess is fluctuant (pag hinawakan mo parang may
tubig na laman sa loob) • Usually, but NOT ALWAYS, start from moles
o Abscess = aureus (Staphylococcus aureus) • If you have a mole with the following characteristics,
• Incision & drainage: make a wide enough incision -> let have them biopsied
all of the pus come out (it should be drained out) • ABCDE- these are the moles that are prone to develop
o HUWAG/BAWAL nyong pigain ang abscess melanoma
because the area is inflamed at naka open
ung pores ng blood vessels so pede sya
pumunta sa loob ng katawan ng patient

• Cellulitis Page 2 of 9
o Cellulitis = Streptococcus cellulitis
▪ Ung 7 groups of antibiotics, any of
those ay may effect so kahit alin
doon gagaling ung patient
o Medical yan hindi ito inoopera
 SURGERY B – Physical Examination of Surgical Patient
Doc Acuna
(PRELIMS)

A – asymmetrical mass o Lung cancer

B – borders are irregular
C – color variegation Pag may bukol sa ulo, and the skin moves over the mass, then it’s
D – diameter > 6 mm probably the bone that’s involved. It can either be an osteoma, or
E – elevation metastasis.

Thyroid and lung cancer are the most common cancers that are known
If you have more than 1 color in a for metastasis to the skull. But if metastasis to bone in general,
mole, that’s a suspicious mole. prostate cancer and breast cancer are included.
Elevation is a bad sign, meaning it’s This was doctor’s patient.
disseminating.

Bleeding is not included

EXERCISE! Identify:

Upon examination, there was thickening of the outer table of skull, skin
glides over the mass, and was thought to be benign. Initial impression
was osteoma.

During surgery, doc cannot remove the mass, and it turned out to be
bone metastasis from thyroid cancer.

Thyroid turned out to have small nodules.

This is a mole with multiple colors, irregular borders, diameter > 6 mm,
and with elevations, so it’s a Melanoma
Treatment: surgery, chemotherapy, occasionally radiation

Q: What type of thyroid cancer is most commonly involved in bone

metastasis?
Answer: Follicular type

NECK
Location
Borders are elevated, with a necrotic center = Basal Cell Carcinoma • Midline
Treatment: surgery alone o Thyroglossal duct cyst vs. goiter
• Lateral
o Over the sternocleidomastoid
▪ Branchial cleft cysts (types I to III)
o Under the sternocleidomastoid
▪ Lymph nodes
▪ Level of nodes determines the primary site
o Posterior to the sternocleidomastoid
▪ Lymph nodes
▪ Lymphangioma

In the neck, location is the most important for diagnosis.

Squamous Cell Carcinoma
Treatment: surgery and radiation, occasionally chemotherapy At the exact midline:
If it’s above the thyroid cartilage = thyroglossal duct cyst
* Sa exam doc will describe the lesion and identify. May kasamang If it’s below the thyroid cartilage = goiter
treatments pero konti lang
Over the SCM:
HEAD May mga butas sa ibabaw ng balat ng SCM, at may lumalabas na
• Skull Masses parang sipon, and may makakapa kang parang tracts that are going
• Osteoma towards the face = Branchial cleft cysts
o Bone tumor, or from trauma
o Benign If the skin is normal over SCM, and when you palpate
• Metastasis under the SCM, and the lymph nodes are enlarged, then it can be
o Thyroid cancer.

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 SURGERY B – Physical Examination of Surgical Patient
Doc Acuna
(PRELIMS)
Posterior to the SCM:
At the posterior triangle of the neck, it can be lymph nodes or
lymphangioma. Lymphangioma yung mga bukol na fluctuant na tubig
ang laman, which are benign (old name is cystic hygroma).
Neck Examination
• From behind
• Swallow
• Pulse rate
Stand behind the patient. Using the 2 hands, 3 fingers each, palpate for
the trachea. If you can feel the trachea, there is no goiter.
To examine the lymph nodes under the SCM, patient should look to the
side and scoop the SCM to put the fingers under the SCM.
Ask the patient to swallow. If the mass goes up, it’s goiter.
The normal pulse rate (since 2012) is 60-90 bpm. If more than 90,
tachycardia na. If the patient has goiter and tachycardia = toxic goiter
Tumors
• Thyroglossal duct cyst (TGDC)
• Goiter
• Branchial cleft cyst
If the mass is above the cricoid cartilage = thyroglossal duct cyst
To confirm, ask the patient to pull out the tongue. The mass should go
up.
Why is the thyroid gland at the midline? The anlage of the thyroid gland
is from the base of the tongue and will descend on top of the cricoid,
and will end at tracheal rings 2,3, & 4.
If only one side of the thyroid gland enlarges = nodular goiter
If both sides are enlarged = diffuse goiter
Branchial Cleft Cyst Types
Type I = if you push the mass over the SCM towards the ear, may
sipon na lalabas sa external auditory meatus
Type II = the primary opening is at the tonsillar pillars
Type III = at the base of SCM, cystic nodule over the SCM. It passes
through the bifurcation of the carotid arteries, and finally through the
vocal cords
Nodes
• Level 1 = Submandibular nodes
o Drains the face & anterior 2/3rds of the mouth
• Level 2 = Superior jugular nodes
o Drains the tonsils & oropharynx
• Level 3 = Middle jugular nodes
o Specific for thyroid cancer
• Level 4 = inferior jugular nodes
o Drain the larynx
• Level 5 = Posterior triangle nodes
o Drains the nasopharynx
• Level 6 = Anterior triangle nodes
o Drains nonspecific structures
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 2/3rds 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.
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 SURGERY B – Physical Examination of Surgical Patient
Doc Acuna
(PRELIMS)

Levels 1-4 will not drain to level 5, but to the superior mediastinum Parotid Tumor
(level 7).
Levels 4-6 will drain to the superior mediastinum (level 7).

Thyroglossal Duct Cyst

Branchial Cleft Cyst

• Kasama ang cricoid pag inopera

• The body of cricoid should go with the specimen otherwise
there will be recurrence

Goiter • Mistaken as epidermal cyst because of parang punctum

• Presence of mucoid substance

Cervical Nodes

• When something elevates in the neck it’s either trachea or

thyroid only
• Thyroid cancer is pinaka mabait na cancer because it rarely
• 80% of of lymph nodes in the neck of Filipinos is tuberculous
metastasize and is known for very slow growth
in origin (no correlation with chest TB)
• Lung pathologists are not associated with neck masses
Nodular Goiter • Needle biopsy: discharge is parang chalk or matcha yung
color

Lymphoma

• Diffuse Toxic Goiter

• Tx: medical only (NO surgery)

Diffuse Toxic Goiter • Black or maitim yung lymph node = Lymphoma

CHEST
• Bony deformities
• Symmetrical expansion
• Percussion
o Dull
• Auscultation
o No breath sounds
Nasopharyngeal cancer
o Transmission of spoken voice
o Ancillary CT scan or ultrasound
• Beck’s Triad
• Percussion + Auscultation
• Dull plus no breath sounds = Fluid (blood, Pus, Effusion) in the
lungs
• Dull with voice transmission = solid/consolidation (pneumonia
or cancer) → perform CT scan
• Ultrasound is used for fluid in the lungs. If air → DO NOT
• Check LN level 5
perform ultrasound
• Tx: Chemotherapy (secondary) and Radiotherapy (mostly)

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 SURGERY B – Physical Examination of Surgical Patient
Doc Acuna
(PRELIMS)

Chest Deformity
Breast cancer (stage 3)
Pectus Excavatum
• Anaesthesiologist might complain of
difficulty in bagging & ventilation
• Notice also that the heart cannot
pump as well because of restriction
Pectus Carinatum
• Like chicken breast
• Easier ventilation
• Non healing wound, painless

Breast non-healing wound = Cancer

• Most common mass in women 16-25 years old

Beck’s Triad Fibroadenoma

1. Neck vein engorgement - hindi
• Painless, movable
maka fill up yung lungs leading to
• Size not affected by menstruation
venous congestion
2. Muffle heart sounds – heart cannot • Progressive growth
expand because of fluid in • Excision if more than 1cm
pericardium
3. Hypotension Breast Examination
That would be a sign of pericardial effusion • In women dapat naka outstretch yung arm
(idk what di nya niliwanag bruh) • Best day to examine: first day after menses
• Watch the vid if you want to practice ;) (1:02:00)
Fibroadenoma Breast Cyst
Breast mass + Asymmetry • Ultrasound: Hypoechoic • Not anymore a lesion
• Cyst – an encapsulated
• Painless structure containing fluid or
• If you look closely there’s blood in the nipple semifluid substance
• NOT a cancer
• Ultrasound: Anechoic

Cyst + Solid nodule → Complex cyst → perform surgery

ABDOMEN
Gynecomastia • Inspect
o Globular vs Scaphoid
o The bigger the abdomen the lower the source of the
obstruction
o Globular- Large Bowel Obstruction due to Rectal
Cancer
o Scaphoid
‘ ▪ Obstructing Esophageal Cancer
▪ Natural walang air and food nakakarating sa taas
• Males have very little amount of estrogen in the body. (may bara / obstruction) so everything below the
Estrogen is excreted in the liver pag di na excrete it will
esophagus will be collapsed.
accumulate leading to enlargement of male breast
▪ Lalagyan ng gastrotomy for food
• Tx: replace liver daw

Accessory breast

• Palpation for mass

o For pain
o For masses
• Responds to the menstrual cycle or breastfeeding o Fluid wave (or Ascites) - That will not happen if walang
• if it’s hormonally responsive it is accessory breast (with or tubig sa Tiyan
without nipple)

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SURGERY B – Physical Examination of Surgical Patient
Doc Acuna
(PRELIMS)
o Easier to relate it if you separate them in quadrants or
region
o Study the abdominal mass for pain using the quadrants
or region
o 9 regions or quadrants
Abdominal Signs (Eponyms)
• Murphy’s sign
o Respiratory arrest on the subcostal area during deep
breathing
• McBurney Sign
o Deep tenderness at McBurney’s point - sign of acute
appendicitis
• Rovsing Sign
o if you press on the left there will be pain on the right.
• Dunphy sign
o Increased abdominal pain with coughing. May be an
indicator of appendicitis
o Ask the patient to cough. Pag umubo siya sumasakit
yung tiyan wherever it is.
• Blumberg sign
o Dinidiinan mo tapos masakit that is direct tenderness but
if you release it then sumakit that is blumberg sign also
known as Rebound tenderness
o *Blumberg and Dunphy sign are both signs of peritonits
• Psoas Sign
o Kinakabit ng psoas muscle yung thigh to the spine. Any
movement sa thigh at may naka Patong na inflammed sa
psoas sasakit yung psoas muscle.
o Most of the time it will be the inflammed appendix
o When you move your thigh or flex your thigh sumasakit
yung psoas
• Cullen Sign
o “U” = umbilical area ; pag may dugo sa pusod that means
there is blood inside the abdomen ( if female: possible
ectopic pregnancy ; male = possible liver or pancreatic
cancer)
• Kehr sign
o “Kaliwa / left” - Left shoulder pain may kasabay na left
upper quadrant pain radiating to the leftshoulder is called
kehr sign.
o Sign of splenic injury, splenic rupture, splenic hematoma
o e.g cyclist who experienced trauma on the left side
o Ask for CT scan or ultrasound
• Palpation
o Murphy sign
▪ Palpating on the subcostal area and ask the patient
to inhale deeply and there will be respiratory arrest
- sumasakit sa cholecystitis and not on
cholelithiasis (if presence of stones and not
inflammed it will not hurt - sasakit lang if namamaga
yung gallbladder sometimes also in liver abscess )
o Rovsing sign
▪ if you press on the left there will be pain on the right.
Kapag pinalpate mo sa kaliwa yung gas doon sa
loob ng colon pupunta sa kanan ; pupunta sa
appendix area
▪ If you PE the abdomen especially in children ang
huli Mong I-PE yung painful sign. Kasi pag inuna
mo yung painful side lahat na ng ipalpate mo
masakit. So the PE will be useless.
o McBurney Sign
▪ Acute and obviously for appendicitis
▪ If this is a woman the diagnosis will be ectopic
pregnancy, ovarian cyst rupture or appendicitis
▪ But for males we know that there are no other organ
in that area it is Appendicitis
• Percussion
• Auscultate
o For bowel sounds – the patient should not take meal
before auscultation
▪ Place stet in periumbilical area → auscultate small
bowels
▪ Normal bowel sounds: 6-11 per minute
▪ <6 : hypoactive
▪ >11 : hyperactive (gastroenteritis)
▪ If you auscultate area of stomach and colon = <6
per minute
Acute Appendicitis
• Usual age for acute appendicitis is 11-
30 years old
• if less than the age bracket usually it is
not appendicitis
• e.g. <10y/o at same complaints.
Periumbilical, masakit ang pusod
masakit sa right lower quadrant pero
less than 10 y/o most likely it is
Meckel’s diverticulitis / diverticulum.
• But if less than 1y/o pwedeng
intussusception with same complaints
Cholecystitis
• Epigastric pain aggravated by eating
• Murphy Sign
Hydrops of the Gallbladder
• Ang laman ng gallbladder instead na kulay bile, kulay tubig na
and that is actually mucin. It is called hydrops of gallbladder
because before the fluid is mistaken as water that is why it is
called hydrops of the gallbladder.
• GB palpable beyond the subcostal margin (normally it is not
palpable)
• (+)Murphy sign
Page 7 of 9
 SURGERY B – Physical Examination of Surgical Patient
Doc Acuna
(PRELIMS)

• Mirizzi syndrome (important board exam question and will be

given on our exam)
o Jaundice without CBD dilation
• When the stone is impacted in the cystic duct, there will be
external compression on the common hepatic duct and the
cbd will seem to be small or normal. The patient is yellowish
but on ultrasound, yes there are stones present at the cystic
duct but the CBD is normal.

Incarcerated or Strangulated Inguinal Hernia

• Violaceous large scrotum - umabot sa scrotum so it is Indirect
Inguinal Hernia
• Naipit ang bituka
• Emergency Operation - open hernia sack and ligaments tapos
makakahinga yan. Notice na hawak yung bowels kasi Baka
Q: Why is the patient yellow? pumasok ulit sa loob kasi naluwagan na. Look for signs of life
A: Due to Mirizzi Syndrome - it will turn to pink if it is without vascular compromise but if it
is strangulated with vascular compromise it will not turn to
pink
Jaundice
• Yellow eyes and skin
• How does jaundice present?
o Earliest presentation of jaundice will be seen at the
frenulum of the tongue (yellow color) of children
o Usually physiologic jaundice occurs for 1 week - so after
1 wk the child is already yellow but it will disappear after
1 week
o Mild - Frenulum only is yellow
o Moderate - frenulum of tongue up to eyes are yellow Incarcerated incisional Hernia s/p open Appendectomy
o Severe - entire skin and body are yellow
• Urine usually is as yellow as the yellow discoloration of the
eyes of patient with jaundice (urine has tinge of green-orange)

Incarcerated incisional Hernia s/p open Appendectomy

Inguinal Examination for Hernias
• You must be able to differentiate hernia prior to surgery but
intra op there will be no problem.
• All of these three types of hernia will need surgery
• Requirement for hernia is Reducible Inguinal Mass NOT
scrotal enlargement
• kailangan lumalaki yung singit and reducible (pag humihiga
nawawala yung bukol - that is a classic reducible inguinal
bulge)
1. Indirect Inguinal Hernia
• Younger patient - inborn (with bukol in singit)
• Scrotal enlargement
2. Direct inguinal Hernia
• usually in elderly ; it does not happen in younger population
because the fascia is strong and intact
• scrotal enlargement does not occur. There is no way that the
sack of direct inguinal hernia will reach the scrotum
3. Femoral hernia
• woman with subinguinal - ilalim ng subinguinal ligament ang
ang bukol
o Femoral triangle is under the inguinal ligament
• Lumalaki tiayn, sumusuka, no DM = obstruction
• The number one predisposing factor for hemorrhoids with
women is Pregnancy. Nakadagan yung matress sa
hemorrhoidal veins galing sa pwet.
• With Males - prolonged sitting in the toilet bowl
• External hemorrhoids
o Brown
o Seldomly operated on since it has presence of clotted
blood only.
o Sometimes local anesthesia is given and we just slice to
remove the blood clot I
• Internal Hemorrhoids
o Pink
o Grade 1 - bleeding only pure red areterialized blood ; No
mass felt
o Grade 2 - Mass is felt but when standing it disappears -
also called as spontaneous reduction - no operation
needed
o Grade 3 - Mass is felt but you have to push it inside to
disappear - also called as manual reduction - Operation
is done
o Grade 4 - Mass is felt, violet in color and even if you try
to push it back inside it will not return - operation is done
o *Grade 3 and 4 are the only ones subjected to surgery

Page 8 of 9
 SURGERY B – Physical Examination of Surgical Patient
Doc Acuna
(PRELIMS)

Hemorrhoid vs Rectal Prolapse

• Rectal Prolapse
o Pag ang lumawit puro circles
• Hemorrhoid
o If the furrose is vertical

Perianal Abscess
• Victims are usually people who sits for a very long time (seat
heats up and with poor hygiene possiblity of pus formation)
o Medical students, call center agents, bank tellers,
taxi drivers
Fistula-in-Ano
• There should no communication between the rectum and the
perianal skin but since there is an abnormal communication
there is a fistula
• Pag hindi mo naipasok ng ganyan walang fistula yun. Dapat
may tract na ganyan. Surgeons will only break it apart and it
will heal by itself.

Necrotizing Fasciitis or Fournier’s Gangrene

• Complaint of wound in the scrotum
• Discharge is blackish and ultra foul smelling
• Caused by clostridium sp. anaerobic infection due to a
neglected fistula.

Exam - description of the lesion and what lesion it is

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