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3rd year Introduction clinical rotation in general surgery

General scheme of surgical patient management includes:

History taking which is very important part. Careful detailed history taking gives a
clue about the exact disease.
Physical examination includes:
• General examination and vital signs
• Local examination including: inspection (proper observation), palpation
(using hands to feel patient’s body), percussion and auscultation for altered or
specific sounds in a particular region.
Provisional clinical diagnosis:
Including list of most probable differential diagnosis
Investigations are done to come into final conclusion. Types of investigations are
decided based on the clinical suspicion of the disease.
Final diagnosis full description of the disease (organ, pathology, stage), thses help
in predict the outcome.
Treatment plan or protocol of treating options often differs for each disease &
depend on individual patient characters.
Postoperative/post therapy care
Treatement complications:
• General complications which related to surgery in general
• Specific complications which is related to each method used
And how to manage both
Adjuvant therapy:
None surgical accomplish therapy either temporary or permanent
Follow-up
Regular interval clinical checks after initial management
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HISTORY TAKING
It is a general scheme and applied to all patients whoever presented to the doctors.
The student should learn this scheme and make it a reflex, so that he can apply this
scheme to all his patients. Ultimately, this will become a habit in his professional
career.
The two important parts in clinical evaluation are symptoms and signs.
Symptom is what a patient complains of. It is the subjective sensation of the patient.
Sign is what a clinician elicits. It is an indication of existence of objective evidence
of a disease.
1. BASIC (PERSONAL) DATA:
a. NAME:
• For identification
• Ease of communication.
• Psychological support to the patient since the patient is assured that
his doctor knows him by name.
• Give indirect clue about the socioeconomic status and background.

b. AGE:
• Certain diseases are peculiar to a particular age e.g. acute
osteomyelitis and Wilms' tumor of the kidney are found mostly in
infants while Sarcomas affect teenagers. Osteoarthritis and benign
hypertrophy of the prostate are diseases of old age.
• Carcinomas affect mostly those who have passed 40 years of age.,
however, it must be remembered that tumors should not be
excluded by age alone
c. SEX:
Certain diseases are predominantly seen in a particular sex, such as
diseases of the thyroid and urinary tract infections are more common in
females, whereas Hemophilia affects males only
d. OCCUPATION:
Some diseases have shown their peculiar predilection towards certain
occupations e.g. jobs requiring lifting heavy predispose to hernias while
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jobs requiring prolonged standing predispose to chronic venous

insufficiency in the lower limbs
e. RESIDENCE:
A few surgical diseases have got geographical distribution e.g. Bilharziasis
is common in Egypt while goiters are common in iodine deficiency
environments such as deserts.
f. MARIETAL STATUS:
To put into consideration the psychological impact on the patient’s history
and condition.
2. CHIEF COMPLAINTs:
• The complaints of the patient are recorded under this heading in a
chronological order of their appearance. The duration of each
complaint must be mentioned.
• In general, a surgical patient will usually complain of either a swelling,
pain or other symptoms that can be correlated to an anatomical or
pathological background
• A single complaint may be a leading complaint to the diagnosis e.g.
jaundice in absence of hematological diseases is diagnostic of
hepatobiliary problems.

3. PRESENT HISTORY:
It is detailed analysis of each complains in relation to onset of the present
condition until present. It should be in order of occurrence. This history
commences from the beginning of the first symptom and extends to the time
of examination. It includes
The mode of onset of the symptoms:
• Sudden: within seconds, usually related to trauma or acute vascular event.
• Acute: minutes to hours, to develop e.g. acute appendicitis.
• Sub-acute: usually due to chronic none surgical conditions.
• Chronic: gradual over weeks or months to develop. It is very important to ascertain
that this is the actual onset not just an exacerbation of an underlying chronic illness
or a recurrence of a chronic problem.
• Insidious (undetermined): and usually painless & accidental discovery
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The course of illness: is th disease either: progressive, regressive,

intermittent or stationary
The treatment which the patient has received & its effect.
4. Past History
History of any Allergey
Previous similar attacks
All chronic debilitating diseases suffered by the patient, previous to the
present one, should be noted and recorded in a chronological order. These
diseases may not have any relation with the present disease. such as systemic
hypertension, diabetes mellitus
Previous operations or accidents, which the patient might have undergone
or sustained. The dates and the types of operations should be mentioned in a
chronological order
Endemic diseases eg in Egypt viral hepatitis & Bilharziasis
5. Family History
The family history includes two subgroups; genetic factor e.g. cancer breast
and environmental factors e.g. colloid goiter
6. Drug history:
The patient should be asked about all the drugs he was on especially
anticoagulants, corticosteroids and anti-cancer chemotherapy
7. Personal habits:
History of personal habits like smoking history of drinking alcohol.

PROVISIONAL DIFFERENTIAL DIAGNOSIS

At this stage the clinician should be able to make a provisional diagnosis.
He should also keep in mind the differential diagnosis. He will now require
a few investigations to come to the proper clinical diagnosis.
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ANALYSIS OF PAIN

Pain is a SYMPTOM referring to an unpleasant sensation of varying

intensity. It is one of nature’s ways of warning us that something is going wrong in
our body. Although it can come from any of the body’s systems, however, there are
certain features common to all pains that should always be recorded.
Tenderness is a sign where pain induced by a stimulus, such as pressure from the
doctor’s hand or forced movement. It is possible for a patient to be lying still without
pain and yet have an area of tenderness. Patients may complain of tenderness if they
happen to have pressed their fingers on a painful area or have discovered a tender
spot by accident. Thus, sometimes tenderness can be both A SYMPTOM AND A
PHYSICAL SIGN.

COMMON ITEMS FOR ANALYSIS OF PAIN: (SOCRATES)

S: Site.
O: Onset.
C: Character.
R: Radiation.
A: Associations.
T: Timing.
E: Exacerbating/relieving factors.
S: Severity.

1. SITE
• The most valuable indicator of the source of pain is its site.
• Although patients do not describe the site of their pain in anatomical terms,
they can normally point to the site of maximum intensity, which you should
convert into an exact anatomical description.
• It is also worthwhile asking about the depth of the pain. Patients can often tell
you whether the pain is near to the skin or deep inside. SPLANCHNIC PAIN
FROM AN INTERNAL ORGAN, which is experienced through the
autonomic system, is poorly localized to the midline, while SOMATIC PAIN
from the body’s surface layers is well localized.
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2. TIMING (ONSET, PROGRESS AND OFFSET)

❖ The onset may be sudden, acute, subacute, chronic or insidious. Acute
inflammatory lesions may progress during a day or overnight, while
claudication from degenerative arterial disease or the pain of an
osteoarthritic knee may build up over many years before the patient
realizes that a vague ache is a specific problem and seeks medical
advice.
❖ The course of the current attack. Pain may gradually increase or
decrease or become continuous or persistent. It may also fluctuate.
There may be total relief from the pain between bouts.
❖ Enquire carefully about previous bouts of pain or anything similar in
the past. Record the patterns of previous attacks, their frequency, how
many there have been in all and their duration. Note whether they are
changing in character.
❖ The offset of pain may be gradual or sudden, and this may be
characteristic of the condition.

3. NATURE OR CHARACTER OF THE PAIN:

• Burning pain from irritation of mucus membrane e.g. cystitis, heart burn
from GERD or sensations in the skin following contact with intense heat
• Steaching pain from irritation of serous membrane e.g. pleurisy, peri-
splenitis.
• Electric pain due to irritation of a nerve
• Sawing or boring pain due to irriation of bone or cartilage.
• Throbbing pain from an inflammatory process such as toothache or an
abscess
• Stabbing pain is sudden, severe, sharp and short-lived e.g. angina pectoris
• Colicky pain comes and goes like a sine wave e.g. intestinal colic or in labor.
• Dragging pain due to stretch on ligament like in splenomegaly
• Dull aching pain with no specific characters

4. RADIATION AND REFERRAL

• Radiation is the extension of the pain to another site while the initial pain
persists. For example, patients with a posterior penetrating duodenal ulcer
usually have a persistent pain in the epigastrium, but the pain may also spread
through to the back The extended pain usually has the same character as the
initial pain.
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• Referred pain is pain that is felt at a distance from its source. For example,
inflammation of the diaphragm causes a pain experienced only at the tip of
the shoulder. Referred pain is caused by the inability of the central nervous
system to distinguish between visceral and somatic sensory impulses.

5. ASSOCIATED SYMPTOMS
• The systemic effects of pain may be primary or secondary. Primary effects
are specific events related primarily to the cause of pain. However, these same
symptoms can be seen as non-specific effects secondary to the severity of pain
originating outside the alimentary tract e.g. vomiting
• It is of paramount importance to ascertain any weight loss due to its frequent
correlation with malignancy. Attempts should be made to quantify this, either
by a change in the patient’s weight on measuring scales or in terms of whether
the patient has noticed their clothing getting looser.

6. EXACERBATING/RELIEVING FACTORS
• Aggravating/exacerbating factors include eating spicy foods (for peptic
ulcers) and fatty foods (with biliary disease), movement such as coughing (for
pleuritic pain and pain due to peritonitis) or walking (with lower limb injuries
or ischemia), and certain postures such as sitting and standing (with lumbar
disc protrusions) and raising the leg (in sacral nerve root compression).
• Relieving factors include analgesics and specific medications such as antacids
for heart burn. Eating may relieve the pain of duodenal ulcers and resting a
limb may ease pain caused by an injury. The severe pain of lower limb
ischemia may be helped by hanging the leg out of bed.

7. SEVERITY
• The quantity of pain is generally related to the severity of the underlying
disease. However, individuals vary extensively in their pain tolerance, and
this is further influenced by anxiety and a fear of the possible implications of
the pain. Sometimes there may be a desire to impress the doctor over the
extent of the problem or conversely to play down the symptoms for some
personal reason.
• A useful indicator is the influence of the pain on the patient’s lifestyle.
• A rough quantitative measure can be obtained using a pain scale of 0 to 10.
The patient is asked to grade their pain on this scale, with 0 being no pain at
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all and 10 being the worst possible pain imaginable. Although this is still very
subjective and dependent on the individual’s response, it can be of value.

Psychogenic pain
• Beware of patients whose mental attitude to their pain symptoms seems out
of proportion – either over-responding to them or ignoring them.
• Munchausen's syndrome is a psychological disorder where someone
pretends to be ill or deliberately produces symptoms of illness in themselves.
Their main intention is to assume the "sick role" so that people care for them
and they are the center of attention. A diagnosis of Munchausen’s syndrome
or psychogenic cause should only be made when all possible organic causes
for the patient’s symptoms have been excluded. In this situation, your clinical
experience is your greatest help.
• Malingering is an act, not a psychological condition. It involves pretending
to have a physical or psychological condition in order to gain a reward or
avoid something. For example, people might do it to avoid military service or
jury duty. Others might do it to avoid being convicted of a crime.

EXAMINATION OF AN ULCER
Definition
An ulcer is a break in the continuity of epithelium either skin or mucous membrane.
Usually with loss of part of a tissue.
Parts of an Ulcer
1. Margin: It may be regular or irregular. It may be rounded or oval.

2. Edge: it is the part which connects floor of the ulcer to the margin.
Types of different edges include:
a. Sloping edge: It is seen in a healing ulcer. Its inner part is red because of
red, healthy granulation tissue. Its outer part is white due to scar/fibrous
tissue. Its middle part is blue due to epithelial prolife ration.
b. Undermined edge: is seen in a tuberculous ulcer. Disease process
advances in deeper plane (in subcutaneous tissue) whereas (skin)
epidermis proliferates inwards.
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c. Punched out edge is seen in a gummatous (syphilitic) ulcer and trophic

ulcer.
d. Enrolled and beaded edge is seen in a rodent ulcer (Basal cell carcinoma).
Beads are due to proliferating active cells.
e. Everted edge (rolled out edge): It is seen in a carcinomatous ulcer due to
spill of the proliferating malignant tissues over the normal skin

3. Floor: it is the part which is seen. Floor may contain discharge, granulation
tissue or slough. Seen by inspection

4. Base: Base is the one on which ulcer rests. It may be bone or soft tissue. Felt
by palpation
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Classification of ulcers
I. Clinical Classification of ulcers:
1. Spreading ulcer: the edge is inflamed and edematous
2. Healing ulcer: the edge is sloping with healthy pink/red granulation
tissue with serous discharge.
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3. Callous ulcer: the floor contains pale unhealthy granulation tissue with
indurated edge/base. It lasts for many months to years. Ulcer does not show
any tendency to heal.

II. Pathological Classification of ulcers:

a. Specific ulcers:
1) Tuberculous ulcer: It is due to breaking of the underlying cold abscess and
collar stud abscess into the surface skin. It is common in neck, axilla and
groin. But it can occur anywhere in the skin. Primary cutaneous tuberculosis
with single or multiple ulcers also can occur.
2) Syphilitic ulcer
3) Actinomycosis.
4) Meleney’s ulcer (post-operative synergistic bacterial gangrene near a
surgical wound)
b. Nonspecific ulcers:
1) Traumatic ulcer: it may be mechanical—dental ulcer along the margin of the
tongue due to tooth injury; physical like by electrical burn; chemical like by
alkali injury. Footballer’s ulcer is a traumatic ulcer occurring over the shin
of males due to direct knocks on the shin of tibia and fibula.
2) Arterial ulcer (ischemic ulcer): Painful non-healing ulcer commonest on toes
and dorsum of foot (least blood supply)
3) Venous ulcer (Post-phlebitic ulcer): Usually occurs in the gaiter area just
above the medial malleolus
4) Trophic ulcer/Pressure sore: Pressure sore is tissue necrosis and ulceration
due to prolonged pressure. Blood flow to the skin stops once external
pressure becomes more than 30 mmHg (more than capillary occlusive
pressure) and this causes tissue hypoxia, necrosis and ulceration. It is more
prominent between bony prominence and an external surface.
5) Infective ulcers
6) Tropical ulcers: it occurs in tropical countries. It is callous type of ulcer, e.g.
Vincent’s ulcer.
7) Cryopathic ulcer: ulcers due to chilblains and frostbite. It is due to exposure
of a part to wet cold below the freezing point (cold wind). It leads to gangrene
of the part.
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8) Martorell’s hypertensive ulcer: a very painful ulcer of the lower leg that
develops in association with poorly controlled high blood pressure
9) Diabetic ulcer.

c. Malignant ulcers:
1) Squamous cell carcinoma (Carcinomatous ulcer): can occur anywhere in the
f ace, usually in lower lip and has a characteristic raised everted (rolled out)
edge. Draining lymph nodes may be enlarged by metastatic deposits.
2) Basal cell carcinoma (Rodent ulcer): usually occurs above a line extending
between corner of mouth and lobule of ear and has a characteristic beaded
edge. Draining lymph nodes are usually not enlarged.
3) Melanotic ulcer.
4) Marjolin’s Ulcer: is a slow growing locally malignant lesion—a very well
differentiated squamous cell carcinoma occurring in unstable scar of long
duration. Often it is observed in burns scar and scar of previous snake bite

CLINICAL EXAMINATION OF AN ULCER

❖ History taking:
a) Exact site
b) Mode of onset
c) Duration
d) Pain—Ulcer may be painful or painless. Often an ulcer is painless to begin
with but may eventually become painful e.g. malignant ulcers due to
secondary bacterial infection or infiltration to deeper plane or nerve ending.
Some ulcers are painful to begin like acute painful ulcer but becomes painless
once it turns to chronicity.
e) Discharge from ulcer
f) History suggestive of associated disease/treatment history

❖ Local examination of an ulcer:

Inspection
a) Site of ulcer: e.g. arterial ulcers are located over the digits; venous ulcers are
located over the malleoli; trophic ulcers are located over heel/pressure points.
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b) Size of ulcer: size should be measured both vertically and horizontally using
a measuring tape.
c) Shape of ulcer: Ulcers of different causes may have different shapes e.g. a
venous ulcer is vertically oval in shape; a tuberculous ulcer is circular in
shape; a malignant ulcer is irregular in shape. Serpiginous ulcer looks like a
serpent (characterized by active ulceration at the leading edge and healing at
the trailing border)
d) Number: a malignant ulcer is usually solitary; Venous and tuberculous ulcers
can be multiple.
e) Margin.
f) Edge.
g) Floor: the part that is seen. It rests on the base (Base is not seen; it is only felt).
h) Discharge from ulcer bed: can be serous (healing ulcer), bloody (malignant
ulcer), purulent (infective ulcer). Quantity, color and smell of discharge
should be assessed.
i) Surrounding area: is to be examined for inflammation, oedema, scarring..etc
j) Inspection of the entire part/limb

Palpation
a) Tenderness over edge, base and surrounding area
b) Warmth over surrounding area.
c) Edge palpation for induration
d) Palpation of base for induration/fixity (mobility of ulcer)
e) Depth of ulcer—trophic ulcer is deep with bone as its base—often it is
measured gently in mm
f) Bleeding on palpation and touching
g) Palpation for deeper structures and its relation to ulcer
h) Examination of adjacent joint for mobility
i) Examination of regional lymph nodes is essential: e.g. Lymph nodes are not
enlarged in BCC/rodent ulcer as malignant cells block the lymphatics early.
Stony hard, initially discrete and mobile lymph nodes, but later when
advanced fixed to deeper structures are features of secondaries from
carcinoma.
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Causes of Non-healing/chronic ulcers in the skin:

a) Vascular disease: The poor blood supply/ venous drainage reduce the body’s
ability to heal following an injury
b) Diabetes Mellitus: Poorly controlled diabetes is a risk factor for narrowing of
the large arteries that supply blood to the legs. It also leads to damage of much
smaller blood vessels. This can damage nerves and leads to loss of sensation
in the feet making the feet vulnerable to trauma.
c) Pressure areas: e.g. sacrum, heals and other parts of the body
d) Recurrent trauma
e) Malignancy
f) Specific infection: e.g. tuberculosis, leprosy ( leads to nerve damage and
patients are more prone to trauma of non-feeling areas, which may lead to
non-healing ulcers.
g) Periostitis or osteomyelitis of the underlying bone.

EXAMINATION OFA SWELLING

SYMPTOMS
a) Site
b) Size
c) Mode of Onset:
i. Accidental e.g. breast swellings
i. Acute onset either sudden (within minutes): Perforation- or rapid
(hours or days): acute inflammation.
ii. Chronic onset (weeks or months): chronic inflammation or neoplastic
swellings
d) Course:
i. Progressive: neoplastic swellings.
ii. Stationary: chronic inflammation.
iii. Regressive: inflammatory conditions.
iv. Fluctuating: chronic inflammation with acute exacerbation.

e) Duration:
i. Short (days or weeks): inflammatory.
ii. Long (months or years): neoplastic (benign or malignant)
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iii. Since birth: congenital.

f) Other swellings
g) Aggravating/ Relieving factors (what increases/ decreases it)

SIGNS
❖ Inspection
a) Number: Single or multiple
b) Site: The anatomical region of the swelling
c) Size: ln cm (best)
d) Shape: oval- round- butterfly- etc.
e) Skin overlying: Normal, Stretched, Pigmented, Show sign of
inflammation (redness, edematous), Dilated veins, Ulcer, Scar

f) Special character:
i. Expansile impulse on cough: hernia.
ii. Pulsating: aneurysm, vascular swelling.
iii. Moves up with deglutition: thyroid.
iv. Moves up with protrusion of the tongue: thyroglossal cyst
PALPATION
To confirm the items of inspection plus
a) Temperature (using the back of hand): increases in inflammatory
swellings
b) Tenderness: inflammatory swellings are mostly tender. Neoplastic
swellings are not tender.
c) Surface: Smooth, granular, nodular, lobulated...etc.
d) Edge: by starting to palpate away from the swelling towards it. An edge
may be ill-defined (finding no border), Well-defined (finding a border
all around), Pedunculated, Slippery (moves in front of my advancing
finger as in Lipoma)
e) Cystic or solid.
f) Consistency: can be either soft, firm or hard
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g) Mobility: fixed to skin, to underlying structure or within tissue it arise

from.
h) Draining lymph nodes.

Tests to differentiate solid from cystic swellings:

i. Fluctuation test: if it contains fluid, it will fluctuate. The test should be done
in 2 perpendicular planes. Keep pressing by receiving fingers against one
pole; exert sharp pressure at opposite pole by displacing fingers
ii. Modified fluctuation test Paget's test: It is used in small or tense swellings (<
2 cm). The test compares the consistency at center with that at periphery.
Solid swelling are more firm at center than at periphery. Cystic swellings are
less firm at center than at periphery.
iii. Cross fluctuation test (to detect weather two adjacent cystic swellings are
communicating or not): Percuss the swelling by a finger & receive the
impulse by a finger of the other hand placed on the 2nd swelling e.g. psoas
abscess.

Trans-illumination Test (using a torch in a dark room):

For cystic swellings, it differentiates opaque from translucent fluids. Translucent
cystic swellings contain clear fluid e.g. primary hydrocele, cystic hygroma,
menigocele, ranula, epididymal cyst. Opaque cystic swellings may contain blood or
pus.

Consistency: Swellings may be:

- SOFT: felt like a lobule of the ear.
- FIRM: felt like tip of the nose.
- HARD: felt like forehead.

Mobility
i. Skin
• Not related to overlying skin= skin can be pinched
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• Attached to overlying skin= cannot pinch up Skin.

ii. Muscle: with muscle contraction, if the swelling becomes

• Less prominent = deep to the muscle.
• More prominent = superficial to the muscle.
• Swelling of the muscle = moves across muscle when it is relaxed &
become fixed on contraction.

iii. Nerves (arising from or attached to a nerve)

• Can be moved across but not along the axis of the nerve.
• May be tender.
• There may be distal signs of motor or sensory affection.

iv. Vessels (arising from or attached to a vessel)

• Can be moved across but not along the axis of the vessel.
• May be pulsating.
• There may be distal signs of ischemia .
v. Tendons (attached to tendon of a muscle)
• moves across the tendon & becomes fixed when muscle is contracted.
vi. Bones:
• fixed and immobile from the start.

Draining lymph nodes:

• No examination of a swelling is complete without examination of the group
of lymph nodes draining the area of the body swelling is located in.

Special characters:
❖ Pulsation
• Expansile pulsation: the swelling arises from the wall of an artery
• Transmitted pulsation: the swelling lies very close to an artery.
• How to differentiate between the two types: two fingers, one from each hand
are placed on the swelling. In Expansile pulsations, the two fingers are
raised and separated with each beat of the artery. In transmitted pulsations,
the two fingers are only raised
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❖ Thrill: felt over aneurysm and A-V fistula

❖ Reducibility: Swelling reduces or disappears as soon as it is pressed upon in
a certain direction and reappears again on coughing or straining e.g. hernia.
❖ Compressibility: Flattening under pressure and regains its original size on
release of the compression. (Hemangioma, saphena varix).
❖ impulse on cough: in swellings which are
• In continuity with abdominal cavity such as hernias.
• ln continuity with pleural cavity such as empyema necessitates.
• ln continuity with spinal cord (meningocele).
PERCUSSION
Over the swelling:
• Resonant: over gaseous swelling e.g. hernia
• Dull: over cystic & solid swellings

AUSCULTATION
• Systolic murmur: aneurysm
• Machinery murmur: A-V fistula
• Venous hum: Portal hypertension
• intestinal sound: hernia
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Investigations for a surgical patient

• After thorough history taking and clinical examination numerous

investigations could be used for different purposes including:
1. To confirm diagnosis
2. To classify, assess severity or stage the surgical condition
3. To assess patient fitness & readiness for intervention
• In general surgery, some surgical conditions are diagnosed clinically like
abdominal wall hernias, cutaneous and subcutaneous swellings, and most cases
of acute appendicitis. On the other hand, a lot of surgical patients require
investigations for the above-mentioned reasons
• Before ordering any investigation, it is important to take into consideration:
1. The add-value of this investigation: what will be the benefit of doing this
investigation or simply why we are doing this investigation
2. The cost of this investigation in relation to its benefit. Any alternative easier
or cheaper investigation
3. The possible investigation-related complications and adverse effects
4. Its sensitivity & specificity
5. The preparation needed to improve the yield of this examination and any
prerequisites before doing it
6. The timing of doing or repeating it
• For simplicity investigations could be categorized into:
1. Laboratory tests
2. Imaging techniques
3. Interventional investigation including for example endoscopies and biopsies
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• Laboratory tests could be used to assess the patient general condition, or it could
be disease specific
• Imaging could include plain radiology, contrast studies, ultrasound, computed
tomography (CT scan) , magnetic resonance imaging (MRI) and even functional
imaging.
• Tissue biopsy:

Definition:

➢ A biopsy is a procedure that removes a small amount of tissue for examination

in a laboratory for microscopic signs of cancer or other diseases.
➢ In some cases, biopsies help to determine prognosis & appropriate treatment.

Indications:

1. Persistent pathological lesion not diagnosed clinically

2. Lesion with malignant or premalignant features
3. Confirmation of clinical diagnosis
4. Patient concern

Types:

1. Fine needle aspiration biopsy (FNAB): a sterile thin needle is inserted

through the skin to take the sample.
2. Core biopsy or Tru-cut biopsy: It is performed with a tru-cut needle of 18-
gauge size or an automatic biopsy gun. the difference between a needle biopsy
and a core biopsy is the thickness of the needle used. If a thin needle is used,
it's called fine needle aspiration. If a thicker hollow needle is used, it's a core
biopsy.
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3. Punch Biopsy: A Punch biopsy involves taking a deeper sample of skin with
a biopsy instrument that removes a short cylinder, or "apple core," of tissue.
After a local anesthetic is administered, the instrument is rotated on the
surface of the skin until it cuts through all the layers, including the dermis,
epidermis, and the most superficial parts of the subcutaneous fat.

4. Open Biopsy
An open biopsy is a surgical procedure in which an incision is made through
the skin to expose the tumor and allow for biopsy taking. Open biopsy is
divided into two types:
➢ Excisional biopsy: When the entire tumor is removed, the procedure is

called an excisional biopsy. An excisional biopsy involves surgical

removal of a tumor and some normal tissue around it.
➢ Incisional biopsy: If only a portion of the tumor is removed, the
procedure is referred to as an incisional biopsy

5. Endoscopic Biopsy

This type of biopsy is performed through a fiberoptic endoscope through a

natural body orifice e.g. mouth or rectum. The endoscope is used to view the
organ in question for abnormal or suspicious areas, to obtain a small amount
of tissue for study.