Difference between Primary aldosteronism and Secondary aldosteronism

Primary Aldosteronism

• Increase intravascular Volume
• Decrease RENIN Level
• Do not have pedal edema
• Hypertension

Secondary Aldosteronism

• Decrease intravascular Volume
• Increase RENIN level 
• Somtimes have Edematous state
• Hypotension

Swellings

Lipoma 

• Benign tumor from adipose tissue
• Commonest benign tumor
• Can be single or multiple(lipomatosis), usually encapsulated, slowly growing, soft swelling
• Usually painless. 
• Types 
• Painful lipomas are called neurolipomas . Dercum’s disease is tender deposition of fat especially on the trunk also known as adiposis dolorosa. It is basically neurolipomatosis.
• Fibrolipoma
• Nevolipoma 

Sites :

• Subcutaneous 
• Subfascial 
• Intramuscular
• Submucosal in GI tract
• Not present in brain

Clinical features

• Usually localized , nontender semifluctuant  mobile mass with edges slipping between palpating fingers 
• It is free from overlying skin
• Differential diagnoses
• Neurofibroma
• Sebaceous cyst
• Dermoid
• Lymph node enlargement

Complications

• Sarcomatous changes
• Saponification 
• Calcification 
• Submucosal lipoma can lead to intussusception

Treatment 

Excision 

Sebaceous cyst

• Retention cyst due to blockage of the duct of sebaceous gland
• Contains yellowish white cheesy material
• Common sites face , scalp and scrotum (not seen in palms and soles)
• Clinical features
• Painless swelling which is smooth, soft, nontender, freely mobile but adherent to skin over the summit, fluctuant, nontransilluminant and punctum over the summit (70%)
• It moulds on finger indentation 

Dermoid

Types :

1.Sequestration dermoid

• Cysts generally develops in line of embryonic fusion. So may be seen anywhere in midline, outer angle of dermoid, behind pinna or root of nose
• Clinical features- painless swelling in the line of embryonic fusion, soft, smooth, fluctuant and nontransillumintating with free skin

2. Implantational dermoid

• Due to minor pricks or trauma, epidermis gets buried into deeper subcutaneous tissue which causes reaction and cyst formation.
• Common in fingers , toes and feet
• Clinical features – swelling is painless , soft , tensely cystic nontransilluminating often adherent to skin

TREATMENT : Excision

Ganglion

• Cystic swelling containing clear gel formed by degeneration of synovial tissue.
• Occur in relation to tendon sheath or joint capsule
• Common sites: dorsum of wrist, flexor aspect of wrist
• Clinical features
• Well localized smooth, soft , cystic, nontender, transilluminant and mobile but mobility restricted when tendon is contracted against resistance

Treatment 
excision but high recurrence rate

Bursa

Bursa is a sac like cavity containing fluid within which prevents friction between tendon and bone

Minor injuries and pressure lead to bursitis which will present as swelling and  pain

Treatment excision if necessary

Neurofibroma 

• Tumor arising from connective tissue of the nerve.
• Can be single or multiple
• Types :
• Nodular neurofibroma – single, smooth, firm, often tender swelling which moves perpendicular to direction of nerve but not in the direction of nerve
• Plexiform neurofibroma – commonly occurs in the direction of Vth cranial nerve in skin of face . It attains enormous size with thickening of skin which hangs downwards.
• Generalised neurofibromatosis (von Recklinghausen’s disease) – it is inherited as autosomal dominant disease. Multiple neurofibromas associated with pigmented spots in skin (café au lait spots) . Associated with MEN type IIb   

Complications 

• Sarcomatous change – rapid enlargement, warm and vascular with dilated veins
• Cystic degeneration
• Hemorrhage into tissues
• Erosion of deeper structures
• Neurological deficits may occur

Treatment : excision for symptomatic , cosmetically problematic or malignant changes

Callosity and corn 

Callosity 

• raised thickened patch of hyperkeratosis common in areas which undergoes excessive wear and tear.
• Histologically there is increased thickening of epidermis particularly the stratum corneum and granular layer 

Corn 

• Circumscribed horny thickening cone-like in shape with its apex pointing inwards and base at surface.
• Occurs at the site of friction and often disappears spontaneously when causing factor is removed
• Histologically composed of keratin masses with intact basal layer
• Often caused by ill-fitting and tight shoes chiefly affecting feet and toes. 

Wart 

• Patches of overgrown skin with hyperkeratosis
• Usually occur in children and adolescents and young adults
• Growth occurs due to stimulation by HPV
• Main complaint is disfiguring 
• Frequently affects hands, face, knees, and sole (plantar warts) .
• Warts are usually firm and covered with rough surface and filifom excrescences.

NUTRITION

Caloric requirement in adults – 40kcal/kg/day

Carbohydrates 50% , fat  30-40% and protein 10-15%

Caloric value- carbohydrate and protein - 4kcal/g and fat – 9kcal/g

Indications of nutritional supplementation

• Preoperative nutritional depletion
• Burns
• Trauma
• Anorexia nervosa and intractable vomiting
• Pancreatitis, malabsorption, ulcerative colitis, pyloric stenosis
• High output intestinal fistulas
• Postoperative complications like sepsis, ileus and fistula
• Malignant disease

Methods of feeding

Enteral feeding

• GI tract is the best route to provide nutrition.
• Can be done 

i.Orally

ii.By nasogastric tube

iii.By enterostomy e.g. gastrostomy and jejunostomy in severe malnutrition, major surgeries, severe sepsis

Total parenteral nutrition (TPN)

Indications:

• Failure or contraindication for any enteral nutrition
• High output intestinal fistulas
• Major abdominal surgery of liver, pancreas, biliary tract, colon
• Septicemia
• Multiple trauma
• Short bowel syndrome
• TPN is given through central vein and not through peripheral vein
• Components used in TPN – carbohydrates, fat, aminoacids, vitamins and trace elements
• Contraindications :
• Cardiac failure
• Blood dyscrasias
• Altered fat metabolism

Complications of TPN 

1.Due to placement of CVP

• Air embolism
• Pneumothorax
• Bleeding
• Infection 
• Catheter displacement, sepsis, blockage, thrombosis

2. Biochemical

• Electrolyte imbalance
• Hyperglycemia
• Hyperosmolarity
• Dehydration
• Azotemia 
• Altered immunological function

3. Others

• Dermatitis
• Anemia 
• Cholestatic jaundice.

PRINCIPLES OF SKIN COVER - GRAFTS AND FLAPS

Characteristics

• Largest organ of the human body- surface area 1.5-2.0 sq.m,  2-3mm thick
• 15% of body weight
• Epidermis- Corneum, Lucidum, Granulosum, Spinosum, Basale,
• Dermis- papillary and reticular, made of collagen, 

Functions of skin

• Protective layer - Langhan’s cells of adaptive immune system
• Sensation
• Heat regulation
• Control evaporation
• Aesthetics 
• Makes vitamins D

When is skin required?

• Loss of large area of skin
• Large wound 
• Post burn raw area
• Release of contracture

Reconstructive Ladder

Graft and Flap

• Graft is free tissue without its vascular supply- skin, bone, tendon, nerve, vessels, muscle, fascia, mucosa
• Flap is tissue with its original blood supply
• Areas where we cannot put graft will need a flap-Flaps for bone devoid of periosteum, cartilage devoid of perichondrium, tendon devoid of paratenon

Grafting 

• Skin graft is essentially dead with no circulation. Under favourable conditions obtain new blood supply from recepient wound or defect. This is known as graft take
• Infection, pressure, hematoma or shear forces can result in graft failure
• Meshing – increase surface area and prevention of collections
• Immobilisation with Sutures / plaster slab
• Prevention of hematoma / seroma
• Dressing of recipient wound
• Donor site management

Process of graft take

1. Imbibition

2. Inosculation

3. Vascularization

Conditions affecting graft take

• Malnutrition- hypoproteinemia, vitamin deficiency
• Presence of hypertension, diabetes
• Compromised immune status
• Collagen vascular disease
• Constant pressure on the area

When to graft?

• Wound flat and red / can see the imprint of gauge piece
• No unhealthy granulation tissue or necrotic tissue
• Margins are healing and spreading
• Not much bleeding on touch
• dressing peels  with difficulty
• Bacterial count less than 105 
• No evidence of beta hemolytic streptococci

Types of skin graft:

Partial thickness- thin intermediate thick

Full thickness

Composite graft- More than one tissue type required to perform reconstruction

Split thickness skin grafting (Thiersch graft)

• Donor site heals spontaneously as part of dermis is left behind
• Contracture may occur
• Sensation function of hair sebaceous gland not present
• Donor area is dressed and dressing is removed after 10 days and after 5 days in recepient area

Skin graft harvesting

Instruments  -  Humby’s knife

Donor sites:

Thigh , legs, arm, forearm, body

Taking split skin graft with a Humby’s knife holder

Differences

Split thickness Skin graft:

• Epidermis and part of dermis
• Donor sites heal spontaneously 
• Extensive defects
• Graft take – good
• More contraction later
• Less stable
• Less colour and texture matching

Full thickness graft:

• Epidermis and whole dermis
• Donor site needs to be closed – direct or SSG
• Small defects
• Graft take – less readily- needs optimal condition
• Secondary contraction less
• More stable
• Good colour and texture matching

Full thickness skin grafting (Wolfe’s graft)

• Harvested with surgical blade
• Accurately fitted to the defect and sutured
• Donor sites – postauricular, upper eyelid, supraclavicular, flexural, abdomen
• Donor site closure
• Recipient site – dressing / immobilisation
• Whole thickness of skin is excised
• Defatting is done to improve graft take
• Blood supply must be restablished
• Where cosmesis is important (face) or flexibility is important (over joint)

Flaps

• Flap is tissue with its original blood supply

Classification:

1. Based on blood supply – 

• Random pattern (dermal and subdermal plexus)

Rotation flap / transposition flap / advancement flap

• Axial pattern (named vessel) e.g. groin flap (lat. Circumflex artery)

Peninsular flap / island / free flap

Free tissue transfer

• Most technically demanding
• Single stage wound closure
• Wide variety of flaps- tailored to coverage needs
• More acceptable aesthetic outcome

2. Classification based on tissue type
1. Cutaneous flap
2.Faciocutaneous flap
3.Muscle flap
4.Musculocutaneous flap
5.Osteocuaneous flap

3. Specialized flaps
1. Fascial flap
2. Vascularized bone flap
3. Functional muscle flap

Signs and Symptoms Associated with Down Syndrome

Down syndrome is the most common autosomal trisomy identified in liveborn infants. As many as 95% of Down syndrome cases arise due to chromosomal nondisjunction during maternal meiosis (47 XX, +21) an abnormality that positively correlates with increasing maternal age. Two of the more prominent and consistent lectures of Down syndrome are mental retardation and facial dysmorphism. Almost every organ and system, however, is affected

Signs and Symptoms Associated with Down Syndrome

Trisomy 21 (Down syndrome) is characterized by mental retardation, facial dysmorphism, single palmar crease, endocardial cushion defects, and duodenal atresia. Affected individuals have an increased risk of AML-M7 and ALL in childhood and early Alzheimer disease in adulthood.