Physical signs

Symptom- what the patient feels

Physical sign- what the doctor finds at clinical
examination of the patient’s segments.

Symptom is subjective
Physical sign is objective
Clinical diagnosis = symptoms + signs
Final diagnosis= symptoms + signs +
lab.tests + investigations.
SURFACE LANDMARKS OF THE
HEAD
Nasion
External occipital protuberance
Vertex
Superior nuchal line
Mastoid process of the temporal bone
Zygomatic arch
Superficial temporal artery
Facial artery
Parotid duct
Surface landmarks
Sebaceous cysts

Swelling-cystic mass-cystic tumor-lump

Hairy parts of the body- scalp
The mouth of the seb. gland opens into the
hair follicle
If blocked mouth, seb. gland becomes
distended
Seb. Cyst

History- slow growing

Symptoms-a lump that gets scratched when
the patient is combing the hair
Such scratches may get infected
If the cyst becomes infected it enlarges
rapidly and becomes acutely painful
Seb. Cyst- examination-physical
signs
Position-hairy parts of the body
Color- the skin overlying the cyst normal unless it
is infected
Tenderness- not tender unless infected
Temperature-normal except when infected
Shape- spherical
Size- variable: mm-4-5 cm.
Surface- smooth
Edge-well defined
Composition- hard depending on the pressure in
the cust “cheesy material”
Sebaceous cyst of the scalp
Sebaceous cyst
Surgical treatment- excision
Intact sebaceous cyst-
specimen
Cut section- seb.cyst- “cheesy
material”-sebum
Lipoma-case report
A 59-year-old woman was admitted with a
10 years' history of a painless swelling at
the right thigh. The lesion became
ulcerative over the past few months with
mild pain.
She had no significant medical and
surgical history.
Examination revealed normal vital signs,
chest, heart, abdominal and rectal
examinations.
Lipoma
On local examination, a large mass
occupying the posterior aspect of the lower
two thirds of the right thigh was confirmed.
There was an ulcerative lesion at the
posteromedial aspect of the mass.
The right popliteal artery was difficult to
palpate, but the posterior tibial and
dorsalis pedis were normal.
There was no neuronal abnormality.
Lipoma- case report
Blood tests showed normal blood count,
liver function, urea and electrolytes as well
as ESR. She had a normal chest and
abdominal X-ray.
The X-ray of the right thigh showed a soft
tissue shadow and normal bone.
Surgical excision was performed and the
findings were consistent with a giant
lipoma.
The wound was closed easily as there was
redundant skin because of the size of the
Lipoma- case report
The patient had an uneventful recovery
and was discharged home with a very good
condition.

Histology of the specimen reported benign

lipoma.
Huge lipoma of the thigh
Ulcerated lipoma on the post-medial
thigh
Specimen- 3.2 Kg.
Lipoma
This is the external
surface of a lipoma, a
benign tumor of
adipocyte origin.
•The bright yellow
color is typical of fat.
•Note the lobulated
appearance. This is
also typical of this
lesion.
•This particular tumor
arose in the
subcutaneous fat (note
Case Report-lipoma

A 60 year old male presented in out patient

clinic with history of progressively increasing
swelling in right thigh, which he noticed 3½
years back. Swelling was otherwise
asymptomatic except that he had to wear
loose fitting trousers.
On examination, right thigh girth was grossly
increased as compared to the left thigh.
Lipoma

There were erythema ab agni over the medial

aspect of both thighs (as is usual in Kashmiri
people because of Kangri – “the fire pot”).

The swelling was firm, non-tender and free

from underlying structures.
Lipoma
CT scan of the right thigh was done which revealed a
hypodense mass in the posterior compartment of the thigh
beneath the hamstring muscles

Lipoma- case report
 FNAC of the swelling revealed mature fat cells, suggestive
of lipoma.

 The patient was operated on under general anaesthesia, in

prone position and the tumour was found beneath the
hamstring muscles and was dissected out easily because of
the pseudocapsule.
 Wound was closed in layers, leaving a suction drain inside
the cavity. Healing progressed uneventfully.
 Histopathological examination revealed features consistent
with lipoma. The tumour removed measured 21x17x14cm in
size and weighed 2,95 Kg.
Specimen.
Six months after surgery, the patient is symptom free and has
no signs of recurrence
Lipoma
 Lipoma is one of the commonest benign mesenchymal
tumour in the body composed of mature adipose cells.

 It is found in almost all the organs of the body where

normally fat exists that is why it is also known as ubiquitous
tumour or universal tumour.

 Most of the lipomas present as small subcutaneous

swellings without any specific symptom.
Lipoma
Giant lipomas, though rare, can present in thigh,
shoulder or trunk. Clinical features of these giant
lipomas are mainly because of their size which
includes pain because of stretching of adjacent
nerves,(restriction in movements of the part
involved or social embarrassment because of
mere size of the swelling).
Although definitive diagnosis of giant lipoma can
be made only by histopathological examination,
but once suspected, other investigations can
provide additional information about the tumour.
Lipoma
The characteristics of benign lipoms on
ultrasonography, CT and MRI have been
well established and even Tc99 DTPA scan
have been used to confirm the diagnosis.
Lipoma
 Surgery is the treatment of choice of these giant swellings
due to their tendency to recur and their potential hazard of
malignant transformation, other option for treatment of
these giant swelling is liposuction.
 The dissection of these lipomas is usually easy because of
continuous pressure on the surrounding tissue, a well
defined pseudocapsule is formed.
 Dead space created because of dissection of the giant
lipomas is usually drained with the help of a suction drain to
avoid collection.
 As already mentioned, these tumours have tendency to
recur and can have malignant transformation, therefore,
should be followed meticulously.
Lipoma
Hemangioma
 Benign skin lesion consisting of dense,
usually elevated masses of dilated blood
vessel.
 Benign neoplasm characterized by blood
vascular channels.
A cavernous hemangioma consists of large
vascular spaces.
 A capillary hemangioma consists of many
small blood vessels. A collection of dilated
small vessels, 3 types:
strawberry nevus,
port-wine stains,
Cavernous hemangioma
Hemangioma
 Congenital benign tumour made of blood vessels in the skin.
 Capillary hemangioma , an abnormal mass of capillaries on the
head, neck, or face, is pink to dark bluish-red and even with the
skin. Size and shape vary. It becomes less noticeable or disappears
with age.
 Immature hemangioma (hemangioma simplex, strawberry mark), a
reddish nub of dilated small blood vessels, enlarges in the first six
months and may become ulcerated but usually recedes after the
first year.
 Cavernous hemangioma, a rare, red-blue, raised mass of larger
blood vessels, can occur in skin or in mucous membranes, the
brain, or the viscera. Fully developed at birth, it is rarely
malignant. Hemangiomas can often be removed by cosmetic
surgery.
Strawberry nevus
Intradermal, subdermal collection of dilated
blood vessels
Congenital lesion- present at birth
Looks like a strawberry
Often regress spontaneously in months/years
after birth
Rubbed or knocked they may ulcerate and
bleed
Strawberry nevus
Physical examination
Position- any part of the body- head/neck>
Color- bright or dark red
Shape- protrude from the skin surface
Size- usually- 1-2 cm.
Surface-irregular
Consistence- soft, compressible not pulsatile
Relations- confined to the skin, freely mobile
over the deep tissues
Port-wine stain-extensive
intradermal hemangioma, mostly
venous
Cavernous hemangioma on the tongue
This angiogram (an X-ray taken after dye has
been injected into the blood stream) shows a
mass of blood vessels (hemangioma) in the
liver.
Meningocele

 Meningocele (MM):Protrusion of the membranes that

cover the spine and part of the spinal cord through a bone
defect in the vertebral column.
 MM is due to failure of closure during embryonic life of
bottom end of the neural tube.
 The term spina bifida refers specifically to the bony defect in
the vertebral column through which the meningeal
membrane and cord may protrude (spina bifida cystica) or
may not protrude so that the defect remains hidden,
covered by skin (spina bifida occulta).

 The risk of MM (and all neural tube defects) can be

decreased by the mother eating ample folic acid during
pregnancy.
A birth defect involving an abnormal opening in the spinal
bones (vertebrae) is called spina bifida. The spinal vertebrae
have not formed and joined normally, leaving an opening
A defect which also includes a small, moist sac (cyst) protruding
through the spinal defect, containing a portion of the spinal cord
membrane (meninges), spinal fluid, and a portion of spinal cord and
nerves is called a meningocele, myelomeningocele, or
meningomyelocele
Surgical treatment is needed to repair the defect and is usually done within 12
to 24 hours after birth to prevent infection, swelling, and further damage.
While the baby is deep asleep and pain-free (using general anesthesia), an
incision is made in the sac and some of the excess fluid is drained off. The spinal
cord is covered with the membranes (meninges) and the skin is closed over the
protruding meninges, spinal cord, and nerves.
The long-term result depends on the condition of the spinal cord and
nerves. Outcomes range from normal development to paralysis
(paraplegia).
Infants may require about 2 weeks in the hospital after surgery.
Physical signs in head injury
Examination of a case of recent
head injury
 The patient is unconscious
 Examine the scalp for a wound or local bruising or
hematoma
 Examine the nostrils and ears for evidence of blood
diluted with CSF
 Compare the size of the pupils and test their reaction to
light
 Make a general survey of the body for other injuries
 Search for paralysis
 Palpate and percuss the hypogastrium for evidence of an
overfull bladder
 Temperature, pulse rate, RR-charted every half-hour
Head injury
Radiographs of the skull should be taken at
the first opportunity compatible with safety

Brain injury is more likely in the presence of a

skull fracture BUT skull fracture of itself does
not indicate brain injury
COMA
Coma is a state of absolute unconsciousness
in which the patient does not respond to any
stimulus
Reflexes are absent, including the corneal and
swallowing reflexes.
Semi-coma- the patient responds only to
painful stimuli and reflexes are present
Head injury
The patient is conscious or semi-
conscious
Patient with skull fracture – hospital admission
Close observation: PR, BP, RR, pupil size and
reaction/ every ½ h.
Signs of neurological deterioration:
Falling pulse rate
Reduced respiratory rate
Falling GCS
Dilatation of pupils
Loss of light reaction or developing asymmetry
of pupils
Complications of traumatic brain
injury
Cranial bleeding
Cerebral hypoxia
Infection
Posttraumatic intracranial bleeding may be:
- extradural
- subdural
- intracerebral
CT of the brain documents the lesions
Local brain compression- focal neurological
effects
Types of skull fractures
Liniar fractures - involve the skull vault,
- overlying scalp bruising or
swelling

Depressed fractures - caused by blunt

injuries,
- the scalp is severely
bruised

Fractures of the base of the skull- anterior

fossa
Fracture of the anterior cranial
fossa

Periorbital hematoma
Subconjunctival hemorrhage
CSF running from the nose
Fracture of the middle cranial fossa

CSF running from the ear or blood escaping

from the ear
Bruising behind the ear over the mastoid area
Risk of facial paralysis or deafness
Fracture of the posterior cranial
fossa

Deep coma
Bruising on the posterior wall of the pharynx
SKULL FRACTURES
Linear skull fractures, the most common type
of skull fracture, occur in 69% of patients with
severe head injury. Usually caused by widely
distributed forces.
In rare cases, a linear fracture can develop and
lengthen as the brain swells, in what is called a
growing fracture.

Diastatic fractures are linear fractures that

cause the bones of the skull to separate at the
skull sutures in young children whose skull bones
have not yet fused. They are usually caused by
SKULL FRACTURES
 Comminuted skull fractures, those in which a bone is
shattered into many pieces, can result in bits of bone being
driven into the brain, lacerating it.

 Depressed skull fractures, a very serious type of trauma

occurring in 11% of severe head injuries, are comminuted
fractures in which broken bones are displaced inward.
 This type of fracture carries a high risk of increasing
pressure on the brain, crushing the delicate tissue. Complex
depressed fractures are those in which the dura mater is
torn. Depressed skull fractures may require surgery to lift
the bones off the brain if they are causing pressure on it.
 Basilar skull fracture
 Basilar skull fractures, breaks in bones at the base of the
skull, require more force to cause than cranial vault
fractures.

 Thus they are rare, occurring as the only fracture in only 4%

of severe head injury patients.

 Basilar fractures have characteristic signs: blood in the

sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking
from the nose or ears; raccoon eyes (bruising of the orbits
of the eyes that result from blood collecting there as it leaks
from the fracture site); and Battle's sign (caused when blood
collects behind the ears and causes bruising).
Depressed skull fracture
Subdural hematoma
Intracerebral hematoma
Liniar skull fractures
Epidural hematoma
Liniar skull fracture
TRAUMA

Leading cause of death and disability

Trauma care involves multidisciplinary team
Trauma care requires both speed and
accuracy
Identification of life threats and emergent
intervention may save life
TRAUMA

1. Prehospital care

2. Primary survey

3. Resuscitation

4. Secondary survey

PREHOSPITAL CARE
Prehospital providers are trained in:

Assessment of the injury scene

Stabilization of the injured patient

Monitoring and transport of critically ill patient

PREHOSPITAL CARE
Efficient method for reporting by the
prehospital providers to the trauma team:
M I V T
M= mechanism of injury
I= injury
V= vital signs
T= therapy
MECHANISM OF INJURY
CAN PREDICT TYPES OF INJURIES
FRONT-END COLLISION CAR: PATELLA
FRACTURE, POST. KNEE DISLOCATION,
POPLITEAL ARTERY INJURY, FR. OF THE POST.
RIM OF THE ACETABULUM
HIGHT FALLS WITH LANDING ON FEET: CALCIS
FR., LOWER EXTREMITIES FR., ACETABULAT FR.,
SPINE COMPRESSION FR.
PEDESTRIANS STRUCK BY VEHICLES: CALF FR.,
HEAD INJURY, UPPER EXTREMITY INJURIES
INJURY INVENTORY

A trapped patient- prolonged extrication:

Rabdomyolisis
Traumatic asphyxia
Hypothermia
VITAL SIGNS
LEVEL OF CONSCIOUSNESS- GLASGOW’S
COMA SCORE
STABLE / UNSTABLE HEMODINAMICALLY
RESPIRATION: CYANOSIS
GCS
Less than or equal to 8 at 6 h.- 50% die
Severe head injury 3 – 8
Moderate head injury 8-13
Mild head injury 14-15
False- hypothermia, intoxication, sedation
Impossible to evaluate- dysphasic, intubated
pts. and with facial or spinal cord injury
THERAPY
AIMED TO STABILIZING THE PATIENT:
- SPINE AND EXTREMITY STABILIZATION
- OXYGEN
- I.V. FLUIDS
- PREVENTION OF HEAT LOSS
INITIAL EVALUATION AND
PRIMARY SURVEY
HISTORY: A M P L E

PRIMARY SURVEY: A B C D E
AIRWAY

ASSURING THE INTEGRITY OF THE AIRWAY IS

THE HIGHEST PRIORITY IN THE TRAUMA CARE

LOSS OF AIRWAY FUNCTION- IRREVERSIBLE

BRAIN DAMAGE WITHIN MINUTES
AIRWAY
SUCTION
JAW-THRUST MANOEVER
GUEDEL PIPE
TRACHEAL INTUBATION
EMERGENT TRACHEOSTOMY
BREATHING
Once airway established- give O2
Auscultation in the axillae
Absence of BS- SIGNALS PT or HT
Chest motions
Position of the trachea
CXR
IMMEDIATE DECOMPRESSION- CHEST
DRAINAGE TUBE
CIRCULATION
Once airway and breathing secured-
assess circulation
BP, PR, SKIN PERFUSION- CAPILLARY
REFILL, MENTAL STATUS, URINE FLOW
The most common cause of shok in
trauma is hemorrhage:
 two venous lines
Obtain blood for cross-matching, FBC, ABG,
basic biochemistries
CIRCULATION
CARDIAC SHOCK- due to cardiac tamponade
or tension pneumothorax
Proeminent jugular venous distension
Cool skin, pale, hypoperfused

NEUROGENIC SHOCK following a spinal cord

injury
Paraplegia, quadriplegia
Warm skin, absence of rectal tonus
DISABILITY
Repeatedly GCS
Pts. who :
cannot follow a simple “ touch your nose”
gross asymmetry of limb motion and pupils
Should be suspected of neurologic injury-
Emergent brain CT SCAN
EXPOSURE

Visual inspection of the entire patient

Inspect the back- logrolling the pt.
Inspect the perineum
RESUSCITATION

Monitoring: ECG, BP, UO, PVC, CO, PO

To assess the progress of resuscitation
SECONDARY SURVEY

HEAD
NECK
THORAX
ABDOMEN
LIMBS
HEAD
LACERATIONS
STEP-OFFS
GCS
PUPILS
CT
NECK
HARD NECK COLLAR
SPINE X RAY
LOCAL TENDERNESS
HEMATOMAS
SUBCUTANEOUS EMPHYSEMA
THORAX
LACERATIONS, WOUNDS
SUBCUT. EMPHYSEMA
CHEST MOTION
BRUISING
FLAIL CHEST
BS
THORAX

CARDIAC TAMPONADE
NECK VEINS
HEART SOUNDS
ECHOCARDIOGRAPHY
PULMONARY CONTUSION-
VENTILATION/PERFUSION MISMATCH
Life threatening condition
ABDOMEN
BLUNT TRAUMA:
Hemorrhagic abdomen- internal bleeding
Peritonitic abdomen
WOUNDS:
Penetrating
Perforating
Fracture of the pelvic
bones
External fixation of the
pelvis