1.

INTEGUMENT DERMATOLOGY
Nodular basal cell carcinoma (BCC):
These tumors are typically found on the face, but (unlike squamous cell
carcinomas) are also often seen in non-exposed areas.
BCC is common around 80%. Seen in Farmers, Pearly Edge, Rodent Ulcer.
Implantation dermoid cysts form firm subdermal cystic nodules following penetrating
trauma, often on fingertips of mechanics.
Amelanotic malignant melanoma can be a source of diagnostic confusion with
other skin malignancies. They usually lack the pearly edge of a nodular basal cell
carcinoma.
External angular dermoids are congenital developmental inclusion cysts. seen as
subcutaneous lumps at the lateral angle of the eye.
Nodular malignant melanoma:
Malignant skin lesions are commonly seen in the white-skinned Australian population.
Any change in the appearance of a pigmented skin lesion should arouse clinical
suspicion. The lesion will need complete excision and histological confirmation of the
diagnosis.
Prognosis Factors:
- Thickness of lesions
- Lesions under 0.7mm in depth/thickness have a significantly better prognosis than
- those above this level of thickness
- Bleeding from skin lesions is suggestive but not specific for malignant change and is
- not prognostically significant.
- Width and color are not discriminatory in prognosis, although amelanotic lesions
- can cause confusion and delay in diagnosis.
- Site of the lesion has prognostic significance - melanomas of the legs have a better
- prognosis overall than those on the trunk.
Neuropathic ulcers
- over pressure points in insensitive areas
- associated with diabetes. syphilis. leprosy and other neuropathies.
Limb lesions due to Burkholderia pseudomaflei are usually in the form of
subcutaneous cellulitis following skin abrasions.
Necrotising fasciitis causes a spreading anaerobic subcutaneous infection. often
crepitant with subcutaneous emphysema. Diabetics are particularly prone to these
infections.

Erythema ab igne describes cutaneous tanning caused by chronic local application

of heat, as from excessively hot water bottles.
Squamous cell carcinoma (SCC):
On the lips they are invariably sited on the mucosa of lower lip, related to solar exposure.
Herpes zoster infection on the face gives c lusters of vesicular eruptions related to the
distribution of cranial nerves V (ophthalmic herpes) and VII (geniculate herpes).
Viral herpes simplex of the lip ('cold sore') gives a classical painful shallow ulcerated
acute lesion, usually self-limiting within days or weeks. They may also give vesicular
painful mucocutaneous lesions which are more chronic.
Multiple symmetrical subcutaneous lipomas:
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Multiple discrete lipomas in subcutaneous fat.

Most such lipomas are non-painful and non-tender; when pain or tenderness is present
the lesions are usually more vascular and may, if removed. be reported histologically as
angiolipomas.

Often a family history is present. suggesting an inherited tendency. The syndrome is

quite common. and the lesions are entirely benign. Reassurance is usually all that is
required. with excision of any painful symptomatic or prominent lesions as required to
provide additional reassurance.

Neurofibromatosis type (Von Recklinghausen disease of nerve):

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accompanying stigmata of cafe-au-lait spots.

pedunculated and sessile skin lesions (molluscum fibrosum).

The relationship of the subcutaneous swellings to peripheral nerves and their firmer
consistency, and the associated anomalies and multitude of signs. will usually make the
diagnosis obvious by pattern recognition.

Adiposis dolorosa (Dercum disease) is a term better applied to diffusely painful

subcutaneous fat deposition without focal discrete lumps. The syndrome is most
common in middle-aged women and the painful fatty deposits are mostly confined
to abdomen and thighs.
Desmoid tumours usually arise from the deeper layers of the abdominal wall, and epidermoid
('sebaceous') cysts are invariably attached to overlying skin. Desmoid tumours
and epidermoid cysts are found in the Gardner syndrome variant of familial
adenomatous polyposis.
Reiter syndrome is a condition that occurs predominantly in young men and con
present with urethritis, joint pains, and occasional cutaneous manifestations.
Acute gout can be symmetrical and affect the ankle and tarsal joints with redness
of overlying skin. The first metatarsophalangeal joints, the most common site for gout in the feet.

2. HEAD AND NECK, EYES, EARS NOSE AND

THROAT
Amaurosis fugax (fleeting transient monocular visual loss) suggests ophthalmic artery
platelet embolisation from an ipsilateral carotid artery plaque.
Associated involvement of the cerebral cortex with right sided embolization to
the motor area of the upper limb will give a transient right cerebral upper motor
neuron lesion.
Descending upper motor neurons cross in the pyramids to supply
contralateral lower motor neuron hand musculature, giving transient contralateral
left-sided hand weakness.
The causative constricting ulcerative plaque of the right internal carotid artery near
its origin is likely to give a systolic bruit over the right carotid bifurcation.
A bruit over the left carotid bifurcation would be associated with opposite effects
- transient left eye visual loss and right-sided hand weakness.
Atrial fibrillation, giving an irregularly irregular pulse rate, can be associated with a
left atrial thrombus causing peripheral emboli, of which an embolic vascular stroke is
one of the most serious. However, transient ischemic attacks in the internal carotid
distribution, as outlined in the scenario, are less likely to be due to atrial fibrillation
than to a carotid plaque.
A pan systolic precordial murmur may be due to mitral incompetence or a left to
right cardiac shunt, neither of which is associated with embolic manifestations.
A mid-diastolic precordial murmur associated with mitral stenosis also is not usually
associated with emboli, but with cardiac failure.
After a blow to the cheek or side of the face, double vision of binocular type is very
suggestive of a depressed fracture of the zygoma/zygomatic. Inspection and palpation of the
orbital margins may reveal a step deformity of the orbital margin or a depressed contour of the
cheek, and there may also be anaesthesia in the distribution of the infraorbital nerve.
Operative elevation is usually required.
Rupture of the globe will cause gross loss of vision rather than diplopia.
Hyphaema (bleeding into the anterior chamber) will cause monocular visual
blurring, and is diagnosed by inspection revealing evidence of blood in the anterior
chamber, often with a fluid level.
Fracture of the mandibular ramus can cause difficulty opening the mouth
Maxillary antrum rupture would be secondary to a comminuted maxillary fracture.
or blowout fracture of the orbit, and usually follows a direct blow to the eye rather
than to the lateral face or cheek.

The usual type of thyroid cancer to give lymph node metastases is the papillary carcinoma,
which has no familial tendency. Papillary thyroid cancer affects young adults of either sex and
is a slow-growing neoplasm.
Spread is predominantly via lymphatic drainage to midline pretracheal and prelaryngeal nodes
in front of the thyrohyoid membrane (the latter called 'Delphic'or 'oracular' node because it
is a predictor of an underlying but in apparent cancer).
Spread also occurs to the deep cervical chain of nodes following superior and middle thyroid
veins, and to nodes around the recurrent (inferior) laryngeal nerve and anterior
mediastinum following inferior thyroid veins. The natural history of the condition is generally
favorable and usually extends over many years. The lesion only rarely spreads beyond head
and neck; repeated operations for recurrent tumor can often contain the disease for years.
Spread via the blood stream is unusual, in contrast to the follicular and medullary types of
thyroid cancer, so repeated local surgery for recurrences after primary surgery is worthwhile.
Subacute (de Quervain) thyroiditis, thyroglossal duct cyst and lymph adenoid
(Hashimoto) thyroiditis have entirely different clinical features, and benign thyroid
adenomas are confined to the thyroid gland itself.
Right third (oculomotor) nerve palsy:
Paralysis of the autonomic motor parasympathetic fibres coming from the Edinger-Westphal
nucleus, results in sympathetic pupillary dilatation and failure of the direct and
consensual responses to light (subserved by afferent impulses along the right and left optic
nerves and efferent autonomic innervation of the right sphincter pupillae).
These autonomic motor fibres are situated in the superior part of the third nerve and are
involved early by focal compression secondary to an epidural haematoma
The corneal reflex is subserved by the sensory fifth nerve afferents, but the efferent motor
side of the reflex arc is via the seventh nerve.
The fourth and sixth nerves do not subserve pupillary reflexes but give isolated ocular
muscle palsies causing:
vertical diplopia on downward gaze (fourth nerve - superior oblique palsy),
or lateral diplopia on outward gaze (sixth nerve - external rectus palsy).
A second nerve palsy causes unilateral blindness with failure of the direct but not the
consensual responses to light, and without change in pupillary size.
Ptosis is commonly associated with a third nerve palsy, as the third nerve supplies the levator of
the upper lid (levator palpebrae superioris) as well as the muscles responsible for ocular
movements apart from the two mentioned above.
In a complete third nerve lesion the eye is displaced downwards and outwardly torted due to
unopposed actions of external rectus and superior oblique - the 'downand-out' eye.
In a partial third nerve paralysis, ptosis may be the most prominent feature as illustrated below.
The other illustration shows a left sixth nerve palsy identified on left lateral gaze.