Surgical Outpatient Department Research Articles

Isolated Breast Lump of Tuberculosis Etiology

Letters to the EditorIsolated Breast Lump of Tuberculosis Etiology Hassan A.A. MusaFRCSI Hassan A.A. Musa Department of Surgery King Faisal Hospital P.O. Box 146 Taif, Saudi Arabia Search for more papers by this author Published Online:1 Jan 1998https://doi.org/10.5144/0256-4947.1998.85aSectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionTo the Editor: Primary tuberculosis (TB) disease of the breast is rare. Clinically, lesions may be mistaken for breast carcinoma. Regional lymph node involvement is common, and occasionally these nodes are intramammary.We report an isolated TB breast lump in a fit female patient. We think it is important to consider TB etiology in patients presenting with breast lumps and/or abscesses. A 20-year-old female patient was seen at the surgical outpatient department complaining of painless lump in the left breast of four months' duration. She stated no other symptoms and had not experienced any significant illness previously. On examination, she looked healthy, of moderate physique and not anemic. Systemic examination revealed no abnormalities apart from a firm, painless mobile lump measuring about 2 cm x 4 cm on the lateral upper quadrant of the left breast. The nipple and skin were normal. Provisional diagnosis of fibroadenoma was suggested and the patient was admitted to hospital for excision biopsy.Through a circumareolar incision, the lump was excised and sent for histopathological study. A granulomatous lesion with a positive acid-fast bacilli typical of TB was reported. Thorough investigation for TB in other organs or body systems proved negative, apart from a high erythrocyte sedimentation rate (ESR). The patient was started on anti-TB therapy for six months. Following treatment she remained in good health and there was no recurrence of the breast lump after one year of follow-up. The ESR dropped to within the normal range. We think that early suspicion of breast TB will save patients the long list of surgical and medical TB complications.ARTICLE REFERENCES:1. Arnaout AH, Shousha S, Metaxas N, Husain OA. "Intramammary tuberculosis lymphadenitis" . Histopathology. 1990; 17: 91–3. Google Scholar2. Sopena B, Arnillas E, Garcia-Vila MM, Climent A, Miramontes S. Infection (Germany). 1996; 24: 57–8. Google Scholar3. Tan KK, Tan TH. Singapore Med J. 1988; 29: 271–5. Google Scholar4. Keane FB, Ryan TD. Ir Med J. 1978; 71: 416–20. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 18, Issue 1January 1998 Metrics History Published online1 January 1998 InformationCopyright © 1998, Annals of Saudi MedicinePDF download

Outpatients revisited: subjective views and clinical decisions in the management of general surgical outpatients in south west England.

To assess the scope for reducing unnecessary outpatient reattendances, using a benchmark an acute specialty at a site recognised to have an especially low ratio of repeat to new attendances. This was a survey of the re-attendance workload at general surgery outpatient clinics over a three month period. Patient re-booking and discharge rates for different grades of staff; clinicians' perception of the ability of the GP to have managed the patient; perception of the value of individual re-attendances; reason given for discharging/re-booking; and outcome of attendance for patients in relation to diagnostic category were determined. General surgery outpatients clinics with re-attendance rates that were 50% below average, in Taunton and Somerset Hospital, a non-teaching district general hospital. Altogether 454 patients who made 470 second or subsequent visits (re-attendances) within the same episode of outpatient care. Thirty eight percent (178/470) of visits were perceived as manageable by the GP, 45% (79, 17% of total re-attendances) of which were also thought to have been of marginal or little value. A substantial group of patients was being followed up largely for reasons of convention and traditional policy. Re-booking rates were higher among junior staff. Subjective views of the value of attendance at the hospital outpatient clinic and the ability of the GP to have seen the patient varied systematically between consultants and junior staff. Judgements varied to some extent according to the diagnostic group. The numbers of patients being followed up equivocally at most general surgical outpatient departments will be 50% more an average than those in this benchmark department. A department seeing 2000 new patients per annum will have 3600 reattendances, 25.5% (918) of which may be avoidable on the basis of these results. A variety of approaches can be used to increase the proportion of patients seen appropriately by GPs. In some cases this might be achieved without the intensive commitment required to plan and develop shared care protocols or new formal discharge guidelines, but by encouraging GPs to manage some patients, increasing of hospital clinicians' access to knowledge of local general practices, and internal clinic review of 'routine' follow up policies as shown in this study. This type of review of outpatient practice can also help prioritise conditions likely to repay the effort of developing and implementing clinical management guidelines and local protocols.

How do general practitioners compare with the outpatient department when requesting upper abdominal ultrasound examinations?

The recent re-organization of the National Health Service has placed a new emphasis on reexamining the services that hospitals provide to General Practitioners (GPs). To assess the positive findings from an existing open access ultrasound service for GPs in a metropolitan District General Hospital, a retrospective study was performed of 300 consecutive patients referred by GPs compared with 300 consecutive patients referred from the general medical, surgical and geriatric Outpatient Departments--specifically with regard to upper abdominal ultrasound. The frequency with which the clinical indication for referral was associated with an ultrasound finding which could explain the patient's symptoms was measured and the similarities and differences in the two groups are discussed. The study did not attempt to assess the complete value of this service since that would have necessitated assessment of the importance of negative findings. In the two groups the total number of ultrasound abnormalities was similar. A total of 25.3% of GP referrals had an abnormality which could account for their symptoms. The corresponding figure for hospital outpatients was 33.6%. On this criterion, the provision of open access for abdominal ultrasound to GPs is justified.

Preliminary observations on myiasis in leprosy patients

Out of 3350 leprosy patients attending the surgical outpatient department for various ulcerative lesions, 18 patients had typical symptoms of myiasis. Maggots were collected in 5 cases from the nose, in 3 cases from ulcers of the hand and in 10 cases from ulcers of the foot. It was possible to rear the maggots into flies in 8 out of 18 cases. The flies were identified as Sarcophaga ruficornis and Chrysomyia bezziana.

Book reviews

This is an excellent book. It is small, readable and cheap, and contains a lot of simple information which will be of great interest and value to every GP who picks it up, even if he only reads part of it, which is unlikely. It is also of great interest in another way. The author has taken on the philosophy that, as every patient “belongs” to a GP, it is very important that not only GPs know what is likely to happen to their patients in hospital but also that GPs should recognize the radiologist as a front-line hospital referral specialist, whose proper use of very expensive diagnostic equipment can expedite the solving of patients' problems, and provide a much faster and better service to patients than the alternative referral to X-ray (imaging) departments only via medical or surgical outpatient departments.

This step increased nurses?? responsibilities and job satisfaction

GAIL L. INGERSOLL, MS, RN, is the Trauma/ Spinal Cord Injury Clinical Nurse Specialise and Instructor, School of Nursing, University of Rochester, Rochester, New York. From 1979 to 1982 she was the Clinician I for the Surgical Outpatient Department at the University of Rochester Medical Center.

The assessment of protein-calorie malnutrition in patients with gastrointestinal cancer.

Daily protein and calorie intake, three plasma protein estimations, two upper limb anthropometric measurements, and estimated weight loss were all determined in 31 patients attending a surgical oncology outpatient department. The patients, who had had prior resection of a gastrointestinal cancer, could be divided into three groups depending on (i) the absence of clinically detectable tumour; (ii) the presence of clinically detectable tumour with survival over the ensuing four-month period; and (iii) clinically detectable tumour without survival over the ensuing four-month period. The variables least able to discriminate between these groups, and to interrelate to the other variable in a cross-correlation matrix, were the dietary intake data and the estimated weight loss. It is concluded that protein-calorie malnutrition can be adequately assessed in patients with advanced cancer from studies of the plasma albumin, prealbumin, transferrin, arm fat area, and arm muscle area.

Effectivity of Injection Sclerotherapy on Early Haemorrhoids Reported to Surgical Outpatient Department

This prospective study was carried out at a Military Hospital over a period of 10 months. Total 96 cases of first degree and early second degree haemorrhoid cases treated by injection sclerotherapy were included in this study. Among them, first degree haemorrhoids were 60% cases and early second degree haemorrhoids were 40% cases. The highest number of patients was in 3rd and 4th decade (81%). After adequate bowel preparation, under proctoscopy three positions of haemorrhoids were identified. By a Gabrial syringe 5% phenol in olive oil (3-5 ml) was injected in the submucosa of the pedicle of each haemorrhoid. The patients were followed up monthly for six months. All the patients were presented with painless per rectal bleeding. Constipation was present in 89% cases. Satisfactory result was observed in 60% cases and out of them 40 cases were having first degree haemorrhoids and rest of the cases were having early second degree haemorrhoids. Second dose of injection was required in 38 cases and third dose of injection was required in 32 cases. Out of 38 patients who received second dose of injection, only 6 patients had satisfactory outcome and almost all but one patient who received third dose of injection showed unsatisfactory result. Reported method is easy, convenient, cheap and effectively practicable at outdoor level.Key words: Haemorrhoid; sclerotherapy; satisfactory outcome DOI: 10.3329/jafmc.v6i2.7270JAFMC Bangladesh. Vol 6, No 2 (December) 2010 pp.25-27

Ganglioneuroma of the cervical autonomic nervous system.

Ganglioneuroma is an uncommon tumor found in association with the sympathetic nervous system throughout the body. Although more than 200 cases are now on record, the occurrence of the tumor in the neck is a rarity. It is found in the cervical sympathetic ganglia, the ganglion nodosum of the vagus, and the carotid body, forming a very characteristic tumor. The consequences of excision are such that preoperative diagnosis is desirable, although rarely achieved. We are presenting a case of ganglioneuroma of the left superior cervical sympathetic ganglion, together with a review of the literature and a discussion of the distinctive features, diagnosis, and treatment, of these rare neck tumors. <h3>Report of a Case</h3> The patient was a 20-year-old white enlisted man, referred to the surgical outpatient department for evaluation prior to his separation from the service. The patient had been aware of a swelling on the left side of his

Gumma of liver with calcification.

ACCORDING to Rolleston (1929) the liver is the commonest internal organ to harbour a gumma. The clinical diagnosis of hepatic gumma, however, is rarely made, and subsequent to the report of Tucker and Dexter (1946), who described two cases and were the first to record the effect of penicillin in late hepatic syphilis, we have been able to find reports of only two further cases, Nicol and Terry (1951) and Viranuvatti and Kochaseni (1953), in which the diagnosis was made during life. A third case was reported by Shapiro and Weiner (1951), but the diagnosis was only made after death. The following case presents certain unusual features and was thought to be worthy of description. A 29-year-old lorry driver attended his own physician in September, 1952, complaining of a painless swelling in his right hypochondrium. He was referred to the surgical outpatient department of a general hospital, where the swelling

Dupuytren's Contracture

DURING THE PAST TWO YEARs 50 cases of Dupuytren's contracture (44 males, 6 females) have presented themselves for treatment at the Surgical Out-Patient Department, Edinburgh Royal Infinnary. Of these, 36 have submitted themselves to a questionnaire and review of their condition. Certain of their features are of interest, and appear worthy of consideration. They form the subject of the present study.

Rapid Development of Bone Changes in a Patient with Syringomyelia as Observed Roentgenologically

We have had under observation a patient with syringomyelia, who within a few weeks developed marked bone changes in several joints. This case is being reported to illustrate the rapidity with which these changes may occur and to emphasize, among other things, their importance in neuropathic joints because of the medicolegal and compensation aspects. Case Report O. H., a 44-year-old Negro, was referred for a roentgen examination of a painful left shoulder on Feb. 17, 1942. A diagnosis of subdeltoid bursitis had been made in the surgical outpatient department and novocain injections had been given to relieve the pain. The roentgen examination showed nothing abnormal (Fig. 1). A month later (March 10, 1942) the patient returned to the surgical outpatient department because of an elevation of temperature, ranging to 102°. The shoulder ached and was swollen and fluctuant. It could be dislocated downward and posteriorly and the dislocation could be reduced without pain. Aspiration yielded about 50 c.c. of serosanguineous fluid. Smears and cultures were negative. A roentgen examination, March 24, showed considerable destruction of the head of the humerus, and a diagnosis of a neuroarthropathy was made (Figs. 2 and 3). Up until this time the previous history of the patient was entirely unknown to members of the department of roentgenology. A request was made for an examination of other parts of the body. The only other abnormal joints observed were the right and left elbows, which showed beginning absorption of cartilage and some hypertrophic changes (Figs. 4 and 5). The patient was an alum packer and had been admitted to the neurology clinic in 1927, complaining of soreness and numbness in his left hand, especially along the distribution of the ulnar nerve. In the next three years his symptoms progressed. The left pupil was larger than the right. Serologic tests of the blood and spinal fluid were negative. By 1940, a limp and weakness of the left knee had developed. Amputation of the right middle finger was done for a non-healing ulcer. Serologic tests were again negative. In December 1941, the reflexes were recorded as follows: Biceps Right: Markedly depressed Left : Markedly depressed Triceps Right: Markedly depressed Left: Markedly depressed Abdominals Right: Absent Left : Absent Cremasteric Right : Exaggerated Left : Exaggerated Patella Right : Exaggerated Left: Greatly exaggerated Achilles Right: Exaggerated Left: Greatly exaggerated Babinski Right: Negative Left: Negative Patella clonus Right: Present Left: Sustained Ankle clonus Right: Sustained Left: Sustained

A DRESSING FOR HEMATOMA OF THE EAR

Hematoma of the ear is seen very frequently at the Surgical Out-Patient Department, and at the Student Health Service of the University of Pennsylvania, where wrestlers and boxers of the university squads are cared for. These hematomas are often treated soon after they appear and while the blood is still liquid, so that aspiration is an easy procedure in most cases. The more difficult part of the treatment is the application of a pressure dressing that will prevent recurrence. Although textbooks state that a snug bandage over the ear is sufficient, my experience has been that recurrence almost invariably takes place with such treatment. Some authors have suggested the use of plaster molded pressure bandages. These have been found to be cumbersome, and many students are content to have a cauliflower ear rather than to wear a large dressing that surrounds the head. A dressing is here presented that has

Injection Treatment of Varicose Veins

T WENTY-FIVE years ago a surgical Outpatient Department and varicose ulcers were inseparable companions; every surgical clinic had a large number of them. The only way in which these ulcers could be cured was by a long period of rest in bed, or possibly by surgical removal of the veins when the ulcer was healed. This for most people was quite out of the question. Patients are now cured of their varicose veins and ulcers, seldom losing any time from their work. The injection method has distinct advantages over the treatment by operation. There is practically no loss of time, no hospitalization, no anesthetic, less expense, with consequent economic benefit to the patient. This type of treatment is made available to a large number of patients. Patients coming to surgical clinics for treatment of varicose veins and ulcers are first re-

Tuberculous Dactylitis in Infancy

'rul)erculous daletylitis, though not one of the commoner tuberculous lesions, is frequently seen in young children of the class who cattend a Hospital Out-Patient Department. It is, however, rare to see adults with scars or deformity resulting from this lesion. We were so much struck by this fact that we thought it would be interesting to try to ascertain the end results of treatment of tuberculous dactylitis in infancy. In the five years from 1920 to 1924 inclusive, 1,403 patients suffering from tuberculosis attended the Surgical Out-Patient Department of the Royal Edinburgh Hospital for Sick Children, and of these 97 had tuberculous dactylitis, representing 6% of all Ccases of surgical tuberculosis. We have had great difficulty in tracing our cases. Many of them are the children of the very poor, who have no fixed homes, and who disappear completely as soon as they stop attending hospital. We have, however, been able to collect a series of 60 cases which illustrate some points of interest.

The Value of the Surgical Outpatient Department in the Teaching of Surgery

The Value of the Surgical Outpatient Department in the Teaching of Surgery

OSTEOPSATHYROSIS: REPORT OF A CASE

The accompanying case of osteopsathyrosis was treated and studied in the surgical outpatient department of the Children's Hospital, Boston. The accompanying series of roentgenograms gives a graphic fracture history of the patient from the time he was 9 months old until his death, at 7½ years. In spite of the large number of cases reported in the literature, osteopsathyrosis, or fragilitas ossium, is a relatively uncommon cause of pathologic fractures. Griffith 1 and Ostheimer 2 had collected 193 cases in all up to 1913, and since then a few cases have been reported. In 1913 one case was reported by Schwarz and Bass, 3 and another by Bamberg and Huldschinsky. 4 In 1914 Bookman 5 reported one, and the following year Kienbock 6 collected thirty-seven cases from the literature (from 1888 to 1914) and added two cases of his own. Blaine 7 reported one case in 1916, and, in 1917,

Surgical Out-Patient Department, Royal Infirmary

Surgical Out-Patient Department, Royal Infirmary

A CASE OF DISLOCATION OF PROXIMAL PHALANX OF GREAT TOE

P. W., male, white, laborer, aged 56, reported at the surgical outpatient department of the University Hospital, service of Dr. B. A. Thomas, May 28, 1913, with the history of having been kicked by a horse nine weeks previously, and of having been treated at another hospital for an injury to the left knee. He now complains of pain in great toe. Examination reveals fixation of great toe in extreme extension and crepitation at metatarsophalangeal joint. The roentgenogram (Fig. 1) shows displacement of proximal phalanx of hallux onto the dorsum of the head of its metatarsal. The antero-posterior view (Fig. 2) is of interest in showing concomitant displacement of the sesamoids from the plantar aspect to each side of the joint. Under nitrous oxid reduction was attempted by means of Levis' apparatus, but owing to laceration of the skin this method was abandoned. A trial was next made of the

A STUDY OF INFECTION OF THE KNEE-JOINT BASED UPON AN ANALYSIS OF 310 CASES

Attending Surgeon to the Lincoln Hospital; Chief of the Surgical Out-Patient Department, Roosevelt Hospital; Instructor in Surgery at the College of Physicians and Surgeons, Columbia University