You are on page 1of 98

Vol

1

MY FINAL CLINICAL
SEMESTER
RaVi KiRaN – 2K8

Well……this book is collection of Clinical cases taken by me
G.RAVI KIRAN a Student of prestigious GANDHI MEDICAL
COLLEGE Hyderabad, during my final Clinical semester &
I tried to cover all the Exam cases.
After every case a small note on case discussion is given
which are clinical notes given by my teachers during my
case presentation.
Personally I feel that History is important for any case sheet
writing so my teachers emphasized on it which I think
would reflect in this book.
Reasons for Asking particular history,& Relavant theory has
to be studied from your respective Books & Clinical skills
must be & Should be learned in your Clinical wards.
I tried my best to avoid mistakes.
…………..Wish you ALL THE BEST FRIENDS…………..

I would like to Thank my friends Shiva, Bose, prashanthi,
Gouthami for helping me in clinical wards & My teachers
for Sharing their Valuable Knowledge with Us………
Hope this Book Helps you in your Preparation friends 

G.Ravi kran 2k8
Vol 1

Page

2

CONTENTS:

1

MEDICINE

2

OBSTETRICS

3

GYNECOLOGY

4

SURGERY

5

PEDIATRICS

1)) Hemiplegia

1
MEDICINE

2)) Ascitis
3)) CVS – MS
4)) Pleural effusion

Page

3

5)) Manual for short cases

IV. HTN. RR: 20/min regular regular (B) Local examination (CNS)– 1)) Higher functions Handedness: R Level of consciousness: Fully consciousness Orientation: +ve Emotional state: Normal Memory: preserved Speech: Articulation disturbed 2)) Cranial nerve Examination: I II Visual acuity Visual fields Colour vision III.HEMIPLEGIA Vijay/Male/39/Cook/Kudappah/ 17 – 07 – 12 C/C: Weakness of R UL & LL & Deviation of Mouth to L with slurring of speech from 2 days H/C/C: PATIENT WAS APPARENTLY ASYMPTOMATIC 1 day back then yesterday he went to work. had dinner & then he slept & woke up at 11 pm went to bathroom . returned home. projectile vomiting NO H/O seizures NO H/O pain in neck NO H/O similar complaints in past NO H/O hypertension / smoking NO H/O memory loss / behavioural changes NO H/O symptoms suggestive of other cranial nerves H/O complete weakness of R UL & LL at the time of attack but now he is able to move his limbs & eat on his own NO H/O Involuntary movements Able to feel ground on walking & Clothes NO H/O tremor of hands while reaching to glass H/O passage of urine at the time of attack but now passage of urine & faces is N (continence maintained) Past H/O: NO H/O similar complaints in past. rhythm No RR/RF delay all PP +ve BP: 120/84 mm hg RUL: supine. epilepsy. TB.Normal Vitals – a febrile. DM. HR: 84/min N in volume. returned to bed then he suddenly developed weakness of R UL & LL (he awakened his wife also) simultaneously he developed deviation of Mouth to L with slurring of speech No H/O loss of consciousness NO H/O head trauma NO H/O headache.VI Light reflex Accomodation Eye movements Nystagmus Normal Normal Normal Normal Normal Normal . chest pain & bleeding disorders Page 4 Treatment H/O: No H/O any surgical procedures / Long term treatment Personal H/O: Diet: mixed Appetite: N B/B: regular Sleep: N Addictions: Non smoker & occasional alchoholic Family H/O: No H/O similar complaint in family & No H/O any chronic illness in family Physical examination (A) general survey – patient is Consious. Moderately built & adequately nourished P (-) I (-) C (-) C (-) K (-) L (-) E (-) No NC markers No tendon xanthomas/ xanthalesma No carotid bruie Facies: Mouth deviated to Left on attempted talking Decubitus:.

finger nose test No dysmetria / No dysdiadokokinesia 4)) Reflexes: Superficial reflexes Abdominal Plantar Deep tendon reflexes Jaw jerk Upper limb Lower Limb Visceral reflexes Released reflexes 1)) Abdominal examination: Umbilicus is midline NO Lumps palpable / Palpable organomegaly NO free fluid 2)) Respiratory system: BLAE: N & N vesicular sounds heard NO adventitious sounds 3)) Cardiovascular system: Heart sound 1 & 2: Heard & No murmurs heard Diagnosis: A case of Complete completed Left hemiplegia due to CVA with Left 7th cranial nerve UMN type of palsy in the stage of recovery (Now hemiparesis) which is probably Embolic in origin in MCA territory at the level of Lost Lost internal capsule.A: + ? Absent 5)) Sensory system: Proprioceptive Exteroceptive Cortical Present & N Present & N Present & N Present & N Present & N Present & N GAIT: N tanden walking CEREBELLAR: Able to do Knee heel test. male as risk factors & No complications of recumbancy ? B. With alchoholism. constipation RAISED ICT SIGNS: Absent MENINGEAL IRRITATION SIGNS: No neck rigidity / Kernings / Brudzunskie signs SKULL & SPINE: Normal PERIPHERAL NERVES: Normal (C) Systemic examination: 26cms 43cms 25cms 43cms Clasp Knife rigidity Normal (?) Normal Normal 3/5 5/5 Absent Absent Able to do Knee heel test.V Sensory Motor VII VIII Vestibular Auditory IX & X XI XII Normal Normal Forehead wrinkling present & Deviation of mouth to L on showing his teeth Normal Normal Palatal reflex + gag reflex NOT done Normal No deviation / fasciculations & Uvula midline Normal / No wasting & N power 3)) Motor System: A)) Inspection No Gross Muscle wasting / Hypertrophy seen No involuntary Movements B)) Palpation Bulk UL LL Tone UL LL Power UL LL Involuntary UL LL Co ordination UL LL 5 Page K. Old age. finger nose test No dysmetria / No dysdiadokokinesia ANS: No abnormal sweating.BR: ++ ? B.A: ++ ? Absent K.T.T.BR: + .

aggravated after taking food. with H/O 3 tappings (he don’t know the colour) H/O Abdominal pain – 4 days: sudden. HTN. Umbilicus everted & displaced downwards & all quadrants move equally with respiration . RR: 22/min regular regular. DM. 30 min after food. orthopnea – 4 days H/O passage of black tarry stools – 4 days NO H/O hematemesis NO H/O facial puffiness NO H/O pedal oedema NO H/O decreased urine output H/O taking local herbal medicine H/O alcoholism – 15 yrs – 500ml/day HR: 88/min N in volume. progressive. ASCITIS Past H/O: Jaundice . pharynx. continous. partially relieved on medication H/O back pain. epigastric pulsations +ve (probably aortic) No visible peristalsis. associated with itching & yellowish discoloration of urine from 15 days H/O weight loss & appetite loss – 6m H/O vomiting – 6m 2/3 per day . progressive. insidious In onset.1 yr back –treated with local medicine & subsided Not associated with fever NO H/O similar complaints in past.Ramraju/55/M/warsiguda/Manual labour Family H/O: No H/O similar complaint in family & No H/O any chronic illness in family C/C: Yellowish Discolouration of eyes – 20 days Abdominal distension – 15 days blood per stool – 15days Physical examination (A) general survey – patient is C/C/C . H/O abdominal distension – 15 days progressive. No blood. epilepsy. contained undigested food. no odour. faucal pillars. rhythm No RR/RF delay all PP +ve BP: 130/86 mm hg RUL: supine. TB. tonsils : within normal range 2)) Abdomen: a)) Inspection: Abdomen is generally distended. twisting type. chest pain & bleeding disorders Page 6 Treatment H/O: No H/O any surgical procedures / Long term treatment Personal H/O: Diet: mixed appetite: N B/B: bladder regular bowel blood per stool & tarry stools passage Sleep: disturbed Addictions: Non smoker & massive alchoholic Parotid enlargement +ve (painless) No loss of axillary hair No hepatic flap hands: Normal No odor from patient No spider neavi No supraclavicular fullness No allergic signs of Tuberculosis (B) Local examination (Abdominal)– 1)) Oral cavity:Tongue. No engorged veins No other swellings visible & Skin over abdomen Normal No echymosis over flanks / around umbilicus No skin nodules around Umbillicus No puncture marks b)) Palpation: No Local rise of temperature/ tenderness/rebound tenderness/Abdominal wall rigidity present No lumps palpable Liver: Lower border & Left lobe Not palpable Spleen: Not palpable Fluid thrill –ve . Hepatic facies +ve P (-) I (-) C (-) C (-) K (-) L (-) E (-) H/C/C: PATIENT WAS APPARENTLY ASYMPTOMATIC 20 days back then he developed yellowish discoloration of eyes. yellowish. Teeth .

Not associated with Polyuria / Chest pain / Lightheadedness Past H/O: NO H/O similar complaints in past. Started as NYHA – 1 now it is NYHA – 3. epilepsy. Aggravated on exertion & relieved on taking rest. Regular. HTN. Insidious in onset.Continous. CVS – MS Kumar/17/M/Student/Medak C/C: SOB – 1yr Palpitations – 1yr Backout episodes – 6m L Chest pain – 1 Month H/C/C: Patient was apparently assymptomatic 1 yr back then he developed SOB & Palpitations Page 7 SOB. DM. Relieved on taking rest. Aggravated on exertion & on lying down No H/O penicillin Injections No H/O sorethroat with joint pain/swellings (C) Systemic examination: 1)) Respiratory system: BLAE: N & N vesicular sounds heard NO adventitious sounds 2)) Cardiovascular system: Heart sound 1 & 2: Heard & No murmurs heard Diagnosis: Alcoholic liver disease with liver cirrhosis in decompensated state. regular . H/O PND attacks – 5months: 3episodes/night H/O Orthopnea – 5months Palpitations .dactyly Vitals – afebrile.obliterated (dull) d)) Auscultation: Bowel sounds heard & Normal pitch & No venous Hums heard Blackout episodes – 6months Where there is brief loss of consciousness. progressive Productive & is red coloured. HR: 84/min N in volume. chest pain & bleeding disorders Treatment H/O: No H/O any surgical procedures / Long term treatment / Penicillin prophylaxis Personal H/O: Diet: mixed & appetite: reduced B/B: regular & Sleep: N Addictions: Non smoker / alchoholic Family H/O: No H/O similar complaint in family & No H/O any chronic illness in family Physical examination (A) general survey – patient is C/C/C Moderately built & adequately nourished P (-) I (-) C (-) C (-) K (-) L (-) E (-) N facies NO SC nodules / Erythema marginatum NO Splinter haemorrhages NO Osler nodes/janeway lesions NO malar flush Normal statured NO high arched palate NO syn. NOT preceded by any sensation of movement / Aura & are NOT followed by any confusion / amnesia / headache GROIN: Orifices Free GENETALIA: N (no loss of pubic hair/ testicular atrophy) PR: NOT done H/O easy fatigubility – 1 yr H/O Cough – 5 months . TB.c)) Percussion: Shifting dullness +ve Liver upperborder: 5 th ICS in MCL (liver span: 14cm) Traube’s space:. insidious. gradually progressive./ Poly. Exertional.

supracavicular.+ve (grade 3) No palpable Rub 3)) Percussion: Right border corresponds to Right sterna border & left border corresponds to apex & 2 nd ics (pulm area) is dull 4)) Auscultation: Apex pulse deficient:. Left sided. continuous.rhythm. TA No other adventitious sounds like Clicks / Tumour plop / Pericardial rub heard (C) Systemic examination: (B) Local examination (CVS)– 1)) Inspection: Chest is Normal with No deformities Trachea is in midline Precordium appears Normal (No buldge / retraction) No pulsations are seen in M/T/P/A area. No RR/RF delay all PP +ve BP: 110/74 mm hg RUL: supine RR: 16/min regular .Normal P:. Stabbing type.Apex beat in 5 th ics 1cm lateral to Midclavicular line Localized with diastolic thrill & is tapping in character T:. No associated wheeze. infraclavicular. Non productive.Pulsations are palpable A:. present at rest. NON progressive. Aggravated on cough.Normal prasternal heave :. No haemoptysis No aggravating / relieving factors No diurnal variation Chest pain – 15 days. Aggravated on exertion & relieved by lying on his L side NO H/O PND attacks NO H/O Orthopnea . Progressive.0 A mid – diastolic murmur harsh & rumbling is heard best in Mitral area with No radiation & heard best in left lateral position with bell & heard best after exercise & end of expiration P S1 N P2 Loud & S2 N split Murmur Murmur Murmur MDM NO ESM Page 8 M S1 Loud S2 N T S1 N S2 N A S1 N A2 N Other Gibsons Neoaortic Murmur Infraclav NO Normal 1)) Respiratory system: BLAE: N & N vesicular sounds heard NO adventitious sounds 2)) Abdominal examination: Umbilicus is midline NO Lumps palpable / Palpable organomegaly NO free fluid Diagnosis: A case of Organic MS Probably of rheumatic origin with No clinical features of CCF / IE & patient is sinus rhythm at present Pleural effusion Rangareddy / 56 / M / Hindu / Nalgonda / Daily labourer C/C: Cough from 20 days L Chest pain from 15 days Difficulty in respiration from 10 days H/C/C: Patient is apparently asymptomatic 20 days back then he developed cough which is Insidious in onset. sneezing partially relieved on medication. No pulsations seen in suprasternal. epigastric / Back Apex beat – Not visible Back is Normal (No spinal deformities) 2)) Palpation: Trachea Midline M:. Insidous. rest & Exertion No radiation & is disturbing sleep Difficulty in taking respiration – 10 days Insidious in onset.

Larynx – NOT examined) 2)) LRT INSPECTION from front Chest is N in shape movements are diminished on left side apical impulse: NOT seen fullness seen on left side in middle & lower part Supraclavicular & Infraclavicular fossa : N (NO swellings / Suction / Fullness) Both the nipples are at same level NO tracheal deviation Skin is Normal (NO scars / Sinuses / Suction marks) NO crowding of Ribs NO chest wall sweelings NO venous prominence / arm swelling NO paradoxical chest Movement From back (Standing position) No spinal deformities Skin is Normal Both shoulders are at Same level . RR: 22/min regular . gums. congestion . TB. DM. polyps) & nasal septum: N NO nasal discharge NO Nasal flare NO lupus pernio NO sinus tenderness elicited Oral hygiene satisfactory NO halitosis Pharynx (Oro – Teeth. chest pain & Bleeding disorders & there is NO H/O suggestive of Skin rash. NO Flapping tremor Eyes : Normal (No ptosis / contracted pupil / Subcj hemorrhage / Chemosis / ruddy cyanosis / Phlyctens) NO scrofula / Scrofuloderma NO small muscles (of hand) wasting Vitals: HR: 88/min N in volume. HTN. epilepsy. palate.NO H/O fever with evening rise / night sweats NO H/O Noisy respiration NO H/O Trauma NO H/O Inhaler usage NO H/O Nasal / Ear discharge NO H/O Recent hospitalization / Ventilation Past H/O: NO H/O similar complaints in past. rhythm No RR/RF delay all PP +ve BP: 130/86 mm hg RUL: supine. post pharyngeal wall: N. Joint pains (Collagen Vascular Disorders) Treatment H/O: No H/O any surgical procedures / Long term treatment Personal H/O: Diet: mixed appetite: N B/B: regular Sleep: N Addictions: Non smoker & occasional alchoholic No drug allergies Occupational H/O: No H/O suggestive of Exposure to organic / inorganic dusts Page 9 Family H/O: No H/O similar complaint in family & No H/O any chronic illness in family General Examination: (A) Physical examination Patient is C/C/C P (-) I (-) C (-) C (-) & there is NO wrist tenderness K (-) L (-) NO cervical / Scalene LN palpable E (-) & There is No Signs of DVT / Erythema nodosum on legs N facies Moderately built & Adequately nourished Normal decubitus N voice & cough NO Tobacco/nicotine staining.Abdominothracic NO use of accessory muscles & there is NO intercostal / Supraclavicular Suction JVP: not elevated (B)Local examination 1)) URT (Favoring Aspiration / not) Nose (turbinates.

Inf border of scapula are at same level NO winging / Drooping Spino – Scapular distance: Same on both sides on inspection NO gibbus Intercostal suction & rib crowding : not seen Coin percussion & Shifting dullness: Absent Hepatic dullness is in 5 th ICL R AUSCULTATION Ant PALPATION NO local rise of temperature / NO local tenderness / Intercostal / punch tenderness Slight tracheal deviation to R NO tracheal Tug Crico Sternal distance is Normal Apex beat not palpable Chest Movements – Reduced on Left side Lower & middle Chest Expansion – 2.5cm on R side & 1cm on L side Vocal fremitus Ant R L Diminished in mammary & Inframammary area Diminished in Infraxillary area Diminished in Infrascapular area N Lat N Post N No other Palpable accompaniments (Friction . pleural / pericardial rub) Normal palpatory findings on R side Page 10 PERCUSSION Ant R Resonant Lat Resonant Post Resonant Apical / Kronig’s isthmus Resonant L Dull in mammary & Inframammary area Dull in Infraxillary area Dull in Infrascapular area Resonant R N vesicular & NO Adventitious sounds VR: N Lat N vesicular & NO Adventitious sounds VR: N Post N vesicular & NO Adventitious sounds VR: N Apical / N vesicular & NO Kronig’s Adventitious isthmus sounds VR: N L Diminished breath sounds In mammary & Inframammary area NO Adventitious sounds VR: decreased in same areas Diminished breath sounds In infraaxillary area NO Adventitious sounds VR: decreased in same area Diminished breath sounds In Infrascapular NO Adventitious sounds VR: decreased in same area N vesicular & NO Adventitious sounds VR: N (C) Systemic examination: 1)) Abdominal examination: Umbilicus is midline NO Lumps palpable / Palpable organomegaly NO free fluid Free hernia sites 2)) Cardiovascular system: Heart sound 1 & 2: Heard & No murmurs heard 3)) CNS: Patient is C/C No neck rigidity (TBM) Within N limit Diagnosis: A case of L sided Pleural effusion probably of tuberculous origin . Rhonchila fremitus.

B2.Males & 13. PCV <55%: Anemia) 2 Cyanosis: Bluish discoloration of Skin & MM due to presence of increased amount of Reduced Hb (>5gm%) / Hb derivatives(Sulfa >0. Tinnitus. dyspnoea Basal Creps Polyneuropathy Leucoerythroblastic picture: Normoblasts & Myelocytes both are seen in Peripheral Blood in •Myelophthisic anemia (Infiltration by granuloma / umour).5gm% OR Methe >1. FA defeciency Excessive Alcohol. Capillary pulsation. Lack of concentration. Palmar erythema Anemia & Polycythgemia: Fallots (If hb <18gm%. Chronic Bleeding hemorrhoids & menorrhagia.5gm%:. Strp infection Glossitis / Bald tongue Angular stomatitis Pale PALM . Malignancy. Palpitations. Uremia & CLD) CVS 11 Sternal tenderness Pallor (pathological entity) is waxy appearance of skin & mucous membrane (depends on blood flow & Qualitaty & quantity of skin) – Anemia (Clinical entity) & Low cardiac output states H/O Weakness. lassitude. Ankle oedema. Renal disorders causing Anemia) 1U packed RBC – raise Hb by 2 gm% (Globally Chronic Blood loss is the commonest Cause) Iron deficiency anemia: •Pica •Glossitis / Bald tongue •Angular stomatitis •Platynychia & brittle nails •Brittle hair & dysphagia (PV Syndrome)* B2 (Megenta colored) . Hook worms.Enterogenous / pigment Cyanosis) in capillary blood .3 .Manual – Short cases 1 Anemia: Qualitative / quantitative decrease in Hb/RBC in relation to Age / Sex / Altitude clinically manifesting as pallor: •Lower palpebral conjunctiva (polycythemia & Scleroderma:. breathlessness. SBE. B12. Fe. Hemetemesis. herpes labialis. Hemolytic disease. B12 (Raw beefy tongue).<7gm % Pale RETINA . Suffused Conjuctiva. RA.5%: 100%) Ankle oedema (Anemia perse. fainting. Candidiasis. CCF. Fe.99gm%: it is not evident clinically as pallor Macrocyctic Hypochromic Anemia: Dimorphic anemia (Pregnancy & Hook worm infection) Causes: Nutritional. Chronic Systemic diseases (SLE. Functional MI & haemic murmer at pulmonary area.6 – 15. Leukemia.15. FA deficiency. Giddiness.females (Clinically 14. CCF Hyperdynamic apex.<4gm% if Hb % is between 81% .tightness during retraction) * •Tongue (tip & dorsum) * •Palate •Nail beds •Palms & soles 14. •M6 variety AML •Myelofibrosis & Sclerosis Polycythemia / Ruddy cyanosis: Mucous membrane is Dusty Red & Facial Plethora.5 gm% . Tobacco.5 gm% . Dysphagia* Treatment H/O: NSAID intake Dietary H/O: Dysphagia Personal H/O: Alcohol & Walking barefooted family H/O Page LR Resp Nervous tissue Tachycardia.

Aniline dye poisoning & Carboxyhb: Cherry red apppearence – NOT TRUE cyanosis 3 Jaundice: Yellowish discoloration of Skin & MM due to excess Bilirubin in blood (Clinically >3gm%) 1 – 3gm%: Latent jaundice 0. Amiodarone giving bluish hue to skin – Ceruloderma) Differential: PDA with Shunt reversal (FEET BLUE) Reverse Differential: COA + TGA (FEET RED) Hypoxia +ve +ve Cyanosis +ve -ve Orthocyanosis: Only in upright position (Pulmonary AV malformations in middle & lower Lobes) -ve +ve Peripheral •Nose Tip •Ear lobules •Outer aspect of Lips •Tip. Atabrine toxicity: Skin & Sun exposed Sclera. Ulcerative Colitis Condition Rhb >5gm % Severe Anemia (hb <5gm%) PCV (red cyanosis) Pigment cyanosis (Spectroscopic Examination): Hb M. rectal mucosa & Retina Hypoxic Hypoxia •CCyanoticHD •Acute Pulm oedma •Acute severe Asthma / COPD/Embolism/ Laryngeal oedema •Pulm AV fistula •Eisenmenger Syndrome NO Effect Cyanosis may improve Usually present May be present Hands: Warm N / HIGH Intermittent Cyanosis: Ebstein’s Anomaly Cyanosis +ve 12 +ve Page Cyanosis + PolyCythemia: CCongenitalHD & COPD -ve Clubbing +ve -ve +ve Condition Central Cyanosis Peripheral cyanosis & Acutely developing Central cyanosis SBE .1gm% : Normal •Upper bulbar Conjuctiva (Lot of ELASTIN: Underlying Sclera) •Palate •Palms & Soles •Skin (DD:. Under)* • Inner aspect of Lips •Lower palpebral Cnj •Nasal.3gm% . Nitrites & nitrates.Carotenemia:Only Skin affected. Argyria.(DD:-CO poisioning. Osteogenesis Imperfecta only sclera. Diffuse xanthamatosis) Unilateral: Hemiplegia & unilateral oedema 4 Pulse: Expansion & Elongation of Arterial wall imparted by Column of blood & is inturn produced by Pressure changes in ventricular Systole & diastole) – mentioned in 8 ways Semi pronated & slightly flexed wrist: lateral to Flexor carpi radialis (For VOLUME & CHARACTER – Carotid artery) Pulse deficit: HR – PR (AF >10 / min & Multiple Ectopics <10 / min) HR 1min then PR 1min (2 Cardiac cycles) Steth & Palpate for Radial Pulse Count dropped . Nail beds of fingers & toes Stagnant & Overutilization Hypoxia •CCF •Raynauds •Shock •Arterial diseases: TAO •Venous diseases: SVC S •Cryoglobulinemia •MS (mitral facies) Application of warmth Cyanosis will decrease reverse with Cold Application of Pure O2 for 10 min: NO response Clubbing & Polycythemia: Absent Usually Respiratory distress: -ve Hands: Cold Pulse Volume: LOW Central •Tongue (sides.

Severe Atherosclerosis.03 Sec (Femoral 1st) but clinically simultaneous Ulnar: Wrist medial side Brachial: Just medial to biceps tendon at / just below elbow Subclavian: Middle of clavicle (Shrug Shoulders & palpate from behind) Carotid: Medial to SCM at / Below the level of thyroid cartilage Femoral artery: Midway btw ASIS & PT Popliteal artery: Semiflexed Knee & Supine with thumbs on Tibial tuberosity & Fingers on middle of PF Post tibial artery: Midway Achilles & MM After INVERSION of FOOT N: CATACROTIC pulse •Percussion wave •Tidal wave •Dicrotic & Ancrotic Notch This is Not palpable become it is Obliterated By N vascular tone Anacrotic notch . 2 HB.Extrasystoles. Takayasu. Multiple extrasystoles.02 to 0. Afl Irregular but N HR: Digitalised AF.AF. Sinus arrhythmia Amplitude / Excursion felt – PULSE PRESSURE (30 – 60mm) •Stroke volume & Arterial compliance High (>60mm) •Hyperkinetic states •Complete HB & Bradycardia of any cause •Atherosclerosis Low (<30mm) •Shock •Severe AS & MS •CCF Wall may be palpable in old age due to Arteriosclerosis / MEDIAL MONCKEBERG’S SCLEROSIS: RF delay Periph pls Block Brachial artery & Palpate Radial OR Exsanguate with middle fingers & then palpate with 2 index fingrers •Cervical rib •Aneurysm of aortic arch •Takayasu’s arteritis •Iatrogenic: Bllalock taussing’s shunt •Pre subclavian Coaorctation • Supravalvular aortic stenosis •Pressure over axillary artery by LN •Embolism **Simultaneously Palpate 2 Radial A • Coaorctation of aorta •Aortoarteritis •Atherosclerosis of aorta ** Simultaneously Palpate 2 arteries *** Normally there is difference of 0.Beats (1 Cardiac cycle) 2 different examiner’s (1 Cardiac cycle) In ectopic Beat / Premaure beat / Extrasystoles (Hypertensive / Thyrotoxis / Cardiomyopathic) : Impulse arises from Ventricular / Atrial wall / AVN – It is small & premature Followed by a compensatory pause (Dropped / Missed beat) Tortuous & Thickened (Atherosclerosis rarely palpable: Intima) Wall RR delay Absent radial pulse: Anatomical abnormality. Embolism Mean pressure:. Pulsus Bigeminus Irregularly Irregular:.Mean of SBP & DBP + 1/3 Pulse pressure 8 CHARACTERISTICS Rate Rhythm Page 13 Volume 60 – 100 / min Tachycardia (>100/min) •Sinus tachycardia •Relative tachycardia •Paroxysmal Tachycardia (SVT / VT) Bradycardia (<60 / min) •Myxoedema •Obs jaundice •Athelets • Increased ICT •Hypothermia •Propanolol / digoxin •Hypoxia Regulary / irregulary irregular Regulary irregular:.

C tamponade.Character (Volume & Waveform) Page 14 1)) Bounding: Hyperkinetic states 2)) Anacrotic : LOW VOLUME PULSE WITH UPSTROKE IN ASCENDING LIMB •Severe AS •Actually in AS: PULSUS PARVUS (low Volume) et TARDUS (slow rising) – PLATEAU PULSE 3)) Dicrotic: LOW VOLUME PULSE WITH UPSTROKE IN DESCENDING LIMB •Endotoxic shock. Restrictive Cadiomyopathy. Constrictive pericarditis •A)) Intrapericardial pressure raises more during inspiration Impedes Diastolic filling thus reducing the cardiac output B)) Anti – Bernheim effect: Increased . COPD. hypovolemic shock & 2 nd week of typhoid fever • Very low CO + decreased PR 4)) WH pulse: HIGH VOLUME + SHARP RISE + ILL SUSTAINED + SHARP FALL pulse •Also called HIGH VOLUME COLLAPSING PULSE •Victorian toy – Half of glass cylinfder is filled with water & other with vacuum if turned upside down Thud heard by Water strike • Classically seen in AI HIGH VOLUME: INCREASED STROKE VOLUME + DECREASED PR (due to stimulation of baroreceptors in aortic arch by large CO resulting in sympathetic withdrawl) COLLPASING : DIASTOLIC LEAK BACK + RAPID DISTAL RUNOFF DUE TO VERY LESS PR •Other causes of High volume can also cause this type of pulse wave ** Webs fall on radial artery & rest of palm on ulnar artery – Examine the volume (both R & U arteries) Now elevate the hand (Gravity ¬ fall of blood column ¬ more amount in aortic arch ¬ Even more Sympathetic withdrawal ¬ Even more reduction of PR ¬ Even more elevation of Pulse pressure & Also artery will be in line with aorta SO pressure changes of rapid rise & rapid fall can be easily appreciable) & Examine the pulse (rapidly rises with thud & rapidly falls) 5)) Pulsus bisferiens: •HIGH VOLUME & DOUBLE BEATING (P wave & T wave) : •AS + AI / Isolated AI & HOCM •if P > T: AI > AS if T > P: AS > AI • 1st wave due to Large volume ejected by LV & 2 nd wave by elastic recoil & also due to VENTURI & BERNOULII’S Effect 6)) Pulsus Alternans: ALTERNATE PULSES ARE WEAK WITH REGULAR RHYTHM •Acute LVF •Compensatory pause absent • Some Myocardial fibres healthy some are degenerated (Defective mechanical coupling) •Gallop rhythm & Basal creps 7)) Pulsus Bigeminus & Trigeminus: 2/3 BEATS & A PAUSE (because 2 nd/3 rd beat is ectopic so there is compensatory pause) •Digitalis toxicity & 3 : 2 HB 8)) Pulsus paradoxus: EXAGGERATED INSP FALL OF SBP > 10MM HG + PULSE V DECREASES IN INSPIRATION & INCREASES IN EXPIRATION •Acute severe Asthma .

9F – Fever Page 15 R (1F)> O (0F) > Ax (1F) (Tympanic membrane thermometer fast & Accurate) Clinical thermometer has a mark at 37C / (98.intrathoracic pressure ¬ more blood is sucked into RV ¬ Reduced Blood into LV & Deviation of Interventricular septum to L ¬ Reduction of CO • Actual paradox is heart sounds may be still audible when no pulse is palpable in radial artery 9)) Thready (Low Volume + Rapid (peripheral c Failure ) / jerky (HIS) Sphygmomanometer: 1)) Hess capillary fragility test 2)) Latent tetany: TROUSSEAU’S Sign (Raise >SBP for 3min: carpal spasm) 3)) Draw venous blood 4)) Hill’s sign in AI 5)) Assess respiratory reserve 6)) Different types of pulses Pulsus Paradoxus SBPe > SBPi (>10mm) Gallavardin’s sign Initially on reducing only Strong beats are heard SO Heard Beat APPEARS only Half actual value On further reducing Both strong & weak are heard – Original HR heard Pulsus Alternans WH pulse PP >60mmhg Oral temperature NOT taken if: Bell’s palsy. inflammatory conditions. Trismus. Mouth breathers.9F & Oral PM >99. Convulsions.6F) clinically above this is taken as fever (When kept in axilla) For 1F rise of temperature RR increases by 2 – 3/min & PR 10/min (adults) & 12 – 15/min (Childrean) Relative Bradycardia Rise of PR is Proportionatly low •Any viral fever •1st week of enteric fever •Brucellosis •Psittacosis & weil’s Relative tachycardia Rise of PR is Proportionatly high •Acute R carditis •Diphtheric myocarditis •PAN . After Hot tea.5 F) Hence Oral AM >98. Mentally dull people Hyperthermia Malaria Aseptic fever •Heat stroke •Leukemia & lymphoma •SLE •Pontine haemorrhage •Porphyria •Thyroid storm •Acute MI Malignant hyperthermia •Halothane •Haloperidol Septicemia Encephalitis Lobar pneumonia Hypothermia Myxoedema coma Enteric fever associated in Prf / Hmrg Alcohol intoxication Prolonged Cold exposure Hypoglycemia Autonomic dysfunction Periodic fever: •Hodgkins •Malaria •brucellosis •Relapsing fever Hectic temperature: Big swing in temperature suddenly with chills & rigors & Sudden fall with sweating after few hours •Pent up pus anywhere •Septicemia & pyemia Fall by lysis Fall of temperature suddenly with sweating very fastly in 6 – 12 hrs •Enteric fever •Acute lobar pneumonia •Dengue •Adrenal crisis Fall by crisis Fall gradually in steps over several days •Uncomplicated EF •Rheumatic Fever •Acute bronchopnemonia 5 Temperature: 98 – 99 F (lowest in morning & highest in evening : diurnal variation of 1.

Barbiturates. Increased ADH levels) .Beri Generalized Anasarca / Dropsy CCF. Hypoproteinemia. quinidine & rifampicin 6 Oedema: Excessive fluid in SC space & / OR serous sacs due to increase in Interstitial component of ECF 2/3 ICF & 1/3 ECF (3/4 IF & 1/4 Plasma) In ALL patients with oedema SACRUM & SCROTUM should be examined…& Never miss PARIETAL oedema (Present particularly over abdominal wall) :. lateral epicondyle. Slaicylates.DVT) lymphatic obstruction Tb. Wet Beri . Wet Beri .5F during 24 hr period & NEVER RETURNS THE BASELINE Remittent •Acute broncho pneumonia •Amoebic LA •UTI & 3 rd week EF ** fever DO FLUCTUATE more than 3F during 24 hr period & NEVER RETURNS THE BASELINE Typhoid state: Untreated EF in 3 rd week which is manifested as neurological manifestations 1)) Semi consciousness 2)) Coma vegil: Half eyes open but ignorant of surroundings 3)) Subtulus tendinum: Inv movements of fingers & wrists 4)) Carphology: Plucking of bed sheets Page 16 Fever with rash 1st day: varicella 2 nd day: scarlet fever 3 rd day: Small pox 4rth day: Measles 5 th day: Typhus 6 th day: DEngue Fever with membrane Follicular tonsillitis Faucal diphtheria Candidiasis Vincent’s angina Infectious MN Increased PR ratio: Narcotic poisioning (n: 4:1) Decreased PR ratio in Acute lobar pneumonia Drug fever: Sulphonomides. Constrictive pericarditis. NS. penicillin. Constrictive pericarditis. dissection.Beri Non pitting Myxoedema Lymphatic oedema Angioneurotic oedema Sclerederma Localized Venous obstruction (Pregnancy. NS.IVC syndrome. Pericardial effusion .S – Magnifies the mercury line & Kink is present to prevent return of mercury Line after it is taken from recorded site Intermittent Quotidian (daily) •Double infection with Plasmodium •TB •UTI Tertian (Alt days) •Benign (Vivax & Ovale) •Tertian (Falciparum) Quartan (2d) ** Fever present for only few hours & ALWAYS TOUCHES THE BASELINE SOMETIMES DURING THE DAY Continued •RF •Miliary TB •2 nd week EF Double quotidian fever / Camel hump fever (Double fever spike in single day) •Kala azar •Gonococcol Endocarditis **fever DO NOT FLUCTUATE more than 1. filariasis. SVC. Pericardial effusion .Thermometer is Triangle in C. Forehead has to be pressed Pitting CCF. Infiltration of LN Allergy: AgNO Inflammatory: Insect / Snake bite Pitting oedema demonstratable if increase In W >10 – 15 % & Circumference >10% CCF : Legs ¬ face ¬ Ascites Renal: Face ¬ legs ¬ Acsites Liver: Ascites ¬ Legs ¬ face Nutritional: Feet + face ¬ Ascites •Low oncotic pressure •High capillary hydrostatic pressure •Increased permeability •Obstructed Lymphatic Drainage •Renal retention (Due to decreased flow. Sec Hyperaldosteronism. Liver F.In upper part of body Sternum. Liver F. Hypoproteinemia. Radiation. Iodides.

Empyema thoracis. NS. DVT Facial puffiness CCF. Wet Beri – Beri. Constrictive pericarditis. Eisenmenger’s 2)) Lung & pleural: Bronchiectasis. Liver F. ABE. >10 PHALANGEAL DEPTH RATIO: (Calipers) : Index finger is used & DISTAL PHLANGEAL DEPTH : INTERPHALANGEAL JOINT ration >1 . Leprosy •Occupational (ViCl2: Acrosteolysis) Koilonychia: Spooning . Constrictive pericarditis.3 stages 1st: Brittleness 2 nd: Flattening (platynychia) 3 rd: Spooning Mechanism Anoxic Toxic Reflexive / Neurogenic Metabolic Humoral Reduced ferritin Hereditary Platelet & Megakaryocytes trapping Opening & Dilation SBE Thyrotoxicosis Acromegaly Dilation & Opening (recent view) Release of PDGF & TNF . Pericardial effusion . Cushings Syndrome. Varicose veins. Hypoproteinemia. NS. Liver F. Wet Beri – Beri SVC syndrome. AngNO In renal Causes Swelling of SCROTAL SAC & EYELIDS is classical 7 Clubbing / Hippocratic fingers / Lovibond’s sign: Bulbous enlargement of Terminal part of Fingers & / OR toes due to increased pulp tissue mass (Proliferation of Subungual Soft Tissue + Interstitial oedema + Capillary Dilation) resulting in increased AP diameter & Transverse diameter Onychodernal / Lovibond’s Angle: Angle Btw nail & nail bed (160) (Adjacent skin fold) – Usually index finger is 1st to Affected 1 See tangentially for loss of LbAngle* ¬ Fluctuation ¬ Window sign / Schamroths’s sign st 1st degree 2 nd degree 3 rd degree Fluctuation + loss of Angle 1st + Increase in T & AP diameter 2 nd + Increased pulp tissue (Parrot beak / Drum stick Appearance) th 4 degree 3 rd + wrist / Ankle selling due to HOA *Most reliable early sign Causes: Page 17 1)) Cardiac: Cyanotic HD. CF 3)) Ulcerative Colitis 4)) Biliary Cirrhosis 5)) Intestinal: Crohn’s & Coeliac disease 6)) Normal / Idiopathic 7)) Genetic / familial Always Look for swelling & tenderness at wrist Painful Reversible •SBE •Brochogenic carcinoma •Lung abscess* •Empyema thoracis* Unilateral Unidigital •Subclavian Coarctation / aneurysm •Cervical rib •Hereditary •Repeated trauma •Sarcoidosis Upper limb Lower limb •Chronic Obs Phlebitis due to chronic IV drug addiction •Subclavian Coarctation / aneurysm •Cervical rib •Infected AAA •PDA with shunt reversal ** Acute clubbing (<2W) *** Pseudo clubbing: Subperiosteal Bone resorption (NO Pulp tisse enlargement / Increased Curvature) •Scleroderma •Acromegaly. Pulm AV fistula. CF. Pericardial effusion . Hypoproteinemia.Pedal oedema CCF. Lung abscess.α DIGIT RATIO: Calculate diameter at Nail base & distal IPJ – Clubbing (+ve) if Sum of all fingers.

Pnemothorax) •Klinefeltar’s & Hypogonadism: (US > LS. +ve barr body. Lens Subluxated downwards. Small firm testis. Pemphigus Lymphoedema.males >1 . Cirrhosis Renal failure Ars poison & Hodgkins HypoAlbuminemia (Any) SBE. Infrascapular & Suprailiac region) •Muscle bulk (Mid arm. Tall.males >102cm females >88cm – High risk of metabolic complications •Hip circumference: 1/3 distance between ASIS & patella males •W/H ratio: Truncal obesity :. AS > H. MR. US > LS. systemic vasculitis Psuedomonas infectio PEutz – jeghers syndrome 8 Page 18 If H <4Feet: dwarfism (below 3 rd Centile) •Pitutary Dwarf (Juvenile facies.AR.5mm (<13mm). Long & narrow facies / Dolicocephalus b)) Ocular: Lens Subluxation (Downwards) & Blue sclera with myopia c)) Cardiovascular: AI. Short 4/5 th Mtcrpls) US = LS: Constitutional & familial 9 If H > 97 th centile •Marfan’s syndrome {defective Crosslinking of collagen due to AD mutation in fibrillin 1 & 2 genes} (a)) Skeletal: US < LS. Metacarpal index >8. Pectus Excavatum. Short limbs. Straight back syndrome. A dissection d)) Others: Cystic bronchiectasis.5mm males (<23mm) & 23mm in females (<22mm) & mid thigh Circumference) •Signs of vitamin. High arched palate.Periosteal thickening due to Sub periosteal New Bone formation & Digit ends show Osseous resorption NAIL Pitting Onycholysis Onychomadesis Beau’s lines Yellow nails Terry’s / White nails (Thumb & index) Lindsay’s nails / half & half nail Mees nails Muehrcke’s nails Horder’s Nails (linear longt. Less intelligence. Bronchiectasis. Sp. Life threatening thrombotic episodes) US = LS: Constitutional & familial.4 – 4 metacarpals length divided by width at midpoint & values are averaged . Cavus. MR.5mm (<10mm) & females: 16. Eunuchoidism) •Homocystinuria (US < LS. MVP. Pectus carinatum. Liver failure. Left: 25. Gynecomastia. large head) •Psedo hyperpara thyroidism (Less intelligence. Reiter’s disease Psoriasis. Hyperpitutarism 10 Nutrition: • Subcutaneous Fat (Triceps – Males: 12. Steinberg’s sign / Thumb sign / Hyper extensibility +ve – Thumb extends beyond ulnar border of Hand. Stouty built. Amyloidosis. Hmr) Green nail Black nail Condition Psoriasis. Pes planus. Reduced Cystathione reductase. Wrist sign +ve – Little finger & thumb overlap >cm around wrist. Normal intelligence. Kawasaki disease Severe systemic illness. US > LS) •Achondroplasia: AD (Normal intelligence. mineral deficiency •BMI •Waist circumference: ASIS & Lower coastal margin midway :. biceps.HPOA / Pierre – Marrie – Bamberger Syndrome: Primary / Hereditary (AD) Secondary (Any clubbing cause) Mostly •Bronchial Carcinoma (1/2) & Pleural mesothelioma •Chronic suppurative lung diseases •Chroniv Liver diseases -Pain is aggravated on dependency -Pathologically:. US = LS) •Thyoid Dwarf / Cretin (Coarse facies. pl effusion (Yellow nail syndrome) Imm dfcny. Sarcoidosis Trauma.

females > 0.Promn •HJ reflex . Acute RV infarction. PIERCE FASCIA • Not a direct reflector of CVP Right internal jugular preferred because (Innominate vein may be compressed by aortic knob which dampens elevates the venous pressure on Left Jugular vein) Prerequisite: Trunk angle 45 with relaxed neck muscles in good light. Constrictive pericarditis. Restrictive Cadiomyopathy.+ve •Prominent movement is INWARD •Abolished by gentle pressure applied above Clavicle •2 +ve waves are seen Arterial •Jerky •Better felt than seen •NO •NO •NO •Prominent movement is OUTWARD •NOT ABOLISHABLE •1 +ve wave seen Due to Opening In normal people A is visible & X is more prominent C – X descent: X descent / Systlc collapse: before S2 V – Y descent: Y descent / Diastlc collapse: After S2 X descent is due to: Atrial relaxation & downward movement of Valves during V systole Wave Pattern A Large A waves Regular Cannon waves Irregular Cannon wave Condition TS. DM.PS. Contraction S1 S2 • Buldging of TV & Impact of Adj carotid in V. AIDS. Sys of Tric.Pulm Hyptn Junctional Rhythm Complete HB . Valve Page 19 Normal value at 45 : 3 – 4cm blood (8 cm Blood = 6mm hg) Venous •Wavy •Better seen than felt •On Exp .9 – risks for metabolic complications •Ponderal Index: H (in) / W in pounds (1/3) Cachexia (Anorexia + Anemia + Emaciation) – Disseminated Pulm Tb. Severe RHF – Paradoxical Rise of JVP after deep inspiration due to NON ACCOMODATION of increased venous return to R heart Passive RA filling S2 A. Anorexia nervosa > 3 Kg loss in 6 months : Significant weight loss 11 JVP: Jugular venous pulse (CVP / mean RA pressure) from which we study JV pressure & wave pattern For Venous pressure measurement Ext jugular vein is NOT measured •Prone to kinking due to Superfecial nature •NOT DRAIN DIRECTLY into SVC •VALVES.Promn • Lying down . Advanced malignancy. Btwn 2 heads of sternocleidomastoid (if in sitting position neck veins are engorged then it is NOT necessary for TRUANK ANGLE at 45) – uppermost portion of distension is taken •definite upper level seen •NOT seen HepatoJugular / Abdomino jugular reflex: (+ve: 10sec of abdominal pressure which shows elevation of >3cm blood & is sustained throughout the application of pressure & rapid fall BACK of venous column more than 4cm of blood on release of compression) •Identify Incipient stages of RHF •Differentiate Arterial / Venous pulsation • Identify Obstructive (SVC & BC syndrome) & NON obstructive causes of Engorged Neck veins •Typical JVP of TR can be elicited even if resting JVP is Normal Kussmaul’s sign / Venous pulsus Paradoxus : C tamponade.

pericarditis 12 Spider naevi / arterial spider / Spider Angioma / vascular spider / arterial telangiectasias. Erythema Chronicum migrans (lyme disease). thyrotoxicosis •Normal people / familial 14 Erythema Nodosum: single / multiple Non ulcerating bluish red / erythematousnodular lesion (F > M & Childrean > Adults) generally present on Extensor surfaces but SHIN is the COMMON site. PeriC TS. centrally dilated arteriole with numerous vesselss Radiating from it usually seen in upper part of thorax (necklace pattern – SVC territory) & Upper back mainly due to increased O/T ratio Page 20 Central arteriole pressed & release:. C. Fill from Periphery to center •Rose spots: DO blanch on P. Legs & lower part of abd. NOT blanch. Shin is common site because Lymphatic supply is very less & hence bacterial clearance is slow DD: Erythema induratum. C. Ant abd wall & are Raised •Venous star: high V pressure states.Immediate blanching with filling from Centre to periphery •2% Normal people •Alcoholics •3 rd trimester pregnancy •RA •Thyrotoxicosis Palmar erythema / liver palms: Thenar & hypothenar eminence & finger pulps – BLANCHES on pressure •Alcoholic & long standing RA • Pregnancy •Hyperdynamic sirculation . Ahich are PAINFUL & TENDER Sometimes BILATERAL & Symmetrical – Self limiting in 2 – 6 W – heal without scarring Causes: •Tuberculosis (10) & Leprosy •Sulphonamide therapy •Sarcoidosis •UC & Crohn’s •Rheumatic fever •Brucellosis.tamponade •Campbell de morgan’s spots / Cherry angiomas – Old age. EF 13 Engorged & Pulsatile • C tamponade & C pericarditis •TR & TS •Restrictve Cardiomyopathy •RHF & Pulm TE •CHB Engorged & NON Pulsatile •SVS syndrome & BC syndrome •Chronic C pericarditis • Vasalva manoeuvre Low JVP •Dehydration •After massive Hamerrohage •After massive diuretic therapy Pericardial Knock: Sound In EARLY DIASTOLE: Restrictive effect of adj pericardium on diastolic expansion of ventricle: C. psittacosis Pathologically: Patchy inflammation of Subcutaneous tissue (Panniculitis) & small BV vasculitis – Type 2 Immune complex Deposition . AF. Ant abd wall. NOT blanch.V X Y Absent A waves Large V waves Increased Prominence Decreased Prominence Rapid Descent (Friedreich’s sign) Slow descent AF TR C tamponade & C pericarditis TR. Erythema multiforme . RVF TR.

Pretibial myxoedema.Helix antihelix. Xanthoma. Rheumatoid nodule. Lichen amyloidosis) ENL: Type 2 lepra reaction – Painful crops of Tender nodules + fever + LN + Arthritis + iritis – Treatment with THALIDOMIDE / PREDNISOLONE + Atropine sulfate 15 Subcutaneous Nodules:. Cysticercosis. Ankle) ** Prolonged Cholestasis & Familial Hypercholesterolemia Tophi:. Metastatic deposits Rheumatic nodule. Jaw muscles associated with Swallowing Rooting Lips follow Stimulating object when it is touched Snout Tap with Knuckle on Patient’s UPPERLIP – Pouting of lips due to ORBICULARIS ORIS muscle contraction Myerson’s / Uninterrupted / continuous Glabellar tap Blinking with tap (N: 3 OR 4) * CONTRALATERAL parietal Lobe lesion ** NO LOCALIZING Valu . Rheumatic nodule.Shin (Erythema Nodosum. Necrobiosis lippoidica diabeticorum. Olecranon process. Acilles tendon. Tophi. Organic Confusional states & CONTRALATERAL frontal lobe Lesion) Grasp Forced Groping Avoiding* By distally moving Stimulus on radial Aspect of palmar surface of hand – Grasp & Unable to relax the Grasp Voluntarily By distally moving stimulus on Ulnar Aspect of palmar surface of hand – Hand move away Palmo mental** Scrathing THENAR – Chin puckering due to MENTALIS muscle Contraction Sucking Lip / Mouth corner – Contraction of Tongue. Knees.PLANOUS (Around eyes) & TUBEROUS (Wrist. Elbow. & other pressure points Page 21 16 Memory: 1)) Short term / immediate recall / Rote memory 2)) Recent memory 3)) Past memory / Long term / Remote memory Registration + Retension + Recall + Reproduction 1 7 digits forward / 5 digits Backward & Telephone number repeat after 30 sec 2 Name of vistors Who came yesterday Ask morning news *(index of severity of Organic Brain disease) 3 Ask imp life events (Resistant) Ask imp Social events (indpnd day) Intelligence: Calculation (Serial 7 substraction test) + Judgment (Asking what he will he do if car is coming on him)+ Insight (Awarness about illness) + Reasoning (tall vs dwarf ??) + Abstract thinking (meaning of proverbs) + Attention (Tap if number is repeated twice) + Concentration (20 to 1) Level of consciousness: Conscious > Confused > Drowsy > Stupor > Semicoma (respond to only Internal stimulus) > Coma OR by using GCS Conscious >15 Deeply comatose 3 Released Reflexes (Dementia.NF. Rheumatoid nodule Smaller Large NOT ULCERATE Freq occur TENDER NON TENDER Skin FREE FIXED to skin Assc Active Carditis Associted +ve RFactor Sec infection: rare SEC INFECTION: freq •Extensor surfaces of •Extensor surfaces of elbows elbows •Extensor Tendons of •Extensor Tendons of fingers & Toes fingers & Toes •Back of head •Back of head •Margins of patella •Margins of patella •Achilles tendon •Achilles tendon •Sacrum •Sacrum ** Bony prominences & Pressure points While lying on bed Xanthomas :.

17 Speech: Symbolic expression of Thought process with Words (spoken / written) Disorder of Production / articulation / Phonation Speech area L side in 95% R handed & 70% L handed & also in Ambidextrous 1st Ask name – NO – S/M aphasia – Write Show me your tongue NO (SENSORY / GLOBAL) Yes (Action) MOTOR aphasia Commonest cause CVA particularly Infarction is Commonest cause NOMINAL APHSIA (In BTW ANGULAR GYRUS & POST part OF SUP TEMPORAL GYRUS): Fails to name common objects 18 Upper eyelid: LPS – 3 rd N & Muller’s – Sympathetic Page 22 Horner’s syndrome: PseudoPtosis + Miosis + Anhidrosis (Ipsilateral face. neck. Front & back of upper chest) + Enophthalmosis + Loss of CSp reflex (Skin poinching of neck .pupil reflex dilation) .

1)) Previous LSCS 2)) Diabetes Complicating pregnancy 2 OBSTERTRICS 3)) Heart diseases Complicating pregnancy 4)) Anemia Complicating pregnancy 5)) Bad obstetric History 6)) Hypertensive disorders Complicating pregnancy Page 23 7)) Breech presentation .

chest pain / Jaundice & bleeding disorders DRUG H/O: Took IFA Tab. 4 pads / day No H/O white discharge No H/O clot passage PAST H/O: NO H/O HTN NO H/O DM. radiating to back & aggravated on lifting weights & relived on taking rest. RHD.5 kg weight & breast feeding initiated 3 hrs after delivery. No blood tranfusions After 2 days baby died. 3/30. cried immediately with 2. W/O Yakub With 6yrs of marital status & is G3P1L1 having her LMP as 5/2/12 (regular cycles) & EDD: 11/11/12 Came with a C/C: This lady was admitted for safe institutional delivery in view of previous CS H/P/I: H/O suprapubic pain from 1 week dragging type . No blood tranfusions Stitches are removed on 6 th day & she stayed in hospital for 7 days puerperal period is uneventful. At term she had bleeding PV with meconium stained liquor & obstructed labour. No H/O burning micturition / dysuria / fever with chills & rigor No H/O vaginal bleed No H/O shoulder pain Page 24 OBSTETRIC H/O: Past pregnancies:1st – 1 yr after marriage & Spontaneous Conception confirmed by local doctor & booked case of Gandhi from 5m of gestation. Then she went emergency LSCS in Gandhi hospital & she has given birth to male child. epilepsy. Sleep: disturbed . cause Unknown Stitches are removed on 6 th day & She stayed in hospital for 15 days because of GHTN & she stopped anti hypertensive drugs for 6 more days & discontinued as per doctor advice puerperal period is uneventful present pregnancy:Spontaneous Conception With episodes of vomiting (5 – 6 times/day)1m & No H/O nausea / morning sickness No H/O fever / burning micturition No H/O bleeding PV / White discharge No H/O radiation exposure No H/O Drug usage No H/O leg swelling In 1st 3 months & In next 3 Months there was No H/O bleeding / draining Pv No H/O leg swelling No H/O fever / burning micturition No H/O dyspnoea / palpitations Quickening in 5m & TT 1st dose in 5m USG -6m & In 3 rd trimester No H/O bleeding / draining Pv No H/O leg swelling No H/O blood transfusions TT 2 nd dose in 8m MENSTRUAL H/O : Attained Menarche at 12 yrs of age. FAMILY H/O: Not significant PERSONAL H/O: Diet: mixed. Baby is healthy & No nicu admissions & vaccinated breast fed continued for 2 yrs 2 nd – pregnancy. IHD. continouswhich is not disturbing sleep. TB. cried immediately with 1. she has given birth to female child. appetite: reduced B/B: regular. 2 yrs after & Spontaneous Conception confirmed by local doctor this time she had GTN & underwent Elective LSCS in Gandhi hospital because of previous LSCS.75 kg weight & breast feeding initiated immediately after delivery.Previous LSCS Tava / 22 / House wife/ ECIL / SE IV..

This definition does not include removal of the fetus from abdominal cavity in case of rupture of the uterus or in abdominal pregnancy. Murmer in pulm area (haemic murmer) No other murmers heard Abdominal Incision Infraumbilical midline vertical (quickest) or a suprapubic transverse incision (modified Pfannenstiel incision. -The incidence of forceps and vacuum deliveries has -Rates of labor induction continue to rise -prevalence of obesity has risen Complete uterine involution and restoration of anatomy may require at least 6 months 4)) Steps: Different approaches 1)) Pfannensteil kerr technique usually 2)) Joel-Cohen and 3)) Misgav. -electronic fetal monitoring is widespread.Ladach methods Page 25 Ausultation – Fetal heart sounds – 136/min regular Per veginal Examination – NOT done CVS examination. Broad mass probably podalic pole Lateral grip – Left side hard board like mass felt probably baby’s back & On right side multiple fetal parts felt 1st pelvic grip – hard ballotable. Non ballotable. HR: 80/min. & rhythm No RR/RF delay No vessel wall thickening BP: 120/86 mm hg RUL: Sitting RR: 19/min JVP: NOT raised Diagnosis: A 22 yr Old G3P1L1D1 with term gestation with fundal height corresponding with gestational age with 2 previous LSCS Done for NON recurrent Indications with No other Obstetric complications OBSTETRIC EXAMINATION: Abdominal examination On inspection: Abdomen is generally distended All quadrants move equally with respiration Flanks full Umbilicus slit like & inverted stria gravidarum & linea nigra present A curvilinear suprapubic scar is seen which is about 7 cm in length & No puckering which seen healed by primary intention No other scars / Sinuses No engorged Veins Palpation: Scar tenderness:. Latin 3)) Incidence rising: -average maternal age is rising. the skin and subcutaneous tissue are incised . Moderately built & with P (+) I (-) C (-) C (-) K (-) L (-) Bilateral pedal oedema. 2)) Julis caeser . N in volume. Lex caesaria. mass probably cephalic pole Discussion: Whatever is abd inscison : tenderness must be seen on lower segment & From lateral to centre 1 – 14 (1st T)– 28 (2 nd T).S1 & S2 heard.Addictions: Chronic smoker & Non alcoholic & NON consangious marriage Respiratory Examination: BLAE +ve & N vesicular sounds heard with No adventitious sounds GCOE: Patient is C/C/C. character. Pitting type which is upto knee No thyroid enlargement Breast Normal Spine & gait Normal Vitals – afebrile.40 (3 rd T) Cesarean delivery : birth of a fetus through incisions in the abdominal wall (laparotomy) and the uterine wall (hysterotomy). -Most fetuses presenting as breech are now delivered by caesarean.absent Fundal height – 32 weeks (with flanks full) fundal grip – Soft.

placenta accreta particularly . transverse. -Uterine rupture.Page 26 using a lower. excluding misoprostol. or -Uterine vessel laceration If there is bladder injury . and the paracolic gutters and cul-de-sac are emptied of blood and amnionic fluid using gentle suction. decreased rates of postoperative pain decreased wound dehiscence and incisional hernia. as well as avoiding misoprostol and sequential use of prostaglandins and oxytocin. However: repeat caesarean delivery. rectus muscles are allowed to fall into place Peripartum hysterectomy .Cystostomy repair Increased risk of uterine rupture with multiple uterine surgeries. appear to offer the lowest risk of uterine rupture. excellent cosmetic results can be achieved. and other debris. Bladder is separated Uterine incision: (The uterine incision should be made large enough to allow delivery of the head and trunk of the fetus without either tearing into or having to cut into the uterine vessels) Incised transversely (Kerr) rarely lower-segment vertical Incision (Kronig). vernix. The upper and lower cut edges and each lateral angle of the uterine incision are examined carefully for bleeding & vessels are ligated Uterine Repair: The uterine incision is then closed with one or two layers (1st layer 2 nd running lock layer) of continuous 0.Peritoneum is incised vertically The reflection of peritoneum above the upper margin of the bladder and overlying the anterior lower uterine segment— the bladder flap—is grasped in the midline with forceps and incised transversely with scissors. paramedian or midtransverse incision (Maylard’s Incision – If need more space) be employed Rectus sheath is dissected longitudinally Recti & pyramidialis is retracted sideways P. reentry through a Pfannenstiel incision usually is more time consuming and difficult because of scarring. were not associated with an increased risk of uterine rupture) 6)) If required epidural analgesia may safely be used during a trial of labor &surgical Exploration of a scar dehiscence is necessary only if significant bleeding is encountered 7)) With multiple C sections there is increased risk of hysterectomy placenta previa.Intractable uterine atony -Lower-segment bleeding associated with the uterine incision or placental implantation.) special circumstances.or #1 absorbable suture (Chromic catgut) & serosal edges overlying the uterus and bladder have been approximated with a continuous 2-0 chromic catgut suture Abdominal Closure: All packs are removed. (Intravaginal prostaglandins alone. Baby delivered (Ant shoulder 1st) & cord clamped Fundal massage (promote placental delivery) Manual placental removal if Not extruded spontaneously uterine cavity is inspected and either suctioned or wiped out with a gauze pack to remove avulsed membranes. clots. uterine tachysystole. slightly curvilinear incision at upper border of pubic hair line Follows Langer lines of skin tension. and thus. attempts at cervical ripening or Induction with Oxytocin Some Factors for Consideration in Selection of Candidates for (VBAC) • One previous prior low-transverse cesarean delivery • Clinically adequate pelvis • No other uterine scars or previous rupture • Physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery • Availability of anesthesia and personnel for emergency cesarean delivery 5)) Main risk for labour induction is uterine rupture: selection of women most likely to have a successful VBAC.

With 10months of marital status & is Primi having her LMP as 18/2/11 (regular cycles) & EDD: 25/11/11 Came with a Page 27 C/C: Difficulty in breathing from 2 days H/P/I: Patient was apparently asymptomatic 10 days back then she developed pain in abdomen. previous uterine rupture. radiation to back. from where she was referred to our hosptl. 5/30. Aching type. sudden in onset. Aggravated on exertion (grade 1) relieved on taking rest. continuous. relieved on medication.. lack of resources to perform emergency cesarean delivery during labor. 2 pads / day & with Congestive dysmenorrhoea No H/O white discharge No H/O clot passage . Now There is NO pain Dyspnoea – 2 days Sudden in onset. No shift of pain & Not associated with fever / Vomitings / Burning micturition. Not disturbing sleep. Non progressive. Associated with palpitations precipitated on exertion & relieved on rest & are continous Not associated with cough / chest pain No H/O orthopnoea / PND attacks No H/O syncopal attacks No H/O anaemia (thella paskarlu) OBSTETRIC H/O: Spontaneous Conception . No aggravating factors . so she went to local govt hosptl (Siddipet) where she was having her regular ANC. Pregnancy confirmed by local doctor With episodes of vomiting (3 – 4/days) for 2m & No H/O nausea / morning sickness No H/O fever / burning micturition No H/O bleeding PV / White discharge No H/O radiation exposure No H/O Drug usage No H/O leg swelling In 1st 3 months & In next 3 Months there was No H/O bleeding / draining Pv No H/O leg swelling No H/O fever / burning micturition No H/O dyspnoea / palpitations Quickening in 5m & TT 1st dose in 5m USG -6m & In 3 rd trimester No H/O bleeding / draining Pv No H/O leg swelling No H/O blood transfusions TT 2 nd dose in 8m MENSTRUAL H/O : Attained Menarche at 12 yrs of age. • Relative: two prior uterine surgeries with no previous vaginal delivery. Pain in hypogastric region . b a a: Lscs b: Lscs / Classical Disadvantages of elective C section: 1)) Iatrogenic prematurity 2)) Atonic PPH 3)) Drainage of lochia difficult (since cervix is not dilated) 4)) Difficulty in suturing (lower segment is not formed) TOLAC (Trial of labour after C section) C section indications (recurrent / NON recurrent) Heart disease Complicating pregnancy Jyothi / 20 / agricultural labour / Warangal / SE IV.Contraindications For VBAC •Absolute: prior classical cesarean.

RHD. Broad mass probably podalic pole Lateral grip – Left side hard board like mass felt probably baby’s back & On right side multiple fetal parts felt 1st pelvic grip – hard ballotable. Sleep: disturbed Addictions: Chronic smoker & Non alcoholic & NON consanginous marriage GCOE: Patient is C/C/C. N in volume. appetite: reduced B/B: regular. & rhythm No RR/RF delay No vessel wall thickening BP: 130/86 mm hg RUL: Sitting RR: 16/min JVP: NOT raised OBSTETRIC EXAMINATION: Abdominal examination Page 28 On inspection: Abdomen is generally distended Umbilicus slit like & everted stria gravidarum & linea nigra present No scars / Sinuses No engorged Veins Palpation: Fundal height – 32 weeks (with flanks full) fundal grip – Soft.?? Perveginal Examination – NOT done CVS examination Inspection – NOT done Palpation . ESM. chest pain / Jaundice & bleeding disorders DRUG H/O: Taking IFA FAMILY H/O: Not significant PERSONAL H/O: Diet: mixed. grade 4 & No radiation Diagnosis: A 20 yr Old primi with term gestation with fundal height corresponding with gestational age with Heart Disease probably AS complicating pregnancy Discussion Hemodynamic Changes (%) Cardiac output +43 Heart rate +17 Left ventricular stroke work index +17 Vascular resistance Systemic -21 Pulmonary -34 Mean arterial pressure +4 Colloid osmotic pressure -14 Parameter Change (Percent) 1)) New York Heart Association (NYHA) • Class I. Uncompromised—no limitation of physical activity: These women do not have symptoms of cardiac insufficiency or experience anginal pain. TB. epilepsy. Non ballotable.PAST H/O: H/O HTN diagnosed at 3m NO H/O similar complaints in past. character.Apex beat Not shifted (4 th ics 2cm lateral to MCL) & Parasternal impulse absent Auscultation: Area S1 S2 Murmur Mitral N + No Tricuspid + + No Pulmonary + No Aortic + N (Split ?) + Soft. . Pitting type which is just above ankle No thyroid enlargement Spine & gait Normal Vitals – afebrile. NO H/O DM. mass probably cephalic pole Ausultation – Fetal heart sounds . IHD. Moderately built & with P (+) I (-) C (-) C (-) K (-) L (-) Bilateral pedal oedema. HR: 76/min.

and labor induction can usually be done safely Page 29 For pregnant women with mechanical heart valves. ** In women judged to be at very high risk of thromboembolism and in whom concerns exist about the efficacy and safety of LMWH or UFH. During labor. Normal findings in Pregnant woman: Jugular venous distension Mammary souffle S2 P increased. digoxin. discomfort is increased. IV verapamil / electrocardioversion chronic fibrillation. or anginal pain results. heparinization with severe stenosis even if there is a sinus rhythm. If continued.Vaginal delivery is preferred in most cases. dyspnea. Vaginal delivery & elective induction is reasonable MR: well tolerated during pregnancy. low-dose aspirin— orally administered. Slight limitation of physical activity: These women are comfortable at rest. • Class III. dyspnea. but less than ordinary activity causes excessive fatigue. narcotic epidural analgesia seems ideal. palpitation. Aortic or pulmonary flow murmurs 2)) Class 3 & 4: a)) If feasible. *** Warfarin is suggested throughout pregnancy with replacement by UFH or LMWH (as above) close to delivery. women with severe cardiac disease should consider pregnancy interruption. 3)) In MR & AR: Ventricular function improves with afterload decrease. S2 split S1 M increased and widely split Occasional S3. In MS (heart failure due to fluid overload) & AS (Moderate stenosis tolerated. thus avoiding potentially hazardous hypotension AR: well tolerated during pregnancy. probably because decreased systemic vascular resistance results in less regurgitation. Heart failure only rarely develops during pregnancy Intrapartum prophylaxis against bacterial endocarditis may be indicated AS: Narrow margin separating fluid overload from hypovolemia & During labor and delivery. Like MR. diuretics are given and bed rest is encouraged. prolonged hospitalization or bed rest is necessary. . diminished PVR will improve the lesion. but if ordinary physical activity is undertaken. such women should be managed on the ―wet‖ side. If any physical activity is undertaken. b)) Epidural analgesia for labor and delivery is usually recommended. If symptoms of heart failure develop. maintaining a margin of safety in intravascular volume in anticipation of possible haemorrhage. • Adjusted-dose UFH administered every 12 hours throughout pregnancy. In addition. discomfort in the form of excessive fatigue. any one of the following anticoagulant regimens is recommended: • Adjusted-dose LMWH twice daily throughout pregnancy. Therapeutic anticoagulation with heparin is indicated with persistent fibrillation. • Class IV. or angina pain.• Class II. and diuretic therapy blocker drug is usually given to blunt the cardiac response to activity and anxiety new-onset atrial fibrillation develops. • LMWH or UFH as above until 13 weeks’ gestation with warfarin substitution until close to delivery when LMWH or UFH is resumed. Marked limitation of physical activity: These women are comfortable at rest. severe is life-threatening with decreased preload) 4)) MS: Limited physical activity dietary sodium is restricted. palpitation. Severely compromised—inability to perform any physical activity without discomfort : Symptoms of cardiac insufficiency or angina may develop even at rest.

• Repaired defect with residual defects. epilepsy. 4 pads / day No H/O white discharge No H/O clot passage PAST H/O: NO H/O HTN NO H/O DM. IE Prophylaxis with Dental Procedures (1) Prosthetic heart valve (2) Previous infective endocarditis (3) Certain forms of congenital heart lesions: • Unrepaired cardiac lesions causing cyanotic heart disease. including palliative shunts and conduits • Repaired defect with prosthetic: for 6 months following repair procedure. chest pain / Jaundice & bleeding disorders DRUG H/O: Took IFA Tab. ** Prophylaxis is recommended for procedures that involve manipulation of gingival tissue / periapical tooth region with any of the following cardiac conditions: Hypertensive disorders Complicating pregnancy Rajashri/ 22 / House wife/ Kurnool / SE IV. IHD. 3/28.Epidural analgesia is used for labor and delivery. TB.. and bacterial endocarditis prophylaxis may be required. W/O rajashekar with 3yrs of marital status & is G1P0L0 having her LMP as 15/2/12 (regular cycles) & EDD: 21/11/12 Came with a Page 30 C/C: This lady was admitted for safe institutional delivery in view of Increased Blood pressure H/P/I: Patient is apparently assymptomatic 2months back & having her regular ANC at Gandhi hospital & was diagnosied as having high bp in her 7 th month No H/O Giddiness No H/O epigastric distress No H/O Vision blurring & headache No H/O Seizure episodes No H/O Swelling of face & limbs No H/O Oliguria No H/O Bleeding PV / easy bruisability OBSTETRIC H/O: present pregnancy:Spontaneous Conception Confirmed by local doctor With episodes of vomiting (5 – 6 times/day)1m & No H/O nausea / morning sickness No H/O fever / burning micturition No H/O bleeding PV / White discharge No H/O radiation exposure No H/O Drug usage No H/O leg swelling In 1st 3 months & In next 3 Months there was No H/O bleeding / draining Pv No H/O leg swelling No H/O fever / burning micturition No H/O dyspnoea / palpitations Quickening in 5m & TT 1st dose in 5m USG -6m & In 3 rd trimester No H/O bleeding / draining Pv No H/O leg swelling No H/O blood transfusions TT 2 nd dose in 8m MENSTRUAL H/O : Attained Menarche at 11 yrs of age. appetite: reduced B/B: regular. RHD. Sleep: disturbed . FAMILY H/O: Not significant PERSONAL H/O: Diet: mixed.

or both) and eclampsia syndrome 3. Broad mass probably podalic pole Lateral grip – Left side hard board like mass felt probably baby’s back & On right side multiple fetal parts felt 1st pelvic grip – hard ballotable. whereas older women are at greater risk for chronic hypertension with superimposed preeclampsia.3. No murmers heard Discussion Working Group classification 1. a urine P/C ratio of >/=0. Preeclampsia (some have atypical preeclampsia with all aspects of the syndrome. Preeclampsia syndrome superimposed on chronic hypertension 4. mass probably cephalic pole Ausultation – Fetal heart sounds – ?? Page 31 Per veginal Examination – NOT done CVS examination. or persistent 30 mg/dL (1+ dipstick) protein in random urine samples Risk Factors obesity. it is redesignated as transient hypertension 2.S1 & S2 heard. alcoholic & NON consangious marriage Respiratory Examination: BLAE +ve & N vesicular sounds heard with No adventitious sounds GCOE: Patient is C/C/C. maternal age older than 35 years. Gestational hypertension—formerly termed PIH If preeclampsia syndrome does not develop and hypertension resolves by 12 weeks postpartum . With No signs of imminent eclampsia Vitals – afebrile. Pitting type which is upto ankle No thyroid enlargement Breast Normal Spine & gait Normal Diagnosis: A 22 yr Old Primi with term gestation with fundal height corresponding with gestational age with Hypertension complicating pregnancy. Moderately built & with P (+) I (-) C (-) C (-) K (-) L (-) Bilateral pedal oedema. character. but without hypertension or proteinuria. HR: 80/min. 3)) Preeclampsia syndrome is a two-stage disorder. multifetal gestation. & rhythm No RR/RF delay No vessel wall thickening BP: 120/86 mm hg RUL: Sitting RR: 19/min JVP: NOT raised OBSTETRIC EXAMINATION: Abdominal examination On inspection: Abdomen is generally distended All quadrants move equally with respiration Flanks full Umbilicus slit like & inverted stria gravidarum & linea nigra present No other scars / Sinuses No engorged Veins Palpation: Fundal height – 32 weeks (with flanks full) fundal grip – Soft.Addictions: Non Smoker. Non ballotable. N in volume. • Stage 1 (preclinical) is caused by faulty endovasculartrophoblastic remodeling that downstream causes the stage 2 clinical syndrome & • Stage 2 is susceptible to modification by . Chronic hypertension ** Proteinuria is defined by 24-hour urinary protein excretion exceeding 300 mg. and African-American ethnicity. *** smoking & Placenta previa reduced risk of hypertension during pregnancy 2)) Preeclampsia often affects young and nulliparous women.

(incomplete invasion of the spiral arteriolar wall by extravillous trophoblasts and results in a smallcaliber vessels with resistance) • Immunological maladaptive tolerance between maternal. and fetal factors) • Placental implantation with abnormal trophoblastic invasion of uterine vessels.1 yr after 1st child birth Spontaneous coneption. obesity. . Preeclampsia (culmination of factors that likely involve a number of maternal. ** This finally leads to release unknown factor (s)—likely placental in origin—are secreted into the maternal circulation and provoke widespread activation and dysfunction of the vascular endothelium: Increased pressor response. With episodes of vomiting (5 – 6 times/day)1m & No H/O nausea / morning sickness No H/O fever / burning micturition No H/O bleeding PV / White discharge No H/O radiation exposure No H/O Drug usage No H/O leg swelling In 1st 3 months & In next 3 Months there was No H/O bleeding / draining Pv No H/O leg swelling No H/O fever / burning micturition No H/O dyspnoea / palpitations Quickening in 5m & TT 1st dose in 5m USG -6m & In 3 rd trimester No H/O bleeding / draining Pv No H/O leg swelling No H/O blood transfusions TT 2 nd dose in 8m Past pregnancies 1st pregnancy . 2nd pregnancy .2yr after LCB Spontaneous Conception Confirmed by a local doctor.preexisting maternal conditions that include cardiac or renal disease. Booked case Pregnancy was uneventful & delivered at home by local dai & baby cried immediately . Confirmed by a local doctor. a)) Soluble Fms-like tyrosine kinase 1 (sFlt-1) b)) Soluble endoglin (sEng) Both these levels are increased before clinical syndrome develops Page 32 Breech presentation Sneha/ 25 / House wife/ Nalgonda / SE IV.3kg – immunized & healthy. Puerpurium also uneventful.1 yr after marraige Spontaneous coneption. W/O Suresh chandra With 6yrs of marital status & is G3P2L1 having her LMP as 2/3/12 (regular cycles) & EDD: 9/12/12 Came with a C/C: This lady was admitted for safe institutional delivery in view of Twin pregnancy H/P/I: No H/O any menstrual abnormalities befor conception No H/O similar complaint in past pregnancies No H/O Cervical discharge OBSTETRIC H/O: present pregnancy:.male . or hereditary influences Hemoconcentration is a hallmark of eclampsia.Vasospasm imbalance between NO & PG levels & between Angiogenic and Antiangiogenic Proteins Most importantly overproduction of at least two antiangiogenic peptides from trophoblastic tissue that are released into maternal circulation. paternal (placental). diabetes. and fetal tissues • Maternal maladaptation to cardiovascular or inflammatory changes of normal pregnancy •Genetic factors including inherited predisposing genes as well as epigenetic influences. placental.

character. FAMILY H/O: Not significant PERSONAL H/O: Diet: mixed.S1 & S2 heard. HR: 80/min. mass probably cephalic pole Lateral grip – Left side hard board like mass felt probably baby’s back & On right side multiple fetal parts felt 1st pelvic grip – Soft. N in volume. epilepsy.2. Sleep: disturbed Addictions: Non Smoker. Pitting type which is upto ankle No thyroid enlargement Breast Normal Spine & gait Normal Vitals – afebrile. an increased frequency of the following complications can be anticipated: • Prolapsed cord • Placenta previa • Congenital anomalies • Uterine anomalies and tumors • Difficult delivery • Increased maternal and perinatal morbidity . Moderately built & with P (+) I (-) C (-) C (-) K (-) L (-) Bilateral pedal oedema.Confirmed by a local doctor. No murmers heard Respiratory Examination: BLAE +ve & N vesicular sounds heard with No adventitious sounds Diagnosis: A 25 yr old Pregnant women with G3P2L1 came with uncomplicated breech presentation for safe institutional delivery Discussion COMPLICATIONS In the persistent breech presentation. Non ballotable. Had regular ANC Pregnancy was uneventful & delivered at home by local dai & baby cried immediately . Broad mass probably podalic pole Ausultation – Fetal heart sounds – ?? Per veginal Examination – NOT done CVS examination..5kg – immunized & healthy. IHD.female . Puerpurium also uneventful MENSTRUAL H/O : Attained Menarche at 12 yrs of age. alcoholic & NON consangious marriage GCOE: Patient is C/C/C. 4/28. & rhythm No RR/RF delay No vessel wall thickening BP: 120/86 mm hg RUL: Sitting RR: 19/min JVP: NOT raised Page 33 OBSTETRIC EXAMINATION: Abdominal examination On inspection: Abdomen is generally distended All quadrants move equally with respiration Flanks full Umbilicus slit like & inverted stria gravidarum & linea nigra present No other scars / Sinuses No engorged Veins Palpation: Fundal height – 32 weeks (with flanks full) fundal grip – hard ballotable. chest pain / Jaundice & bleeding disorders DRUG H/O: Took IFA Tab. appetite: reduced B/B: regular. 3 pads / day No H/O white discharge No H/O clot passage PAST H/O: NO H/O HTN NO H/O DM. TB. RHD.

the cervix.) 3)) Specialized forceps can be used to deliver the aftercoming head. Previous perinatal death or children suffering from birth trauma 10. Uterine dysfunction—some would use oxytocin augmentation 6. If the forward roll is unsuccessful. The entire body of the fetus is extracted by the obstetrician (Dead baby & 2 nd baby after podalic version with transverse lie) Delivery of the Aftercoming Head 1)) Mauriceau Maneuver 2)) Modified Prague Maneuver (necessitated by failure of the fetal trunk to rotate anteriorly. Piper forceps or divergent Laufe forceps may be applied electively or when the Mauriceau maneuver cannot be accomplished easily Climbing Up: when buttocks visible at introitus (similar to crowning in cephalic presentation) Piper forceps: Also have perineal curve Page 34 Cesarean delivery (commonly. the operation is designated cephalic or podalic version. making no attempt at delivery of . Lack of an experienced operator. The incisions are so placed as to minimize bleeding from the laterally located cervical branches of the uterine cavity External Cephalic Version: A forward roll of the fetus usually is attempted first. Factors That May Modify the Success of External Cephalic Version Increase Success Increasing parity Ample amnionic fluid Unengaged fetus Tocolysis Decrease Success Engaged fetus Tense uterus Inability to palpate head Obesity Anterior placenta Fetal spine anterior or posterior Duhrssen incision being cut at 2 o’clock. A request for sterilization 11. Infrequently. at times. FAIL Duhrssen incision / intravenous nitroglycerin / GA FAIL Zavanelli maneuver A cardinal rule in successful breech extraction is to employ steady. A hyperextended head 4. gentle. ØTotal breech extraction. which is followed by a second incision at 10 o'clock. but not exclusively. an additional incision is required at 6 o’clock. A large fetus 2.) Entrapment of the Aftercoming Head: With gentle traction on the fetal body. but the remainder of the body is extracted or delivered with operator traction and assisted maneuvers. may be manually slipped over the occiput. used in following circumstances) 1. When delivery is indicated in the absence of spontaneous labor 5. downward rotational traction until the lower halves of the scapulas are delivered. The fetus is delivered spontaneously as far as the umbilicus. Incomplete or footling breech presentation 7. An apparently healthy and viable preterm fetus with the mother in either active labor or in whom delivery is indicated 8.Ø Partial breech extraction. respectively. then a backward flip is attempted (According to whether the head or breech is made the presenting part. Severe fetal-growth restriction 9. with or without maternal expulsive efforts. Any degree of contraction or unfavorable shape of the pelvis determined clinically or with CT pelvimetry 3.

It makes little difference which shoulder is delivered first. & rhythm No RR/RF delay No vessel wall thickening BP: 120/86 mm hg RUL: Sitting RR: 19/min JVP: NOT raised OBSTETRIC EXAMINATION: . appetite: reduced B/B: regular. TB. Traction is used to deliver a foot into the vagina Diabetes complicating pregnancy Laxmi/ 27 / House wife/ zaheerabad/ SE IV. W/O nagarjuna With 6yrs of marital status & is G3P2L1 having her LMP as 2/3/12 (regular cycles) & EDD: 9/12/12 Came with a C/C: This lady was admitted for safe institutional delivery in view of Twin pregnancy Page 35 H/P/I: OBSTETRIC H/O: present pregnancy:Spontaneous Conception With episodes of vomiting (5 – 6 times/day)1m & No H/O nausea / morning sickness No H/O fever / burning micturition No H/O bleeding PV / White discharge No H/O radiation exposure No H/O Drug usage No H/O leg swelling In 1st 3 months & In next 3 Months there was No H/O bleeding / draining Pv No H/O leg swelling No H/O fever / burning micturition No H/O dyspnoea / palpitations Quickening in 5m & TT 1st dose in 5m USG -6m & In 3 rd trimester No H/O bleeding / draining Pv No H/O leg swelling No H/O blood transfusions TT 2 nd dose in 8m MENSTRUAL H/O : Attained Menarche at 11 yrs of age. Two fingers are inserted along one extremity to the knee. IHD. 4 pads / day No H/O white discharge No H/O clot passage PAST H/O: NO H/O HTN NO H/O DM. epilepsy. chest pain / Jaundice & bleeding disorders DRUG H/O: Took IFA Tab.. The appearance of one axilla indicates that the time has arrived for delivery of the shoulders. N in volume. FAMILY H/O: Not significant PERSONAL H/O: Diet: mixed. alcoholic & NON consangious marriage GCOE: Patient is C/C/C. 3/28. Sleep: disturbed Addictions: Non Smoker. Pitting type which is upto ankle No thyroid enlargement Breast Normal Spine & gait Normal Vitals – afebrile. Frank Breech Extraction: Frank breech decomposition using the Pinard maneuver. RHD. Moderately built & with P (+) I (-) C (-) C (-) K (-) L (-) Bilateral pedal oedema.the shoulders and arms until one axilla becomes visible. character. which is then pushed away from the midline after spontaneous flexion. HR: 80/min.

• Intravenous infusion of normal saline is begun. mass probably cephalic pole Ausultation – Fetal heart sounds – ?? Per veginal Examination – NOT done CVS examination. • Regular (short-acting) insulin is administered by intravenous infusion at a rate of 1. Broad mass probably podalic pole Lateral grip – Left side hard board like mass felt probably baby’s back & On right side multiple fetal parts felt 1st pelvic grip – hard ballotable.5mg/wk increments until 10 mg/d. and 2-h <130. • Morning dose of insulin is withheld.S1 & S2 heard.5 mg orally with morning meal. the infusion is changed from saline to 5-percent dextrose and delivered at a rate of 100–150 mL/hr (2. then switch to twice-daily dosing until maximum of 20 mg/d reached. Non ballotable. • Glucose levels are checked hourly using a bedside meter allowing for adjustment in the insulin or glucose infusion rate. these agents are not currently recommended for overt diabetes except on an investigational basis. • Once active labor begins or glucose levels decrease to < 70 mg/dL. increase daily glyburide dose by 2. No murmers heard Respiratory Examination: BLAE +ve & N vesicular sounds heard with No adventitious sounds Discussion There is increasing support for the use of glyburide as an alternative to insulin in the management of gestational diabetes Page 36 Glyburide Treatment Regimen for Women with Gestational Diabetes Who Fail Diet Therapy • Glucometer blood glucose measurements fasting and 1/2 hours following breakfast. lunch & dinner. Insulin Management During Labor and Delivery Recommended by the American College of Obstetricians and Gynecologists • Usual dose of itm-acting insulin at bedtime. • Glucose level goals (mg/dL): Fasting <100. 1-h < 155.Abdominal examination On inspection: Abdomen is generally distended All quadrants move equally with respiration Flanks full Umbilicus slit like & inverted stria gravidarum & linea nigra present No other scars / Sinuses No engorged Veins Palpation: Fundal height – 32 weeks (with flanks full) fundal grip – Soft. Neonatal Problems are:•Respiratory Distress Syndrome •Hypoglycemia • Hypocalcemia • Long-Term Cognitive Development • Inheritance of Diabetes • Hyperbilirubinemia and Polycythemia •Cardiomyopathy Although oral hypoglycemic agents have been used successfully for gestational diabetes . • Glyburide starting dose 2. ** Switch to insulin if 20 mg/d does not achieve glucose goals Diabetes is not associated with increased risk for fetal chromosomal abnormalities.5 mg/kg/min) to achieve a glucose level of approximately 100 mg/dL.25 U/hr if glucose levels exceed 100 mg/dl GDM risk assessment (Should be ascertained at the first prenatal visit) • Low Risk: Blood glucose testing not routinely required if all the following are present: — Member of an ethnic group with a low prevalence of GDM — No known diabetes in first-degree relatives — Age _ 25 years — Weight normal before pregnancy — Weight normal at birth — No history of abnormal glucose metabolism . • If necessary.

or glucosuria. acardiac anomaly. Uterine leiomyomas 7. Fetal macrosomia (late in pregnancy) Pregnancy outcome: 1)) Spontaneous abortion Management of Db KA in pregnancy 2)) Malformations (According to Schinzel anomalies in monochorionic twins generally fall into one of three categories ) ** Obtain arterial blood gases to document degree of acidosis present. A closely attached adnexal mass 8. and 25 percent fat with less than 10 percent as saturated fat. — One–step procedure: Diagnostic 100-g oral glucose tolerance test performed on all subjects. 20 percent protein. ketones.2–0. •Fluids Isotonic sodium chloride Total replacement in first 12 hours of 4–6 L 1 L in first hour 500–1000 mL/h for 2–4 hours 250 mL/h until 80 percent replaced •Glucose 5-percent dextrose in normal saline •Potassium •Bicarbonate (if pH is <7. impaired glucose metabolism.to 2-hour intervals Defects resulting from twinning itself twinning. hydranencephaly.4 U/kg Maintenance: 2–10 U/h Defects resulting from vascular interchange microcephaly. • High Risk: Perform blood glucose testing as soon as feasible.— No history of poor obstetrical outcome • Average Risk: Perform blood glucose testing at 24 to 28 weeks using either: — Two-step procedure: 50-g oral glucose challenge test (GCT). *** Two or more of the venous plasma glucose concentrations indicated below must be met or exceeded for a positive diagnosis Page 37 • An ideal dietary composition is 55 percent carbohydrate. using the procedures described above if one or more of these are present: — Severe obesity — Strong family history of type 2 diabetes — Previous history of GDM. measure glucose. Inaccurate menstrual history 4.1) Twin Pregnancy In women with a uterus that appears large for gestational age. Diagnosis of Gestational Diabetes by Oral Glucose Tolerance Testing. Elevation of the uterus by a distended bladder 3. . Hydatidiform mole 6. the following possibilities are considered: 1. Time Fasting ! hr 2 hr 3 hr 100-g Glucose 95 180 155 140 75-g Glucose 95 180 155 - ** The test should be performed in the morning after an overnight fast of at least 8 h but not more than 14 h and after at least 3 days of unrestricted diet and physical activity. Multiple fetuses 2. neural-tube defects •Insulin Low-dose. Hydramnios 5. and electrolyte levels at 1. followed by a diagnostic 100-g oral glucose tolerance test for those meeting the threshold value in the GCT. intravenous Loading dose: 0.

which cauterizes umbilical vessels in the malformed recipient twin so as to terminate blood flow from the dono Twin-Twin Transfusion Syndrome (TTTS): (In this syndrome. chronic TTTS results from unidirectional flow through arteriovenous anastomoses. often also accompanied by a vein-to-vein shunt where ultimatly only the lower body of rcpt twin is perfused. the duration of gestation decreases (twin gestations have empirically been considered to be prolonged at 40 weeks.) Acardiac twinning: (Twin reversed-arterial-perfusion (TRAP) serious complication of monochorionic multifetal gestation). hemodynamically significant shunts develop between fetuses. giving rise to the descriptive term stuck twin or hydramnios- oligohydramnios–―poly-oli‖–syndrome Treatment: The prognosis for multifetal gestations . aplasia cutis. blood is transfused from a donor twin to its recipient such that the donor becomes anemic and its growth restricted & recipient becomes polycythemic and may develop circulatory overload manifest as hydrops. . Two such significant patterns include acardiac twinning and twin-twin transfusion syndrome.Failure of any recognizable structure to form is acardius amorphous Radiofrequency ablation. The donor twin is pale. . Page 38 ( In the TRAP sequence. however.Partially developed head with identifiable limbs is called acardius myelacephalus. and its recipient sibling is plethoric Similarly. Defects may develop from fetal crowding** Talipes equinovarus (clubfoot) or congenital hip dislocation. ** Dizygotic twins are also subject to these 3)) Birthweight Multifetal gestations are more likely to be low birthweight than singleton pregnancies. and the recipient fetus develops severe hydramnios Virtual absence of amnionic fluid in the donor sac prevents fetal motion. Typically presents in midpregnancy when the donor fetus becomes oliguric from decreased renal perfusion & develops oligohydramnios. In others.Failure of head growth is called acardius acephalus. .) Vascular anastomoses between twins are present only in monochorionic twin placentas (Most of these vascular communications are hemodynamically balanced & are little fetal consequence. and disrupted growth and development of the upper body results. one portion of the placenta often appears pale compared with the remainder) Classically. due to restricted fetal growth and preterm delivery **The degree of growth restriction in monozygotic twins is likely to be greater than that in dizygotic pairs 4)) Duration of Gestation As the number of fetuses increases. there is usually a normally formed donor twin who has features of heart failure as well as a recipient twin who lacks a heart (acardius) and other structures) TRAP sequence is caused by a large artery-toartery placental shunt.between monochorionic twins intestinal atresia.

laser ablation of vascular anastomoses. and prophylactic cervical cerclage. (How ever none had valid evidence of improving outcome) 5)) Corticosteroids for Lung Maturation Anemia Complicating Pregnancy Discussion Monochorionic twins: The modest fall in hemoglobin levels during pregnancy is caused by a relatively greater expansion of plasma volume compared with the increase in red cell volume The disproportion greatest during the second trimester. cephalosporins) Aplastic or hypoplastic anemia Hereditary Thalassemias Sickle-cell hemoglobinopathies Other hemoglobinopathies Hereditary hemolytic anemias • Amount of iron diverted to the .complicated by TTTS is extremely guarded. and septostomy (intentional creation of a communication in the dividing amnionic membrane ** Once identified.) 3)) Antepartum Surveillance: (An AFI of <8 cm– Iron-deficiency anemia Anemia caused by acute blood loss Anemia of inflammation or malignancy Megaloblastic anemia Acquired hemolytic anemia (Cold-agglutinin disease may be induced by Mycoplasma pneumoniae or EBV / Drug induced : penicillin. TTTS is typically staged by the Quintero staging system (I – V) + cardiovascular profile score or CVPS below the 5 th percentile or >24 cm–above the 95th percentile–was considered abnormal at gestational ages of 28 to 40 weeks) 4)) Prevention of Preterm Delivery: bed rest– especially through hospitalization. selective feticide. Late in pregnancy. With multifetal gestation. while hemoglobin mass continues to increases Symmetrical Asymmetrical Causes of Anemia During Pregnancy Acquired Separate Conjoined Ventral Lateral Dorsal caudal External Internal Trap Parasite TTTS Fetus in situ Page 39 Antepartum management 1)) Diet 2)) Mangaemnt of hypertension (fetal number and placental mass are involved in the pathogenesis of preeclampsia. hypertension not only develops more often but also tends to develop earlier and to be more severe. prophylactic administration of beta-mimetic drugs or progestins. Therapies currently used:amnioreduction. plasma expansion essentially ceases.

Adenomyosis Endocrine 1. Acquired a. Antiphospholipid antibodies b. Chromosomal 2. Medical illnesses (cardiac. Cervical incompetence 2. Cervical incompetence b. Sickle cell anemia: Pregnancy complications Cerebral vein thrombosis Pneumonia Pyelonephritis deep-venous thrombosis Pulmonary embolism Sepsis syndrome Delivery Complications Gestational hypertension/preeclampsia Eclampsia Placental abruption Preterm delivery Fetal-growth restriction Bad Obstetric History Traditionally. recurrent pregnancy loss (RPL) occurs in approximately 1 in 300 pregnancies Causes of recurrent abortions 1. Antithyroid antibodies d. recurrent abortion has been defined as the occurrence of three or more clinically recognized pregnancy losses before 20 weeks from the last menstrual period. Luteal phase insufficiency 2. Th1 immune responses to reproductive antigens (embryo or trophoblast) 2. Smoking) 3.fetus is similar in a normal and in an iron-deficient mother. Other androgen disorders 4. Thyroid disorders 6. Incomplete mullerian fusion or septum resorption b. Cellular mechanisms 1. Blocking antibody deficiency Thrombotic factors Other factors 1. Using this definition. Congenital a. Environmental (Toxins. marginate) 4. PCOD 3. adhesion molecules) 2. Uterine artery anomalies c. one or more clinical and one or more laboratory criteria must be present (BARDA’S Criteria) : Clinical ● One or more confirmed episode of vascular thrombosis of any type a)) Venous b)) Arterial c)) Small vessel ● Pregnancy complications a)) Three or more consecutive spontaneous pregnancy losses at less than 10 weeks of gestation b)) One or more fetal deaths at greater than 10 weeks of gestation c)) One or more preterm births at less than 34 weeks of gestation secondary to severe preeclampsia or placental insufficiency Laboratory ● Positive plasma levels of anticardiolipin antibodies of the IgG or IgM isotype at medium to high levels ● Positive plasma levels of lupus anticoagulant . Single gene defects 3 Multifactorial Page 40 Anatomic factors 1. Altered uterine receptivity (integrins. the newborn infant of a severely anemic mother does not suffer from iron-deficiency anemia & neonatal iron stores are related to maternal iron status and to timing of cord clamping. Th2 cytokine or growth factor deficiency 2. Diabetes mellitus 5. renal hematologic) 5. Humoral mechanisms a. Leiomyomas d. Prolactin disorders Infectious factors Immunologic factors 1. Dyssynchronous fertilization For a patient to be diagnosed with APAS. Antitrophoblast antibodies e. Placental abnormalities (circumvallate. Synechiae c.

Thyroid examination Following conception.Personal or familial thrombotic history 7.Lupus anticoagulant (activated partial thromboplastin time or Russell Viper Venom) 5.Anticardiolipin antibody level 4. and placental infarction 1st trimester scan:. and characteristics of prior pregnancy losses 2.Menstrual history 4. G20210A prothrombin gene mutation. ** Psychological counseling and supportis recommended for all patients.Family history of recurrent spontaneous abortion.Thyroid-stimulating hormone level.Factor V Leiden. protein S activity.Protein C activity. false positive test for syphilis) 8.TIFA (targeted scan for fetal anomalies) – early 14 – 16w / late >20w 3 rd trimester scan:- 4.Breast examination/galactorrhea 5.Signs or symptoms of thyroid.Prior or current gynecologic or obstetric infections 5. serum prolactin level if indicated 3. . glucose tolerance and PCOS 6. antithrombin level if personal or family history of VTE ** Postconception Evaluation: Normal weight gain: starts from 12w (2kg/month) Investigative Measures Useful in the Evaluation of Recurrent Early Pregnancy Loss History 1.Pelvic examination (infection / masculinization) Laboratory 1.Pattern.Genetic relationship B/W reproductive partners 9.Complete blood count with platelets 6. activated protein C resistance 7. obstetric complications.Features associated with the antiphospholipid syndrome (thrombosis. trimester.Parental peripheral blood karyotype 2. and a variety of immunologic interventions and drug treatments.Obesity 2.Dating scan 2 nd trimester scan:. patients with histories of RPL should be monitored closely to provide psychological support and to confirm intrauterine pregnancy and its viability.** The presence of antiphospholipid antibodies (anticardiolipin or lupus anticoagulant) during pregnancy is a major risk factor for an adverse pregnancy outcome Pathogenesis Antibodies against phospholipids could increase thromboxane and decrease prostacyclin synthesis within placental vessels. The incidence of ectopic pregnancy and complete molar gestation is increased in women with a history of recurrent spontaneous pregnancy loss. platelet adhesion. prolactin.Hirsutism/acanthosis 3. or any syndrome associated with embryonic or fetal losses Page 41 Physical Examination 1. The resultant prothrombotic environment could promote vascular constriction. homocysteine level. • There has been increasing support for the Use of insulin sensitizing agents in the treatment of RPL that occurs in the presence of PCOS Therapeutic options that currently exist 1)) Use of donor oocytes or sperm 2)) Use of preimplantation genetic diagnosis 3)) Use of antithrombotic interventions 4)) Repair of anatomic anomalies 5)) Correction of any endocrine abnormalities 6)) Treatment of infections.History of subfertility or infertility 3.

50– 100 µg.Membrane Stripping for Labor Induction ** Improve Bishop score (Promote cervical ripening) *** Insert has shorter I-D times than gel LABOR INDUCTION AND AUGMENTATION WITH OXYTOCIN In most instances.Mechanical Labour induction Terminology 1. High dose 4 4. as described above. magnesium Sulphate)** . repeat in 6 hr. 20 25. however. 16. 12. permit 3 doses total Posterior fornix. Hatfield’s Score for cervical length was used Where Cervical length is assessed by transvaginal sonography and used to predict successful induction.5 6 4 4. Uterine tachysystole is defined as >6 contractions in a 10-minute period.5 6 Quickening + 22w = EDD For twins: Gravida 1 para 2 and glyceryl Trinitrate) Grade Level (upto) edema 15 15 . ―ripening‖ will also stimulate labor. ***Hyperstimulation is more common with shorter intervals. 30 15 Cervical 0. repeat 3–6 hr prn Oral. Uterine hyperstimulation is when either condition leads to a nonreassuring fetal heart rate pattern As an alternate to the Bishop score. If not. Uterine hypertonus is described as a single contraction lasting longer than 2 minutes. pre-induction cervical ripening and labor induction are simply a continuum. it is restarted at 1/2 the previous dose and increased at 3 mU/min incremental doses.5 1 15 . 8. Often.5–1.5 mg. 3. 10 mg Low dose Vaginal.30 20 – 40 . 2. induction or augmentation may be continued with oxytocin Regimen Pharmacological** -Prostaglandin E2 (dinoprostone) (GEL – Prepidil / INSERT . 25 µg. repeat 3–6 hr prn ** With hyperstimulation and after oxytocin infusion is discontinued.Cervidil) -Prostaglandin E1 (Misoprostol—Cytotec) (TABLET – 100 / 200 µg) Page 42 -Nitric Oxide Donors (isosorbide mononitrate Starting Incremental dose increase Interval (Min) 0. ** However it was found that cervical length determination by sonography was not superior to use of the Bishop score Technique & Agent Route -Transcervical 36F catheter* * -Extra-amnionic Saline Infusion (EASI)** -Hygroscopic Cervical dilators (Laminaria.40 2 4.

visual disturbances.1 2 3 4 Ankle Knee Ant abd wall anasarca Physiological Grade 1 During evening times Disappears on early morning / 8hrs of bed rest > 28 w (usually) Venous compression.100 Microg anti –D after 12w:. H/O decreases fetal movements: in 3 rd trimester Iron prohylaxis given from 16w: due to increased demands Standing L side of patient: Only during lap. harmones Pathological >1 During morning times also Don’t disappear Mid trimester also Anemia. headache.300 Microg anti –D In Rh –ve pregnancy: Clamp is applied immediately & NO cord milking done During labour NO external cephalic version NO manual removal of placenta NO artificial rupture of membranes Trial of vaginal delivery in Platypelloid pelvis: Engagement takes place for long time . Cardiac Iminent eclampsia: Confusion. In HTN: methyl ergometrine & PGF2alpha contraindicated For any procedures before 12w:. low UO. vomiting + eigastric pain. Once it occurred then delivery is fast (coz Only AP diameter of inlet is shortened other part is Normal) Page 43 Munrokher muller test : NO BRIM cpd Unengaged head reasons (primi) ** •Post position of occiput •Pelvic contraction •Pelvic tumours •High pelvic inclination •Placenta previa •Conjoined twins •Deflexed head •Fetal anomalies (Hydrocephalus) •Wrong dates ** Even at term . pre eclampsia. If head is ballotable then don’t do 2 nd pelvic grip.

1)) Prolapse Uterus 3 Page 44 GYNECOLGY 2)) DUB 3)) Fibroid uterus 4)) Ovarian mass .

Atrophic labia majora. IHD. Labia minora Not visible.S1 & S2 heard. Pink mass per vaginum with cervical lips seen On ant vaginal wall . TB. No other murmers heard Respiratory Examination: BLAE +ve & N vesicular sounds heard with No adventitious sounds Diagnosis: A 65 yr old post menopausal women came with P3L3 with 3 degree uterine prolapse with cystocoele & Enterocoele & also poor pelvic floor tone. N in volume. . epilepsy.. chest pain / Jaundice & bleeding disorders Page 45 MENSTRUAL H/O: Reached menopause 10 yrs back previous cycles . RHD. HR: 83/min. appetite: reduced B/B: regular.4/28. & rhythm No RR/RF delay No vessel wall thickening BP: 160/90 mm hg RUL: Supine RR: 18/min regular JVP: NOT raised LOCAL EXAMINATION Perineal examination: Scanty pubic hair. 3-4 pads / day No H/O white discharge No H/O clot passage No H/o dysenorrhoea OBSTETRIC H/O: P3L3 1st pregnancy – FTNVD – Male . Puborectalis (at 4 & 8 o clock) – poor tone SYSTEMIC EXAMINATION CVS examination.Home – Local Dai – 43 yrs – N baby – After 2 yr 3 rd pregnancy – FTNVD – female – Local Dai – 45 yrs – N baby – After 1 yr Not sterlized FAMILY H/O: Not significant PERSONAL H/O: Diet: mixed. C/C: Mass per vaginum – 4 yrs H/P/I: Patient was apparently assymptomatic 4 yrs back then she noticed mass per veginum which is initially lemon size gradually progressive to reach present size.Home – Local Dai – 45 yrs – N baby – After 1 yr 2 nd pregnancy– FTNVD – Male . Levator ani tone poor. character. Moderately built & with BMI ?? P (-) I (-) C (-) C (-) K (-) L (-) Vitals – afebrile.Prolapse Ananthamma/65/nizamabad/SEIV & labourer 10 yrs back.Keratinization (3*3 cm) seen & vaginal mucosa – atrophic No urine passage with coughing P/S: Enterocole & No rectocoele P/V: Uterus retroverted. Sleep: disturbed Addictions: Non smoker & Non alcoholic & NON consangious marriage GCOE: Patient is C/C/C. gaping introitus. Reducable manually & increases in size on lifting weights & coughing H/O back ache initially for 1st 2 yrs which was localized aggravated on standing & relived on sleeping Now there is No back ache H/O difficulty in micturition on straining H/O lifting weights for 30 yrs No H/O Chronic cough No H/O any discharge PV NO H/O wound on mass PV NO H/O constipation NO H/O leaking of urine on coughing NO H/O irreducibility episodes NO H/O fever with chills & rigor with burning micturition No H/O frequency of micturition PAST H/O: NO H/O HTN NO H/O DM.

DISCUSSION:

symphisis & Highest Point on post vaginal
fornix.

Different classifications
1)) Shah’s classification
2)) Malpas Classification:
a)) UV prolapse:
ligament weakening
b)) Nulliparous / general:
Muscle weakening
3)) Jaffcoat’s Classification
4)) POP – Q Classification
POP – Q:The classification uses six points along the
vagina (two points on the anterior, middle &
posterior compartments) measured in relation to the
hymen.
The anatomic position of the six defined points
(Aa,Ba,C,D,Ap,Bp) should be measured in
centimeters proximal to the hymen (negative
number) or distal to the hymen (positive number),
with the plane of the hymen representing zero.
Three other measurements include genital hiatus,
perineal body, and the total vaginal length.
Accordingly divided into stage 0 – stage IV
Treatment
a)) Non surgical (PFMT, pelvic floor muscle tone,
Biofeedback in rectocoele & Pessary:

Pessaries

Page

46

Support and Space filling
1)) Ring pessary (with diaphragm) is
a commonly used support pessary, and
2)) Gelhorn pessary is a commonly used
space–filling pessary.
** Support pessaries are recommended for
stage I and II prolapse {O,U,R,I pessaries},
*** Space–filling pessaries are used for stage
III and IV prolapse {X,L,M,N,W,G,F}
Cystocoele &/or rectocoele {J,I}
Pessary measured – Bimanually: pubic

b)) Surgical: U2/3, L 1/3 with U1/3 (enterocoele)
M1/3 (Rectocoele) L1/3 (perineal body prolapse)
1)) UV prolapse:
Radical / Waldmeyer
[ >40, >35*]
conservative [Shirodkar’s surgery – No stenosis,
patulous & fothergill’s surgery – Stenosis, patulous]
2)) Nulliparous: Abd / Vaginal sling operations &
org (purandeswar’s – Lat sling) / Inorg (shirodkar’s –
Lat. & Khanna – Post)
Decubitus ulcer pathology:
- arterial kinking
- Venous congestion
- trauma
Measurement of supravaginal portion of cervix:
Passing sound upto Internal os (resistance felt) –
minus Passing sound into lat fornix (difference gives
the length)

Ovarian mass

Uterine mass

Usually cystic

Usually firm / hard

R/L

Midline

Movable side to side &
also vertcally

Movable side to side

Transmitted movements
-ve

Transmitted movements
+ve

Can feel all borders

Lower border is usually

not felt
Hingorin Sulcus present
between ovarian mass
& uterus

Absent

Midline masses: adenomyosis, fibroids, pregnancy,
encysted acsitis, full bladder
Tendercervical movements: Endometriosis & PID
Frozen pelvis: TB, PID, Radiation, retroperitoneal
fibrosis, Invasive mole
Common diseases of reproductive age women:
Fibroids, endometriosis, PID
Dictum any uterus >12w: fibroid
If < 10w: fibroid / adenomyosis

Page

47

Endometriosis & Adenomyosis: Triple
dysmenorrheal:- pain before, during & after
menstruation

1)) Varicose veins
2)) Thyroid swelling
3)) Breast swelling
4)) Inguinal hernia

4
SURGERY

5)) Hydrocoele
6)) Salivary gland swelling
7)) PVD (Chronic)
8)) Abdominal lump

Page

48

9)) Ortho Cases

NON pulsatile swelling are seen in upper ½ of medial aspect of R leg extending upto lower ½ of medial aspect of thigh. TB. HR: 84/min BP: 120/84 mm hg RUL: supine. Healed ulcer on dorsum of R foot: Irregular in shape. Insidious in onset & initially progressed for 1 month with serous discharge then by medication decreased in size and at present there is no discharge Associated with pain – insidious in onset . Insidious in onset & gradually progressive: initially noticed below knee gradually extended from mid thigh to mid leg level. continuous . DM. epilepsy. NO H/O similar complaints in past. engorged.VARICOSE VEINS Vijay/Male/39/Cook/Kudappah/ 17 – 07 – 12 C/C: Multiple linear swellings in R Lower limb From 22 years wound and pain in R foot from 2 months H/C/C: Patient was apparently asymptomatic 22 years back then he noticed Swellings just below his R knee which where asymptomatic until 2 months back when he developed wound on dorsum of R foot then he went to local Govt hospital (RIMS) where Some treatment is given and was referred to Gandhi hospital. dilated. Not associated with pain Page 49 Wound on dorsum of R foot – 2 months. extending from 2 cm in front of medial malleolus to . Aggravated during walking & end of day. Moderately built & adequately nourished with N gait P (-) I (-) C (-) C (-) K (-) L (-) E (-) Vitals – a febrile. No H/O Rupture & resulting in blood loss. chest pain & SOB No H/O prolonged travel/immobilization No H/O difficulty In walking. Past H/O: Jaundice . Comfortably seated. Multiple linear swellings in R lower limb – 22 years. elongated.1 yr back – hospitalized & treated with medications. HTN. NO radiation of pain & Not disturbing the sleep No H/O intermittent claudication No H/O Night cramps No H/O painful swelling / discoloration of Lower limb No H/O fever No H/O trauma (orthopedic – knee) No H/O any swelling in abdomen No H/O Ankle swelling / Skin Itching No H/O Constipation No H/O Hmptysis. chest pain & bldng disorders Treatment H/O: No H/O any Injection treatment & No H/O any surgical procedures / Long term medical treatment Personal H/O: Diet: mixed Appetite: N B/B: regular Sleep: N Addictions: Non smoker & occasional alchoholic Family H/O: No H/O similar complaint in family & No H/O any chronic illness in family Physical examination (A) general survey – patient is C/C/C . (using a pillow under the foot) No H/O decrease In size of swelling on walking No H/O Thickness/tenderness of swellings. RR: 20/min (B) Local examination – Patient is undressed upto umbilicus & examined in standing & supine position 1)) Inspection: Attitude of limb: N On inspection multiple linear tortuous. dragging type . Relieved on taking rest & sleeping with elevated leg. aggravated on standing & relieved on sleeping .

Flush: Close / near to Short saphenous Vein stripping: NOT done usually 1)) Incompetent perforators are hardly found in association with SSV 2)) Causes long standing oedema 3)) May permanently damage Sural Nerve Varicose Ulcer management: Bisgard Conservative management →→ surgical correction of varicose veins →→Split skin graft (last) . Upper L.2 cm behind great toe.falre are visible NO swelling visible at saphaneous opening Other limb appear N on inspection 2)) Palpation: NO local rise of temperature NO redness along the swellings / ulcer area No oedema / Tenderness on lower part leg Brodie trendelenberg test Test – 1 : +ve Test – 2 : +ve Multiple tourniquet test: Below knee perforator in incompetent Modified perthes test Schwarz test: .ve Neuhof’s sign: -ve All Peripheral pulses: palpable (R & L) Other Limb: N 3)) percussion: Schwartz -ve 4)) Auscultation: Continous Murmur / Bruie absent at saphenofemoral junction.ve Mose’s sign: .ve Homan’s sign: .present Swellings disappear spontaneously on lying down NO redness along the swellings NO areas of any Blow outs / NO V. Vertical: Not palpable) Popliteal: Not palpable 6)) Measurements – Mid leg circumference R(31cm)/L( 29cm) 7)) Movements – range of movements of lower limb are with in N range (C) Systemic examination: 1)) Abdominal examination: Umbilicus is midline NO Lumps palpable / Palpable organomegaly NO free fluid 2)) Respiratory system: BLAE: N & N vesicular sounds heard NO adventitious sounds 3)) Cardiovascular system: Heart sound 1 & 2: Heard & No murmurs heard Diagnosis: Primary Right sided Partial varicosity of Great Saphenous Vein with Competent SFJ and Incompetent below knee perforators with Complicating as venous Ulcer Discussion: If Skin changes : +ve → Chronic venous insufficiency (CVI) → Treatment Only surgery NO role of conservative truss usage.ve Fegan’s test: a defect in deep fascia is felt 2cm below tibial tuberosity on medial side of leg Morrisay’s cough impulse test: . 5)) Regional Lymph nodes examination: Page 50 Inguinal (Upper M. surrounding skin – healed scars present discoloration of skin from toe to 2 cm above ankle is seen & hair loss on foot & brittle nails .

CVI causes (3): HIGH AMBULATORY VENOUS HYPERTENSION 1)) Varicose veins 2)) DVT (After recanulation gravitational pressure of blood column transmitted unimpeded to ankles which alone is not sufficient enough to produce serious stasis it must occur along with incompetent perforators) 3)) Perforator incompetence (high ambulatory V pressure developing within deep veins of calf during excersie → directly transmitted to superficial venous system → ↑ capillary pressure in surrounding skin → oedema. Perforators: Page 51 1)) Indirect (upper part of leg) 2)) Direct in Thigh: adductor canal Leg: medial (5cm .17cm above lateral malleolus) Short SV & peroneal veins. 12cm. Lateral (5cm.Drainage of short SV (7 – 13 valves) to Popliteal fossa: 3 to 7.11 days after post . recurrent. surrounding bluish discoloration & erythematic. Pulmonary embolism usually occurs 6 . 15cm above medial malleolus) 1st 2 enter POST TIBIAL VEIN Where Soleal venous sinuses also enters it. ulceration Venous ulcer: Shallow. last perforator connects long SV with posterior TV. Surgical management of pulmonary embolism: 1)) Ligation of IVC just distal to R renal vein 2)) venous interruption (lower limb): arterial sutures/plastic clip : proximal to site of thrombus (determined by phlebography) 3)) Pulmonary embolectomy . this give rise to swelling of ankle: ANKLE FLARE. fat necrosis.op period In case of varicosity of Long SV small veins from sole of foot & ankle which drain into this venous system through MEDIAL MARGINAL VEINS becomes dilated.5cm above the level of knee joint Forcible contraction of calf muscles → force blood through perforating veins in reverse direction → destruction of valves of perforating veins → varicose veins (rickshaw pullers) Cramp (sudden change in caliber of communicating veins which stimulates the muscles through which they pass) in calf shortly after retiring to bed. tender. Central: Short SV to veins of gastrocnemius & soleus (practically UNIMP). Not extend beyond deep fascia appear spontaneously preceded by itching /trivial trauma . Sclerotherapy: varicose veins confined below knee. 10cm.

inflammation & pigmentation) / ankle flare. The lower abdomen and the affected leg are prepped. High ambulatory V pressure defective microcirculation Extravasation of RBC Fibrin Haemosiderin Eczema & Dermatitis WBC (mast cells. 52 Venous entrapment: Axillary (1st rib & clavicle) & Popliteal vein (abnormal insertion of Gastrocnemius muscle) → Sweeling of limb after exercise Page Gaiter’s area: area between calf muscles & ankle: COCKETT PERFORATORS JOIN POST TIBIAL VEIN & POST.monocytes) Fibrin cuff release of ROS & proteolysis E Diffusion block Hypoxia Poor repair tissue damage (ulcer) Loss of SC fat Std Doppler is NOT AN ACCURATE method of establishing Incompetence in SSV coz of its variable termination so Duplex scans is mandatory Another cause of ulcer has to be sought is there is no surrounding evidence of Lipodermatosclerosis (Thickening. Next. 3)) These tributaries are ligated & The junction of 2 veins is dissected and exposed. the greater saphenous vein is divided between clamps . The procedure can be performed under either SA/GA. and an oblique longitudinal incision is placed just medial to this point 2)) The patient is placed in the supine position. and a stockinette is placed over the leg. (Avoid damage to saphenous N). ARCH VEIN Ulcers due to LSV Varicosity: medial side of calf Ulcers due to SSV Varicosity: lateral side Post thrombotic: Any part of calf skin Operative Notes: 1))Incision: femoral pulse is palpated in the groin.Above knee stockings are never preferred Great SV is stripped only up to just below knee. indurations.

dragging type. NO H/O Significant loss of weight NO H/O any swellings in abdomen. HYDROCOELE Venkatnarayana/55/Khammam/agricultural labour/ 31 – 07 . 8)) The saphenopopliteal junction is carefully dissected while avoiding any injury to popliteal artery and sciatic nerve. Surface over swelling is even except there is constriction in middle at about 4 cm from root of scrotum. Continuous. NO H/O Increase of swelling with cough / Straining. a Goldman vein stripper with the olive head at the distal end is gently passed 6)) alternative method of addressing the varicosed venous branches is to ligate the preoperatively identified perforators in the thigh and the leg 7)) In SSV varicosity: A transverse incision is placed along the popliteal fossa crease with patient in prone position varicosed lesser saphenous vein is identified and followed through the fascia toward the popliteal vein. NO Excoriation of skin. Special care is taken not to narrow the femoral vein during this process.12 Page 53 C/C: Swelling of right side of scrotum from 2 years H/C/C: The patient was apparently asymptomatic 2 years back then he developed swelling on R side of scrotum then went to local Doctor where some medications are given & used them for 1 month the swelling did not resolve & started increase in size so went to local govt hospital from where he was referred to Gandhi hospital Swelling in R side of scrotum – 2 years Insidious in onset. NO expansile cough impulse. there is NO scars / sinuses (on POSTERIOR region of scrotum) / Ulcer (ANTERIOR part of scrotum) / engorged veins seen. 4)) The saphenofemoral junction is ligated with 0-0 silk sutures. No radiation of pain & pain Not disturbing the sleep NO H/O reducibility of swelling (Spontaneously on sleeping/manually). 2)) Palpation: NO local rise of temperature. Local examination: Patient is Undressed from umbilicus to mid thigh level & examined in standing & supine positions. NO H/O fever with chills & Swelling of feet NO H/O sudden increase / spontaneous decrease of swelling NO H/O burning micturition / white discharge NO H/O of frequency of micturition with polyura/dysuria & loin pain NO H/O exposure to venereal diseases NO H/O evening rise of temperature with cough & sputum. Consistency: Firm (cystic) . NO H/O trauma. Associated with pain which is Scrotal in location. The short saphenous vein is divided between clamps and ligated & finally a suture ligature is placed at the saphenopopliteal junction.approximately 1 cm away from the saphenofemoral junction. 5)) The next step depends on whether stripping of the greater saphenous vein is to be performed. and a 2-0 silk transfixion suture ligature is placed. progressive Rlved by sleeping. NO local tenderness. NO H/O any surgeries in groin region. 1)) Inspection: A 6 (horizontal) x 10 (vertical) x 6 (thickness) swelling is seen on R side of scotum which is vertically oval extending from root of scrotum to base of scrotum which is at midthigh level & Skin over swelling is N except for loss of rugosity. Penis is deviated to left and buried partially. gradually progressive. If stripping of the greater saphenous vein is to be performed. Aggravated by walking. Getting above swelling: +ve. Stripping of the greater saphenous vein can be avoided because the vein usually collapses and becomes sclerosed as long as the saphenofemoral junction and any incompetent perforators have been ligated.

comparably tense. Abdominal examination: Umbilicus is midline NO Lumps palpable / Palpable organomegaly NO free fluid PR: Not done Diagnosis: R sided primary uncomplicated vaginal hydrocoele Discussion Page 54 Hydrocoele: FLUCTUATION +ve (trans illumination may/may not +ve).Reducibility: -ve Compressibility: -ve Fluctuation: +ve Transillumination: +ve. Testis: palpable & testicular sensation +ve 3)) Percussion: DULL 4)) Local lymph nodes (inguinal): NOT palpable. During palpation: we feel cord:. In tense swelling fluctuation is difficult to perform but present. Cord thickened + Appear nodular : Tuberculosis. N vaginal fluid: 3 – 5 ml.Vas + fibres of cremastric muscle. Haematocoele → late complication testicular atrophy. Infections: treat it (even if then persists – Surgical management). Decrease of swelling size spontaneously on lying down – . Urogenital TB: always secondary to primary focus (pulm/renal). (Secretion ↑ → secondary & absorption ↓ → primary hydrocoele) Treatment: Secondary – Small swelling: conservative. (To tell hydrocoele never tell coz getting above swelling is +ve – it just tell that the swelling is confined to scrotum) Transillumination +ve: Clear fluid + sac is thin (if any of them / both –ve: Test –ve). tumor cells reach tract then skin finally paraoartic LN → UPSTAGING of cancer. Testicular sensation: by applying pressure on testis pain is felt in EPIGASTRIC region. [ lord’s fibrous band: in midgut malrotation & Lord’s fundoplication in GERD] Usually CORRUGATED rubber drainage tube is kept (BLUE colour). In Congenital hydrocoele: treatment is HERNIOTOMY Getting above swelling: -ve Cough impulse: -ve (By which Congenital inguinal hernia is distinguished) Fluctuation: +ve Reducability: +ve In infantile Hydrocoele: treatment is EVACUATION + SAC EVERSION In lord’s plication usually drain is NOT kept post operatively. Scrotal contents: Testis with its coverings + epididymis + lower part of spermatic cord. Tumour: treat tumour (NO separate treatment for hydrocoele). testis lymphatic drainage is para aortic LN so if done. [In seminoma testis NO BIOPSY/FNAC – scrotum lymphatic drainage is inguinal. N physiology: visceral layer secretes → Parietal layer absorbs. Causative history is absent. Sometimes Cord may appear thickened: because of hypertrophied cremastric muscles due to chronically bearing weight of big swelling. testis NOT palpable. Vaginal: getting above swelling +ve – Swelling is confined to scrotum.] Operation principle: Evacuation + NO sac + ↑ area of absorption (Now fluid is exposed to undersurface of skin → absorption). area of constriction may present (DUMBBELL: NO explanation). Primary: Moderate to large.

Spermatocoele. Spermatocoele (some cases). cysts of epidydims. Inguinal lymph nodes are not enlarged in pyocoele +ve sign of empty – Compressability (can regain its previous size on its own if pressure is released). Lymph varix. Skin rugosity increases in elephantiasis. with powerful torch is may appear as transillumination (falsely +ve). recent haematocoele. In lodd’s operation drain is not kept usually. Constipation) NO H/O symptoms suggestive of primary hyperthyroidism ( weight loss inspite of increased appetite . Cystic areas of teratoma. Filariasis of genital areas: Hydrocoele . Fluctuation: Transmission of impulse at 2 planes right angles to each other. In transillumination 1st illuminate N side scrotal skin then interpret diseased side (In some skin is very thin. Varicocoele. Protruding eyes. Elephantaisis THYROID SWELLING Lakshmi /25 /F /house wife / adilabad / married / 07 – 12 C/C: Swelling in front of neck H/C/C: The patient was apparently asymptomatic 2 years back then she noticed a swelling in front of neck which was initially pea sized then she went to local govt hospital 6 months where she was given some treatment for 1 month but swelling did not reduce in size and was finally referred to Gandhi hospital NO H/O evening rise of temperature & cough NO H/O any discharge from swelling NO H/O trauma NO H/O radiation exposure to neck NO H/O pain and fever NO H/O Spontaneous regression/ sudden increase in size of swelling NO H/O symptoms suggestive of hypothyroidism (like loss of hair. weight gain inspite of decreased appetite. lethargy. memory disturbances. After opening of sac if testicular atrophy is present we perform low orchidectomy.fatigue. Cystic Swellings of scrotum – hydrocoele. Congenital hydrocoele Tuberculosis sinus – posteriorly & Chancre – anteriorly: May be reversed if there is an ANTEVERTED testis – (7 – 8%) of cases: diagnosed by examination of opposite testis. Excoriation of skin in hydrocele: 1)) buried penis – urine pass over the swelling – excoriation 2)) Rubbing of thigh. Transillumination +ve: Cysts of hydatid of morgagni. Another use of transillumination is identify position of testis (N / anteverted) Page 55 Nodules on surface of scrotal skin – 1)) sebaceous cysts 2)) herniation of hydrocoele sac – Tunica vaginailis herniates through fibres of cremastric & spermatic fascia to lie underneath skin 3)) malignancy of testis. Double vision. Cysts of hydatid of morgagni. Chylocoele. lymph varix. PR examination – Tubercular epidydimis: enlarged seminal vesicle sometimes enlarged prostrate also. hydrocoele. tiredness.Inguinal hernia. cysts of epidydims & Cystic areas of teratoma Torch never kept posterior in hydrocoele coz testis obstructs light path making transillumination falsely –ve: however it is kept posteriorly to see transillumination of cysts of epidydimis. Difference between lodd’s & jabouly’s is that in the later. Difficulty in eye closure) NO H/O symptoms suggestive of secondary . chylocoele. sac is dissected out of scrotum and then incised & drained.

Constipation. appetite: N B/B: regular.Not moist / warm / Inelastic Vitals – a febrile.confirmatory Margins well defined & regular (including upper) Surface: smooth & even Consistency: uniformly firm plane of swelling : deep to sternocleidomastoid Mobility: Horizontal: +ve & vertical –ve Swelling do not moves on protrusion of toungue. No H/O passage of any clots Marital life: 4 years & 2 children Page 56 Family H/O: No H/O similar complaint in family & No H/O any chronic illness in family Physical examination (A) General survey – patient is C/C/C. palpitations. Eye Movements : N range No periorbital puffiness & tongue show NO tremors & there is no enlargement. N facies Patient mental status is N (No anxiety/dullness). Surrounding skin is N. Swelling moves with deglutition. N flow.smooth & skin over swelling is N with no engorged veins/ scars/ sinuses. DM. epilepsy. Surface of swelling . Trachea is midline Pemberton’s sign & platysma sign -ve NO dilated veins over upper part of chest NO other swellings visible in neck NO increase in size on coughing (plunging type) (2) Palpation: NO local tenderness NO local rise of temperature Site size shape extents. RR: 16/min (B) Local examination: Patient is exposed upto upper chest and examined with neck slightly flexed in sitting position from behind and from front & examining at same level as patient. [pizollo’s in obese & Short necked indivisuals] (1) Inspection: A solitary hemispherical swelling of 3 (horizontal) x 3 (vertical) size present infront of neck in midline with distinct lateral & inferior border. Thinly built & adequately nourished with P (-) I (-) C (-) C (-) K (-) L (-) E (-) Cnj – N & pupils are N & reacting equally. TB. Comfortably seated. Jaundice & bleeding disorders Treatment H/O: No H/O any surgical procedures / Long term treatment Personal H/O: Diet: mixed Salt +ve NO special predilection to cabbage like vegetables. Legs: Normal Skin: Normal . exertional dyspnoea. HR: 76/min regular BP: 120/86 mm hg RUL: supine. Eyes & eye lids are N. Extent:. HTN. NO tracheal rings palpated in suprasternal Notch Fluctuation: -ve Kocher’s test: NOT done trachea is NOT deviated Carotids: palpable & not displaced Cervical lymph nodes: NOT palpable Other part of gland is NOT palpable clinically NO Thrills / pulsations on swelling .hyperthyroidism (chest pain. Lateral border is 2cm lateral to midline. Ankle swelling) NO H/O Difficulty in breathing No H/O preference to Cold/Hot weather NO H/O difficulty in swallowing NO H/O recent significant Change in voice NO H/O noisy respiration NO H/O similar complaints in neighborhood / in her village NO H/O any recent change in menstrual Cycle NO H/O recent Child delivery NO H/O Nocturnal dyspnoea NO H/O scalp / abdominal swelling NO H/O bone pains Past H/O: NO H/O similar complaints in past. chest pain.2 cm above sternal end of clavicle: upper border. Sleep: N Addictions: Non smoker & Non alcoholic Menstrual & obstetric history H/O: Age at menarche – 13 years 5/30 regular .

laryngeal prominence & Suprasternal Notch: same line Diagnosis: A case of Solitary Thyroid nodule (with D/D: adenoma. Ligation sequence: MTV → superior pedicle → Inferior pedicle. 1st vein to be ligated in surgery is MTV: 1)) Short vein after cutting mobility of gland is increased 2)) It is friable & drain directly into IJV if this is cut then a direct hole in IJV is created resulting in massive hemorrhage.(3) Percussion: resonant on sternum. Localized hashimoto’s. early differentiated carcinoma. dominant nodule of MNG) involving isthmus & Patient is in Euthyroid state clinically 2)) palpation: trail sign & triple finger test 3)) auscultation: Auscultated in following 3 areas:where breath sounds are heard more clearly it indicates: Tracheal location Strap muscles during surgery are cut at upper third because their N supply comes from below: Ansa Cervicalis Page 57 Why thyroid?? NECK. Tense thyroid cyst. 3)) Cardiovascular system: Heart sound 1 & 2: Heard & No murmurs heard 4)) Musculoskeletal system: N gait with Spine Normal & No long bone tenderness (C) Systemic examination: 1)) Abdominal examination: Umbilicus is midline NO Lumps palpable / Palpable hepatomegaly NO free fluid 2)) Respiratory system: BLAE: N & N vesicular sounds heard NO adventitious sounds Discussion Trachea in midline: 1)) inspection: chin . During surgery: Recurrent laryngeal nerve is identified because it is the only structure which passes vertically in trachea oesophageal groove. MOVES ON DEGLUTITION. (4) Auscultation: No Brue heard over swelling. . DEEP TO DEEP FASCIA. BUTTERFLY SHAPED SWELLING (rarely) Thyroid moves on deglutition: 1)) enclosed in pretracheal fascia 2)) berry’s ligament 3)) post lamina of pretracheal fascia is closely adherent to trachea 4)) Some times: Levator glandulae thyroidae: attached to hyoid.

We flex neck in standard method of palpation 1)) Relax deep cervical fascia 2)) relax sternocleidomastoid. 2)) Adenoma usually occurs at the junction of isthmus & lobe. In diagnosis: 1)) Number 2)) Thyroid yes/No 3)) Location 4)) Physiological status 5)) benign/malignant 6)) D/D. Page 58 Lobe involved is based on trachea position not based on midline . performed. Thyroid enlargement occurs posterior mainly because anterior layer is tough & not yielding & posterior layer is thin. IN this case Fascia tense test must be In Inspection (description) 1)) Swellling 2)) Movement 3)) Lower margin comment 4)) Trachea 5)) Other swelling. In Thyroid swellings see the carotid pulse at (lower part: NOT at classical site): Classical site (red) Lower site (black) Benign +ve +ve malignant +ve -ve Why isthmus is removed???: 1)) Compensatory hypertrophy compression on trachea. sternothyroid. How do we know that we entered Thyroid: VENOUS PLEXUS IS SEEN OVER. and superior belly of the omohyoid): 1)) if present exactly in midline (As in this case) On muscles contraction → fascia relaxes → swelling becomes more prominent 2)) if part of gland is in gap zone (arrow marks) & remaining is behind strap muscles then On muscles contraction→ pushing Out of the part behind muscles → swelling becomes more prominent. The thyroid swelling may sometimes becomes prominent on strap muscles contraction (strapsternohyoid.Pretracheal fascia is cut during surgery vertically to enter thyroid. In unilateral swelling dysphagia never occurs – Esophagus is a muscular tube & is easily displacable.

the common carotid artery laterally. degenerative. This can be achieved medically by the use of carbimazole. 5)) Physiology : Ingested Iodine → iodide → iodine trapping → PEROXIDASE → iodine → MIT & DIT MIT + DIT → TIT [T3] (oxidative condensation) DIT + MIT → R. Page 59 Thyroid gland: C5 – T1. There is NO real dyspnoea. a betablocker such as propranolol is added.Recurrent laryngeal nerve is usually found in Simon’s triangle. it is essential not to damage the recurrent laryngeal nerve supplying the normal vocal cords). Thyroid selling do not moves on deglutition: 1)) Intrathoracic extension 2)) Thyroiditis extending to surrounding region 3)) Invasion to surrounding structures 4)) Very large swelling. 5)) Redel’s & Granulomatous Thyroid MNG nodules are: colloid. which is formed by the inferior thyroid artery superiorly. Sympathetic: S.Palpation of each Lobe (from front):.M. and the esophagus medially.I cervical ganglia Parasympathetic : External & recurrent lrngl nerves. Most diagnostic feature is Presence of engorged veins on upper chest. T3]. In retrosternal Goitre Duspnoe occur when lying on 1 side only. it is rather called obstructive breathing. If the patient has evidence of sympathetic overdrive such as tachycardia. TIT [R. haemorrhagic & calcification Crile’s Method: Place thumb on gland ¬ Ask to swallow ¬ Nodules are better appreciated Lahey’s method:. cystic. Pre – op measures: 1)) Routine workup 2)) Serum Ca levels (detect hyperparathyroidism may coexist. 4)) Patients who are thyrotoxic should be rendered euthyroid. Indications for surgery in NON NODULAR goiter (partial thyroidectomy): 1)) rapid increase in size due to intraglandular hemorrhage 2)) Cosmetic reasons 3)) pressure symptoms +ve 4)) Intrathoracic extension causing respiratory obstruction.Palpate L lobe by pushing it towards L with L hand & Plpate it with R hand Age Feature Malignant lymphoma 50 – 60 yrs Medullary carcinoma 50 – 70 yrs Granulomatous Thyroiditis 40 yrs Firm painless mass indistinguishable from anaplastic type Firm smooth lump indistinguishable from Solitary Nodule Firm irregular enlargement Hashimoto Thyroiditis Colloid goitre Diffuse hyperplastic 50 yrs 20 – 30 yrs 10 – 20 yrs Soft rubbery diffuse enlargement Diffuse soft elastic enlargement Diffuse soft elastic enlargement .) 3)) Indirect laryngoscopy is performed preoperatively to evaluate the mobility of the vocal cords and detect unsuspected vocal cord paralysis (if paralysis is present.

whereas the inferior gland is ventral to the nerve.(treatment always partial thyroidectomy).5 cGy). enlarged tonsils and adenoids (750 cGy) .5 nmol/L Total T3 12–28 pmol/L Free T4 3–9 pmol/L Free T3 Page 60 H/O radiation exposure: (For what in history): therapeutic radiation has been used to treat conditions such as tinea capitis (6.type Diffuse irregular enlargement with Bosellated surface (Nodules with variable consistency) Colloid goiter DD: Lymphadenoid goiter.5–5 µU/mL 55–150 nmol/L Serum ThyroidStimulating Hormone Total T4 1. Relationship of recurrent laryngeal nerve to the inferior thyroid artery N in TOG (Commenest) N btw branches of Inf thyroid artery N lateral to trachea N Ant / Post to artery N far anterior ** The superior parathyroid is characteristically dorsal to the plane of the nerve. thymic enlargement (100 to 400 cGy). MNG 30 – 40 yrs In Retro Sternal Goitre casuing obstruction NO place for thyroxin / antithyroid drugs / radioiodine: RESECTION Tremor is demonstrated in Extended & abducted fingers.5–3. Normal Value Hormone 0.

MANAGEMENT OF SOLIATRY THYROID NODULE TSH test Euthyroid Thyrotoxic Radio isotope Scan Cold Warm Hot Ultrasound neck Solid Aspirate & analyze Cystic FNAC Benign malignant Suspicious Benign malignant No cells Frozen section Papillary follicular Repeat aspirations Total throidectomy Recur even after 3 aspirations Page 61 Thyroid Lobectomy .

and several passes are made while aspirating the syringe. skeletonized.Propyl thiouracil: Prothrombin deficiency – Vit K supplementation. and divided low on the thyroid gland to avoid injury to the external branch of the superior laryngeal nerve 4)) The inferior thyroid vessels are dissected. skeletonized. The patient is placed in a reverse Trendelenburg position 2)) A Kocher transverse collar incision. 62 Complications Of radioiodine therapy Acute Long-Term Neck pain. ligated. 3)) The dissection plane is kept as close to the thyroid as possible and the superior pole vessels are individually identified. c)) fewplaced in a 90% alcohol solution for cytospin or cell pellet.( if performed too early: Thyroid crisis) & propanalol has to be added in graves disease: to relieve tremor anxiety & HR. ** If a bloody aspirate is obtained. Operative complications: Immediate Haemorrhage Infection Recurrent laryngeal N paralysis Thyroid crisis / storm Transient hypocalcemia Respiratory obstruction Horner’s syndrome Injury to oesophagus Late Thyroid insufficiency Recurrent thyrotoxicosis Hypertrophic scar/keloid 1)) 23-gauge needle is inserted into the thyroid mass.ca – after 6W & Thyroid status – after 6M & then yearly. 3)) The slides are stained by Papanicolaou's or Wright's stains and examined under the microscope. After releasing the suction on the syringe. Bone marrow suppression Fertility infertility Increased spontaneous abortion rate Pulmonary fibrosis Anaplastic thyroid cancer Gastric cancer Lung cancer Bladder cancer Hypoparathyroidism Increased risk of cancer Operative Points: 1)) Supine position initially with the neck extended by placing a ring beneath the head and a sandbag roll beneath the shoulder. It is given Pre op 100mg thrice daily in hyperthyroisism to make thyroid euthyroid & operation performed 2 months later. Post op: S. and tenderness Thyroiditis Sialadenitis Hematologic Cerebral edema Vocal cord paralysis Nausea and vomiting Bone marrow suppression Progressive Exophthalmosis Wound cellulitis Parathyroid insufficiency FNAC Page Multicentricity in papillary carcinoma is not due to direct extection but due to lymphatic spread within the rich intrathyroid lymphatics.to 30gauge) needle. typically 4 to 5 cm in length. is placed in or parallel to a natural skin crease 1 cm below the cricoid cartilage. swelling. ligated. the needle is withdrawn and the cells are immediately placed on prelabeled dry glass slides 2)) 3 ways a)) some are immersed in a 70% alcohol solution b)) others are air dried. and divided as close to the surface of the thyroid gland as possible to minimize devascularization of the parathyroids (extracapsular dissection) or injury to the RLN. The RLN is most vulnerable to injury in the vicinity of the ligament of Berry (Any bleeding in this area should be controlled with gentle pressure before carefully identifying the vessel and ligating it. The superior flap extends upward to the thyroid notch and the lower flap extends downward to the sternal notch. the patient should be repositioned in a more upright position and the biopsy repeated with a finer (25. Use of the electrocautery should be avoided) .

(b) had previous thyroid operations (c) primary mediastinal goiters with no thyroid tissue in the neck may require a median sternotomy ** The sternum usually should be divided to the level of the third intercostal space and then laterally on one side at the space between the third and fourth ribs 7)) Minimally Invasive Approaches BREAST LUMP Suguna /30 /F /House wife / Warangal C/C: Swelling in the Left breast from 10 years Pain in the left breast from 3 months Page 63 H/C/C: Patient was apparently asymptomatic 10 years back when she 1st noticed a swelling in left breast during feeding her baby. and soft and pliable. Lump in left breast from 10 years. The axillary.5)) LN / Parathyroid?? : a)) Parathyroid glands are small. pricking type. continuous. NO spontaneous regression / sudden increase in size. yellowish brown. confirmed as parathyroid tissue by frozen section. noticed in outer & upper part of breast and reached the present size occupying outer & upper part of breast. in contrast to lymph nodes or thyroid nodules. and reimplanted into individual pockets in the sternocleidomastoid muscle b)) single small artery can be seen entering the gland. Totally endoscopic approaches also have been described. Patient is multiparous NO H/O trauma NO H/O radiation exposure NO H/O OCP usage NO H/O Evening rise of temperature & cough NO H/O similar complaint in mother/aunt NO H/O menstrual irregularities & leucorrhea NO H/O nipple discharge / wetting of breast garment NO H/O skin changes NO H/O axillary swelling NO H/O swelling of limb No H/O Significant weight loss NO H/O of previouis breast disease / biopsies No H/O of recent nipple retraction NO H/O fever with or without rigor (inflm carc) NO H/O pain in back/hip/shoulders NO H/O chest pain. Pain in left breast from 3 months. and breast approach. via the supraclavicular. came to Gandhi hospital where she was assured that is a normal swelling during lactation & regresses after lactation. Coughing out blood NO H/O yellowish discoloration of eyes/ abdominal selling/pain/distension NO H/O convulsions . But the swelling did not reduce in size and gradually progressed to present size and she had developed pain from last 3 months for which she came to Gandhi hospital. gradually progressive which was initially pea sized. The Platysma : reapproximated with interrupted 3-0 absorbable sutures. the artery radiates out over the capsule in a fernlike pattern. axillary. Insidious in onset. insidious in onset. and breast approaches eliminate the skin incision in the neck but are more invasive 8)) Intrathoracic Goitre Virtually all intrathoracic goiters can be removed via a cervical incision. difficulty in breathing. anterior chest. Patients who have (a) invasive thyroid cancers. anterior chest. divided into 1mm fragments. The skin : subcuticular 4-0 nonabsorbable monofilament or absorbable sutures. which are firm (Parathyroid glands: been inadvertently removed during the thyroidectomy should be resected. aggravated during menstrual cycle & pain relieves partially on medication. NO radiation of pain & NOT disturbing the sleep. 6)) Wound closure: The deep cervical fascia: with 3-0 absb sutures.

Nipple is not displaced / elevated / Not prominent / Flat NO retraction / active discharge from nipple or adjacent area (fistula) Surface appear N with no cracks/fissures/eczema & Areola appears Normal on both sides Right side: NAC appear normal. Arm & Thorax: N on both sides. No browny oedema of Arm & No nodules / midline swellings seen. Family H/O: No H/O similar complaint in mother/ sister/ aunt & No H/O any chronic illness in family Physical examination (A) general survey – patient is C/C/C. BMI: P (-) I (-) C (-) C (-) K (-) L (-) E (-) Vitals – a febrile. Spontaneous conception 1st child 2 years after marriage Children ( 2. A mass is felt in UO quadrant which is about 5 cm (horizontal) x 4 cm (vertical). Right side breast appear normal. NO H/O similar complaints in past. Moderately built & adequately nourished. HTN.Past H/O:. Axilla & supraclavicular fossa: N on both sides. on hips. epilepsy. Tenderness felt in UO quadrant. NAC: Left NAC is comparatively bigger than right side. Irregular in shape with ill-defined margin. No mass felt on palpation of sub areolar breast tissue. Cycles: regular 28/4. Page 64 (1)Inspection Breast: Both the breasts are N in position. 6 & 8 yrs). chest pain & bldng disorders Treatment H/O: No H/O any surgical procedures / Long term treatment Personal H/O: Diet: mixed appetite: N B/B: regular Sleep: N Addictions: Non smoker & non alchoholic. TB. No H/O leucorrhoea. fluctuation & transillumination : -ve. skin can be slide over it & is not fixed to breast tissue / underlying fascia / Muscle / chest wall. Breast feeding: ( 8 months). Left breast is enlarged in size showing fullness in outer & upper quadrant. Married at 18 years Menstrual and obstetric H/O: Attained menarche at 14 years. & uniformly firm in consistency. semi recumbent & bending forward positions. Comfortably seated. Submammary folds: N (no nodules/obliteration) Shoulder movements: No restriction WITH arms raised: Fullness becomes more prominent & Both nipples are present at same level ON bending forward: Both breasts fall freely (NO fixity to chest wall) ON supine position: both breasts appear N (2) Palpation: (Sitting then Semi recumbent finally in recumbency: Done with palmar surfaces of fingers with hand flat NOT with Flat of hand & also between pulp of fingers & Thumb) No local rise of temperature. surface appear nodular. raised) in supine. Skin over selling is pinchable. No clot passage. On pressing No nipple discharge is seen & on movement of swelling so puckering / tethering seen. & Skin over breast shows NO puckering/dimpling/any ulceration/fungation/engorged veins/scars/peau de orange/Nodules. No swellings seen. Nipple L 20 cm & 13 cm R 20cm & 12 cm (clavicle & midline) . HR: 74/min BP: 110/80 mm hg RUL: supine. RR: 16/min (B) Local examination: Patient consent is taken & undressed to expose both the breasts & axilla up to abdomen & examination is done in sitting (with arms by side. DM.

pelvis. tumour type) Not conclusive Excision biopsy Not conclusive Frozen section biopsy . FNAC Not conclusive True cut biopsy (receptor status. genetic markers. Liver involvement by: 1)) Hematogenous (Parenchymatous) 2)) Grossman’s pathway (Surface) [breast → rectus sheath → sub diaphragmatic lymphatics → L.Other part of breast Tissue N including axillary tail Other breast N on palpation Palpation of LN (both sides): NOT palpable 1)) Axillary 2)) Cervical 3)) Supraclavicular (3) Percussion: Resonant: sternum (C) Systemic examination: 1)) Abdominal examination: Umbilicus is midline NO Lumps palpable / Palpable hepatomegaly NO free fluid PR : NOT done Discussion Page 65 Anterior chemotherapy – Pre op Chemotherapy (down staging)& Posterior chemotherapy – Post op Chemotherapy (residual).Sternum Normal & No long bone tenderness Diagnosis: A case of primary benign neoplasm of left breast probably fibroadenosis involving outer and upper quadrants.falciparum of liver]: basically inferior & medial quadrants (thus they have usually associated with free fluid in abdomen) PV: NOT done 2)) Respiratory system: BLAE: N & N vesicular sounds heard NO adventitious sounds 3)) Cardiovascular system: Heart sound 1 & 2: Heard & No murmurs heard 4)) Musculoskeletal system: N gait with Spine. PR examination: for Blummer shelf PV examination: for Blummer shelf & ovarian masses.

adenosis. Tumour size if >2cm: Then usually LN:+ve. fibroadenosis (No signs of inflammation).: Cannon ball metastasis (X ray finding) Conditions in which carcinoma of breast with lump But no axillary metastasis 1)) Early carcinoma 2)) Medial breast involvement 3)) Rarely may be sarcoma Bone metastasis: 1)) Breast (osteolytic & osteoblastic) 2)) Thyroid (osteolytic) 3)) prostrate (osteoblastic) 4)) kidney 5)) Lungs Painful breast: breast abscess. Pain appear 1st later swelling). SIZE.Lung metastasis in breast ca. SO x ray shows pathological fracture/ metastasis – Advanced stage.fat lobules size (larger in breast & less vascular) If excessive SC fat removed: skin flap necrosis (min of 7 mm SC fat thickness req for survival) if less amount of breast fat removed: recurrence. 1st LN usually involved (central & pectoral) late (lateral & posterior) last (apical). Fibrosis). Fibroadenosis: vary in size. Scar is a place where recurrence occurs usually Why patient is examined in supine?? – Breast mass moves towards axilla & MEDIAL breast lumps are more appreciable. Puckering +ve: Tumour extended to Ligaments only Paeu de orange: Tumour extended to Skin (Omnious sign of carcinoma) recur Page 66 20 If LN are palpable Note: NUMBER. papillosis. CONSISTENCY Breast lump with palpable lymph nodes BUT NOT carcinoma: BREAST ABSCESS (Inflammatory signs +ve. number. 5 changes in fibroadenosis (cystosis. On table breast fat is differentiated from skin fat by:. LN NOT fixed. FIXITY. epitheliosis. . trauma. shape. Usually breast enlarges if there is any lump (Only exception is SCIRRHOUS ATROPHIC carcinoma) 10 Surgery is always aims at LOCOREGIONAL CURE Nerve that can be scarified during surgery: INTERCOSTOBRACHIAL NERVE. Bone scan pick up bony metastasis earlier than CT which in turn pick up earlier than X ray. breast engorgement. late stages of Ca breast Nulliparity is risk factor coz NO breast feed & Continued estrogen exposure. latrlty.

which may have been obtained by fine-needle aspiration. duct ectasia Black Duct Papilloma & Infiltating / NON infiltrating duct carcinoma & Fibroadenosis FNAC must be followed by true cut biopsy. Hyperprolactinemia. Discharge Milk Serous Pregnancy. •Mammogram to evaluate whether the malignancy is multifocal or multicentric. • Ultrasonography or computed tomography of the liver if metastasis is suspected. milk fistula. ovary (hyper oestrogen). Breast is freely mobile over pectoralis muscle: due to Retromammary space. duct ectasia/ papilloma. because these issues are important when discussing surgical options. galactocoele Pus Acute mastistis creamy Duct ectasia SPECIAL PREOPERATIVE PREPARATION Review of the following investigations is necessary before the operation: • Histology of the breast lesion. uterus. Fibroadenosis. The lymphatics from all groups of axillary LN ultimately drain into apical & from there efferent vessels unite to form subclavian trunk which also drains suprclavicular LN & opens into R lymph duct on R & Thoracic duct on L. Traumatic fat necrosis: haemorrhage → central liquefactive necrosis surrounded by zone of inflammation → well defined nodule with firm consistency → dense fibrous scar. core biopsy. Blood Duct Papilloma & Infiltating / NON infiltrating duct carcinoma Green Fibroadenosis. Family H/O: lobular carcinoma (which is usually co exists with fibroadenoma). or excisional biopsy. Carcinomas co exist with breast carcinoma: breast. NON infiltrating duct carcinoma Management of discharge: Discharge 1 duct Page 67 NOT blood stained Blood stained Multifocal NOT blood stained Blood stained Mammography is performed (> 35 yrs: exclude maliganancy) Microdochectomy Microdochectomy Cefotaxime/flucloxacillin Hadfield’s operation . OCP.Contra lateral breast is involved through: Internal mammary LN & by Skin lymphatics.

The duct is then excised. Breast cysts: Mammary dysplasia Tumours Retention cysts Benign malignant Misc Page 68 The sensitivity of mammography increases with age as the breast becomes less dense. called the ―mammary ridge. Fibroadenoma (usually seen in lower part of best) is usually concurrent with Lobular carcinoma in situ Phylloid tumour: Cut surface is Soft brown & shows cysts. Lymphatic spread is early in scirrhous carcinoma. Breast lump palpated best with palm of hand is probably carcinoma coz fibroadenoma & -sis are better palpated with fingers & thumb.In pericanilicular : enucleation done in Intracanalicular enucleation not done excision is done. A papilloma is nearly always situated within 4 – 5 cm of nipple orifice. and (c) lateral branches of the intercostal arteries to the second. Cone excision: Bleeding duct is unidentified / multiple duts +ve peri areolar incision is made & cone of tissues removed with its apex just deep to . Nipple retraction: 1)) Duct ectasia (Slit like). 2)) blood supply of the breast is derived from (a) perforating branches of the internal thoracic (mammary) artery to the second. The venous drainage corresponds to that of the arteries. US is particularly useful in young women with dense breasts. third. and hemorrhage. and fourth intercostal spaces. which is a branch originating from the second part of the axillary artery. third. Which show appearance of leaves arranged side by side. 3)) Post surgical. Lumpectomy / Tylectomy. 2)) Carcinoma & periductal mastitis (circumferential). (b) branches of the lateral thoracic artery. Super radical mastectomy (extended radical + mediastinal & supraclavicular LN removal) Extended mastectomy (radical + internal mammary LN removal) 1)) thickened strip of ectoderm.‖ develops and extends from the base of the forelimb to the proximal part of the hindlimb. and fourth intercostal arteries. necrosis. Microdochectomy: Tennis racket racquet to encompass the entire duct / periareolar incision used Fibroadenosis Sclerosing adenosis Blue domed cyst of blood good Galactocoele Papillary cystadenoma Cystosarcoma phylloides Intracystic papillary carcinoma Colloid carcinoma Medullary carcinoma Lymph cyst Blood cyst and a nipple flap is dissected to reach the duct.

The overall limits of the dissection include the clavicle superiorly. the lateral sternal edge medially. → Resulting defect is obliterated by purse string sutures. Non tense cyst & Chronic abscess Any tumour lying deep to nipple is fixed (benign & Malignant) 1)) India rubber consistency : fibroadenosis If axillary LN can’t be palpated in sitting then performed in lying down position (basically to relax pectoral fascia) 2)) In supraclavicular LN palpation always Flex the neck if needed passive elevation of shoulder will relax muscles & fascia. BRCA 1: ovarian. the latissimus dorsi muscle laterally. The skin is prepped & The surgeon stands on the side of the mastectomy to be performed 2)) Incision: Elliptical usually 3)) The upper limit of the dissection is at the level of the clavicle & The inferior flap extends down to the rectus sheath from the fifth rib medially to the latissimus dorsi laterally. There is Total restriction of mobility along the line of muscle fibres if it is fixed but slight movement along right angles to fibres is possible Surgical Notes 1)) Postion: The patient is placed in the supine position with the ipsilateral arm abducted at 90 degrees. Phylloid tumour & Rapidly growing sarcoma Fluctuation (done from behind +ve): Lipoma. which simulates a female breast Disorder Risk Nonproliferative lesions of the breast No No Sclerosing adenosis Intraductal papilloma Florid hyperplasia No 2-fold . and external oblique abdominal muscles. serratus anterior. PO: unable to feed & altered nipple sensation. The axilla is shaved. Lymphangiosarcoma treated with: Interscapulothorasic (4 quarter) amputation. The patient undergoes general anesthesia and endotracheal intubation. Peau d’ orange occasionally seen over CHRONIC ABSCESS. Breast louse / Floating tumour 3)) Antibioma is soft in center in contrast to carcinoma which is hard in center Page 69 4)) The deep or posterior surface of the breast rests on the fascia of the pectoralis major. and the rectus sheath inferiorly 4)) Because the breast tissue is more adherent near the sternum. and the upper extent of the rectus sheath.surface of nipples & its base on pectoral fascia. colorectal & prostrate carcinoma Ulceration: Adv carcinoma large Soft fibroadenoma & Rapidly growing sarcoma (in later 2 it is due to Pressure atrophy of Skin & Probe test is Useful : CAN be probed in later 2) Engorged veins: Huge breast abscess. Paget’s cells are located in malphigian layer of skin. this dissection should be started from the lateral aspect and extended in the medial direction 5)) Closure: The skin flaps are temporarily aligned with the aid of staples ** Closure of the incision by 2 closed suction drains if axillary dissection is laso performed Gynecomasta: Clinical classification Grade I Mild breast enlargement without skin redundancy Grade IIa Moderate breast enlargement without skin redundancy Grade IIb Moderate breast enlargement with skin redundancy Grade III Marked breast enlargement with skin redundancy and ptosis.

Page 70 HER-2/ neu Negative (Non–TrastuzumabContaining Regimens) HER-2/ neu Positive (TrastuzumabContaining Regimens) FAC/CAF TAC (T = docetaxel) TCH (docetaxel. T = Taxane (docetaxel or paclitaxel) Combination of intraoperative gamma probe detection of radioactive colloid and intraoperative visualization of isosulfan blue dye (Lymphazurin) is more accurate for identification of sentinel nodes ** (injected either in the breast parenchyma around the primary tumor or prior biopsy site or into the subareolar region or subdermally in proximity to the primary tumor site) . F = 5fluorouracil.Atypical lobular hyperplasia Atypical ductal hyperplasia Ductal involvement by cells of atypical ductal hyperplasia Lobular carcinoma in situ Ductal carcinoma in situ 4-fold 4-fold 7-fold angiogenesis index. (c) indices of angiogenesis such as vascular endothelial growth factor (VEGF) and the Mammography 1)) With screening mammography. two views of the breast are obtained. (b) indices of apoptosis and apoptosis modulators such as bcl-2 and the bax:bcl-2 ratio. (d) growth factors & growth factor receptors such as human epidermal growth factor receptor 2 (HER-2) Woman leans forward to accentuate any skin retraction . The 90-degree lateral view is used along with the CC view to triangulate the exact location of an abnormality. C = cyclophosphamide. including the upper outer quadrant and the axillary tail of Spence. such as the 90-degree lateral and spot compression views. a diagnostic examination may use views that better define the nature of any abnormalities. 3)) CC view provides better visualization of the medial aspect of the breast and permits greater breast compression. E = epirubicin. 4)) In addition to the MLO and CC views. carboplatin. trastuzumab) A¬ CMF E ¬CMF Chemotherapy followed by trastuzumab sequentially CMF AC x 4 ** A= Adriamycin (doxorubicin). M = methotrexate. 1010fold Biomarkers (a) indices of proliferation such as proliferating cell nuclear antigen (PCNA) and Ki-67. the craniocaudal (CC) view and the mediolateral oblique (MLO) view 2)) The MLO view images the greatest volume of breast tissue.

** For women with stage I. 2)) Radiotherapy: Current recommendations for stages IIIA and IIIB breast cancer are (a) adjuvant radiation therapy to the breast and supraclavicular lymph nodes after neoadjuvant chemotherapy and segmental mastectomy with or without axillary lymph node dissection (b) adjuvant radiation therapy to the chest wall and supraclavicular lymph nodes after neoadjuvant chemotherapy and mastectomy with or without axillary lymph node dissection (c) adjuvant radiation therapy to the chest wall and supraclavicular lymph nodes after segmental mastectomy or mastectomy with axillary lymph node dissection and adjuvant chemotherapy. followed by adjuvant radiation therapy.1)) Neoadjuant Chemotherapy: Current recommendations for treatment of operable advanced local-regional breast cancer are neoadjuvant chemotherapy with a doxorubicincontaining or taxane-containing regimen. IIA. adjuvant radiation therapy is given to reduce the risk of local recurrence Page 71 3)) Others: antiestrogen (tamoxifen for premenopausal women or an aromatase inhibitor for postmenopausal women & Pamidronate may be given to women with osteolytic bone metastases . ** For inoperable stage IIIA and for stage IIIB breast cancer. neoadjuvant chemotherapy is used to decrease the local-regional cancer burden. or IIB breast cancer in which negative margins are achieved by segmental mastectomy. This may then permit subsequent modified radical or radical mastectomy. followed by mastectomy or lumpectomy with axillary lymph node dissection if necessary. which is followed by adjuvant radiation therapy.

RR: 12/min (2) Palpation: No local rise of temperature No local tenderness A Hemispherical shaped swelling of 4 X 4 X 3cm cm is seen just below the earlobe at angle of jaw. TB. Able to hold air in mouth No loss of taste Sensation (4) Lymph node examination: Cervical & parotid Ln NOT palpable (5) Jaw movements: Normal Diagnosis: A case of benign swelling arising from parptid gland. Upper border is 4cm above angle of mandible.SALIVARY GLAND SWELLING (B) Local examination: Raju/60/M/hindu/agricultural labour (1) Inspection: A Hemispherical shaped swelling of 4 X 4 cm is seen just below the earlobe at angle of jaw. No uvula deviation C/C: Sweeling below the ear – 6months H/C/C: Patient was apparently asymptomatic 6m back then he developed below the ear. DM. HR: 84/min BP: 124/80 mm hg RUL: supine. Upper border is 4cm above angle of mandible. No swelling at floor of mouth. epilepsy. Insidous in onset slowly progressive – initially pea sized & gradually reached Present size. No pus at opening of parotid duct. margins are well defined. Retroauricular grove is obliterated No other swellings are seen (Neck / other side) Oral cavity: Hygeine is satisfactory. Eyes are normally closed No bells phenomenon. Skin over & surrounding skin is Normal. & Normosthenic P (-) I (-) C (-) C (-) K (-) L (-) E (-) Vitals – a febrile. Ear lobule is raised. No oedema Curtain sign +ve Skin over swelling is Pinchable Swelling is Mobile (In Masseter contarcted & relaxed positions) Bimaual palpation: Deep lobe Not enlarged Bidigital palpation: No Stone in duct Oral cavity: No pus / Blood from duct on pressing the swelling (3) Facial Nerve examination: No loss of forehead wrinkling. chest pain & bldng disorders Treatment H/O: No H/O any surgical procedures / Long term treatment Personal H/O: Diet: mixed appetite: N B/B: regular Sleep: N Addictions: Non smoker & Non alchoholic Family H/O: No H/O similar complaint in family & No H/O any chronic illness in family Page 72 Physical examination (A) general survey – patient is C/C/C. HTN. surface over swelling is regular. margins are well defined.probably Pleomorphic adenoma & clinically there is No involvement of deep lobe . surface over swelling is regular. Skin over & surrounding skin is Normal. NO change in consisitency/surface of swelling NO H/O Spontaneous regression/ sudden increase in size of swelling NO H/O evening rise of temperature & cough NO H/O any discharge from swelling NO H/O trauma NO H/O pain and fever NO H/O deviation of mouth while talking NO H/O any swelling on other side / floor of mouth/ above the eye NO H/O pain in joints NO H/O Increase in size / pain during meals NO H/O Difficulty in mastication NO H/O Significant weight loss Past H/O: NO H/O similar complaints in past.

Swelling do not reach bottom of scrotum H/O gurgling feeling on reduction H/O strenuous work with lifting heavy weights H/O straining at micturition H/O urinary hesitancy from 1 year H/O straining at stools from 6 years NO H/O trauma NO H/O decrease in swelling by micturition NO H/O chronic cough NO H/O vomiting / abdominal distension NO H/O colicky abdominal pain NO H/O fever NO H/O any other swelling in other groin NO H/O truss usage Past H/O: NO H/O similar complaints in past. Pain – 1 year R groin & Insidious in onset dragging type. Skin over swelling is N. which was marble size initially & gradually reached present size.INGUINAL HERNIA Madhusudhan/55/M/warsiguda/Manual labour/ C/C: Pain in R groin from 1 year Swelling in R groin 15 days later the appearance of pain H/C/C: Patient was apparently asymptomatic 1 years back then he developed pain in R groin which he neglected & swelling appeared 15 days later during his occupational work. HR: 74/min BP: 134/90 mm hg RUL: supine. continuous & progressive aggravated by lifting weights & straining relieving on sleeping & temp on medication NO shift / radiation of pain NOT disturbing sleep. & Comfortably seated. DM. NO scars/sinuses/ engorged veins/visible peristalsis. This is about 6cm (horizontal) x 4cm (vertical) in its greatest diameter. RR: 14/min (B) Local examination: Patient is exposed from umbilicus to midthigh level & examined in supine & standing positions (1) Inspection: A Pyriform shaped swelling is present in R groin. TB. Swelling first appeared in the outer part of groin & gradually extending towards scrotum but did not extend into scrotum Swelling increases in size by lifting weights & straining Do not decrease in size on sleeping but reduces in size completely by manually. epilepsy. Page 73 Swelling – 15 days later in R groin progressive. With distinct medial border which is 3cm from midline & lower border which is 9 cm below umbilicus. chest pain & bldng disorders Treatment H/O: No H/O any surgical procedures / Long term treatment Personal H/O: Diet: mixed appetite: N B/B: regular Sleep: N Addictions: Non smoker & occasional alchoholic Family H/O: No H/O similar complaint in family & No H/O any chronic illness in family Physical examination (A) general survey – patient is C/C/C. Moderately built & adequately nourished P (-) I (-) C (-) C (-) K (-) L (-) E (-) Vitals – a febrile. HTN. now he came to Gandhi hospital because of same. then he went to local hospital where he was referred to Gandhi hospital but he did not admit due to financial reasons. Expansile cough impulse +ve Penis is deviated to L side (2) Palpation: No local rise of temperature & No local tenderness .

MIKULICKZ operation (exterioration & resction ) . pethidine & atropine (relax muscles) 5)) an attempt to reduce hernia 6)) Anesthesia: G/A or field block by L/A 1inch Medial to ASIS to anesthesia to ILIO HYPOGASTRIC & ILIO INGUINAL NERVES 7)) incision is extended UPTO FUNDUS & fluids aspirated (avoid risk of contaminating peritoneal cavity & contents will not get an opportunity to slip back before they are examined) & THEN external oblique is Cut Page 74 8)) Constriction ring is cut (deep ring is cut parallel to IEA – UPWARDS & INWARDS) & apply hot wet mops for 10 min 9)) bowel must be drawn out to examine the area proximal to ring 10)) check viability Intestine Circulation Viable NOT viable Light colour & mesentery bleeds if pricked Persistent dark colour & mesentery NOT bleeds if pricked Dull & lusture less Peristalsis –ve & pressure rings NOT disappear -ve Peritoneum Shiny Musculature Peristalsis +ve & pressure rings disappear Mesentery vessel pulsations +ve 11)) If bowel in non viable/ doubtful viable: Linear patch: invaginating with lambert’s sutures whole loop: end to end anostomosis omentum: healthy portion above transfixed & distal part excised Large intestine: PAUL .(3) Percussion: Dull (?) (4) Auscultation: Bowel sounds heard (C) Systemic examination: 1)) Abdominal examination: Umbilicus is midline NO Lumps palpable / Palpable organomegaly NO free fluid 2)) Respiratory system: BLAE: N & N vesicular sounds heard NO adventitious sounds 3)) Cardiovascular system: Heart sound 1 & 2: Heard & No murmurs heard Diagnosis: right sided indirect incomplete reducible inguinal hernia probably enterocole with straining factor of lifting heavy weights . chronic constipation & BPH Discussion Hernia is common on R side: later descent of testis & more chances of patency of process vaginalis. catheterization & IV fluids 4)) inj. Strangulated hernia management: emergency operation 1)) Foot end is raised (advantage of gravity for reduction) 2)) ice bag is applied locally (reduce congestion & chance of gangrene is delayed) 3)) nasogastric tube.

oliguria) absent absent Damage to it causes in its lateral part which is predominantly mixed (during appendicectomy): Loss of tone of conjoined tendon (Weakened post wall & loss of shutter mechanism) → direct inguinal hernia & in its medial part as during inguinal surgery. Contents in constriction in order: Small intestine → Omentum → large intestine Gangrene usually occurs : 5 .6 hrs after Blood supply obstruction (Bowel) In Omentum gangrene (usually begins in centre) is delayed if strangulated coz unlike intestine san survive even with meager blood supply Neck of sac is identified during operation by: 1)) Constriction of neck of sac 2)) Preperitoneal pad of fat 3)) Inf epigastric vessels lie medial to it. warmth) present Features of septicemia Features of septicemia (fever. predominantly sensory causes anesthesia in medial part of thigh. Direct hernia herniotomy NOT performed usually . In infants ONLY herniotomy coz: 2 rings overlap → canal like AP tube→ NO POST wall → NO repair. If sliding hernia is present (suspected in a very large globular hernia descending well into scrotum & neck is unduly bulky) No attempt is made to separate it from perotonium (confused to adhesions) it may lead to faecal fistula / peritonitis. sac is intimately related in whole extemnt of cord & its complete separation from cord causes hematoma of scrotum and injute testicular vessels hence sac is transacted in inguinal canal & distal part is left in situ During reduction watch for 5 points 1)) Gurgling sound (Coz of displacement of intestinal gases through fluid contents of ileum through narrow ring) 2)) Speed of reduction (easy in later part for intestine coz intestines are distended & on initial reduction → gas is escaped → intestines collapse → reduce easily) 3)) Consistency 4)) Complete / Partial 5)) present / absent Varicocoele: Inguinoscrotal swelling where Penis is not deviated. Basically herniotomy will cure indirect hernia however mesh is used as a preventive measure in future to prevent recurrence. In complete /funicular indirect hernia.12)) Hernioplasty usually NOT performed because of fear of infection however Biosynthetic meshes made from collagen and dermis can be used coz they are more suited for use in contaminated environment (that too if patient condition permits) Sites of constriction in order: deep ring → superficial ring → any where in the sac → midway b/w 2 rings. Ilioinguinal nerve L1 [(mixed nerve) pierces the IO muscle fibers & distributing filaments to it & then enters inguinal canal in its midway & lies below the spermatic cord]. warmth) absent (redness. Herniotomy: G/A → Skin drape → Inguinal incision → EO aponeurosis Incision (along the fibres & structures beneath are carefully separated from its deep surface before completing the incision through superficial inguinal ring & exposure of canal → securing IIN & incision of spermatic cord → separating sac from cord structures → incision of sac → reduction of contents → twisting → transfixation → excision distal to transfixation. Besseni’s repair: high recurrence 1)) It is not physiological 2)) It is a tension repair 3)) All groin hernias are due to weakened Transverse fascialis which is not repaired. Page 75 Obstructed strangulated Mild tenderness Severe Features of inflammation Features of inflammation (redness.

Malignant extension of testis. :Peritoneal dialysis → enlargement of patent ductus vaginalis → Hernia when Polypropele mesh is placed fibroblasts grow through interstices & lay down collagen making it into a sheet of dense collagen Page 76 Fallacies in deep inguinal ring: 1)) Insufficient force 2)) Double hernia 3)) Ring defect > thumb size Usually diagnosed clinically but investigation is needed then U/S – 1st choice (particularly obese with small hernia) coz it gives information about Prostrate enlargement. DD of inguinoscrotal swellings: Encysted hydrocoele of cord. hiatus. Undescended & ectopic testis. then tell the cause as patent process vaginalis Strangulation but no obstruction: Omentocoele. enlarged LN. Mesh size usually taken is 16 x 8cm: in lichenstein’s repair (Tails of mesh are overlapped & crossed finally single suture is placed to create new internal ring). In all cases when there Is NO Straining etiology. Inflammatory thickening of cord & undescended Testis torsion . Undescended testis with hernia.strangulated hernia] retractile testis DD of groin swellings: Femoral hernia. Diffuse lipoma of cord. If desired the cremastric muscle are reconstituted: external oblique is directly sutured / overlapped leaveing a new external ring. Obesity → accumplation of fat B/w muscle fibers → separation of muscle bundles & layers → weakening of muscle & aponeurosis → direct. In Large inguinoscrotal swelling usual antiseptic solution is NOT extended to perineal aspect of scrotum Coz high bacterial contamination. Adherent sac is separated from cord → hydrodisscetion (injecting saline under posterior wall) Usually obstructed enterocoele ends as peritonitis where as obstructed omentum ends as Scrotal abscess. [funiculitis. Disappear on lying down: Lymph varix (lymphangiectasis). Richter’s & litter’s hernias. psoas abscess. saphena varix. lymph varix. Contents may sometimes: bladder). Cough impulse: Lymph varix (lymphangiectasis). Varicocoele. Lipoma. varicocoele [feels like thrill not expansile] . Smoking → Acquired collagen deficiency → weakening of connective tissues → Hernia. hyfrocoele of hernia sac . enlarged psoas bursae. Wide sac. paraumb. Femoral aneurysm. varicocoele & direct hernia. In repair care has to be taken not to pick up suturing from same tendinous bundle (NO value if taken from muscle fibres). In infants surgery is usually done in child > 3 m age (earlier if strangulation occurs which is common in female infants [ovary] & after conservative management with gallow’s traction fails) In direct hernia actually the main mass will be omentum. hernia.(No preformed sac.

epilepsy.N in volume. chest pain / Jaundice & bleeding disorders Treatment H/O: No H/O any surgical procedures / Long term treatment Personal H/O: Diet: mixed. & rhythm No RR/RF delay No vessel wall thickening BP: 120/86 mm hg RUL: supine. disturbs sleep. H/O smoking – 2 packets/day – 20 years No H/O other form of tobacco abuse H/O tingling & numbness sensation on left foot – 10 days No H/O rest pain No H/O any ulceration/discharge from toe/foot No H/O trauma No H/O severe cold exposure of foot No H/O black out episodes / paralysis of 1 side of body No H/O abd pain/sudden vision loss No H/O chest pain No H/O palpitations No H/O impotency No H/O pain in hands on writing/combing NO H/O similar complaints in other lower limb Past H/O: NO H/O similar complaints in past. Blackish discolouration of left little toe – 35 days. appetite: reduced B/B: regular. HR: 76/min. sleeping on bed. Pain In left foot – 35 days. H/O linear red cord like swellings associated with pain & fever inlegs 15 days back. initially only tip gradually progressed & involved entire little toe. initailly used to walk for 400 – 500m then now 10m only. character. No inflammation of superficial veins is seen No ulcer / skip lesions No pulsatile swelling in popliteal fossa Buerger’s postural test: R: N L: 20 Capillary filling time: R: N L: 35 sec Venous refilling time: R: No venous guttering L: >5 sec Skin changes: brittle nails. Moderatly built & adequately nourished with P (-) I (-) C (-) C (-) K (-) L (-) E (-) Vitals – afebrile. RR: 16/min Gait: Limping with pain No tendon xanthomas / xanthalesma / No markers of IE Facies: Wincing in pain (B) Local examination: (1) Inspection: Attitude: legs hanging by the side of cot No visible deformity / No wasting of leg muscles On inspection dry blackish mummified discoluration of entire Left little toe which is ending as a band of hypereamia. burning type. shiny skin present (2) Palpation: Skin temp: Coldness of leg upto 2cm below tibial . initially pain used to appear on walking & then it used to relieve on continued walking slowly pain continous with walking & has to stop due to pain & used to relieve on taking rest for 5-10 min. insidious in onset. TB. HTN. aggravated by walking & relived on taking rest. 2 cm behind little little toe there is congestion & purple – blue in colour. Sleep: disturbed Addictions: Chronic smoker & Non alcoholic Family H/O: No H/O similar complaint in family & No H/O any chronic illness Physical examination (A) General survey – Patient is C/C/C. No radiation.PERIPHERAL ARTERIAL DISORDER Venkanna / 40 / M / hindu / manual labour / adilabad C/C: Pain in Left foot – 35 days Blackish discolouration of left little toe – 15 days H/C/C: Page 77 Patient was apparently asymptomatic 2 months back then he developed pain in left foot on walking then he went to local hospital where some medication is given but pain was not relieved. DM. which subsuded on its own In 3 days.

ABPI >/= 1 0. Capillary refilling: 5 sec: L Venous refilling: ? Fuchsig’s test: +ve on both sides Cold & warm water test: (not done) NO crepitus Midline trachea with BLAE: N & N vesicular sounds heard NO adventitious sounds 3)) Cardiovascular system: Apex – Normal & Heart sound 1 & 2: Heard & normal No murmurs heard Peripheral pulses: (No tenderness/vessel wall tenderness) Diagnosis: A case of dry gangrene of distal half of little toe due to peripheral arterial disorder may be due to buerger’s disease.5 Healthy IC CLI 0.9 <0.pedis artery -ve -ve Movements: 4rth & little toe are limited & ankle movements are normal Measurements: L: 25cm R: 30 cm Neurological examination: Sensory: all sensations are absent in little toe. Superficial temporal +ve +ve C.3 Rest pain <0.3 Gangrene Left ABI = Higher Of Left ankle Systolic BP (DPA / PTA) / Higher of Left / Right UL Systolic BP ** Limitations of relying on segmental limb pressures include: (a) missing isolated moderate stenoses (usually iliac) that produce little or no pressure gradient at rest. (b) falsely elevated pressures in patients with . gangrene for >2W & ABP <50mm Hg) & Sub critical limb (rest pain only & ABP >50mm Hg) Ischemia Pain is usually at night coz beneficial effects of gravity on perfusion are lost Patients BP & hence perfusion pressure reduces in sleep In diabetes = spuriously high ABPI coz of arterial calcification.tuberosity. Remaining foot upto 4cm infront of ankle hyperaesthetic sensations in leg – Normal Motor: Tone: R: N L: N Power: R: dorsiflexors & plantar flexors: N on both sides Reflexes: N on both sides Regional lymphnodes – Not palpable Page 78 (C) Systemic examination: 1)) Abdominal examination: Umbilicus is midline NO Lumps palpable / Palpable hepatomegaly NO free fluid 2)) Respiratory system: Discussion Definitive diagnosis of TAO: Arterial wall biopsy (excision biopsy) Severe Limb ischemia = Critical (rest pain +/. radial +ve +ve Femoral +ve +ve popliteal +ve +ve Ant & post tibial +ve -ve D.5 – 0. with intermittent claudication distance of 10 m & cold upto 5 cm below tibial tuberosity.5 – 0.carotid +ve +ve Subclavian +ve +ve Axillary +ve +ve Brachial & Ulnar.tissue loss like ulceration.

Popliteal artery is palpated in the popliteal fossa with the knee flexed to 45° and the foot supported on the examination table to relax the calf muscles. In a day atleast 3 sittings should be performed .Hyporeflexia in Ischemic neuritis & In neuropathy of diabetes Femoral pulse usually is palpable midway between the anterior superior iliac spine and the pubic tubercle. and (c) the inability to differentiate between stenosis and occlusion Buerger’s Buerger’s aetiology (Smoking. Palpation of the popliteal artery is a bimanual technique. Both thumbs are placed on the tibial tuberosity anteriorly and the fingers are placed into the popliteal fossa between the two heads of the gastrocnemius muscle. Note should also be made of nail changes and loss of hair these findings are indicative of chronic ischemia Traditional Scale Basic Scale 4+ Normal 2+ Normal 3+ Slightly reduced 1+ Diminished 2+ Markedly reduced 0 Absent 1+ Barely palpable — — 0 Absent — — Abdominal swelling / Lump Ramulu/60/M/Nizamabad/Agricultural labour/Hindu C/C:Lump & Pain in abdomen – 2m H/C/C:Patient was apparently asymptomatic 2 months back then he developed swelling in upperpart of abdomen in midline Sudden in onset Initially lemon size gradually progressed to reach present size . which dorsiflexes the great toe and is clearly visible on the dorsum of the foot. this is repeated several times in 1 sitting. vein & nerve sometimes bound together by fibrous adhesions & elstic lamina of artery are thickened) Beurger’s sign (Absence of Post tibial pulse is highly suggestive of diagnosis) Page 79 Examination of Joints . familial.diabetes and end-stage renal disease. Autoimmune & rickettsial) Beurger’s position (head end of bed is raised & at the same time foot end is gradually lowered about 6inches / day .improve circulation of lowerlimb ) Beurger’s pathology (Acute lesion – Acute arteritis & phlenitis & periarteritis & periphlebitis with thrombosis of vessel containing microabscess Chronic lesion – Artery.Charcot joints of diabetes Power .improve circulation of lowerlimb ) Beurger’s exercise (affected lower limb is elevated for 2 min & then lowered below the bed side for another 2min. The popliteal artery is palpated by compressing it against the posterior aspect of the tibia just below the knee. The dorsalis pedis is detected 1 cm lateral to the hallucis longus extensor tendon. hormonal. The posterior tibial pulse is detected by palpation 2 cm posterior to the medial malleolus. ** The foot also should be carefully examined for pallor on elevation and rubor on dependency.Weakness of flexors & extensors of foot may cause Abnormal foot architecture Reflexes .

No relation with food No relieving / aggravating factors. Exhibit pulsations & doesn’t move with respiration. paraspinal area: N Supraclavicular area: No fullness Renal angle: No fullness Ext genitalia: Normal b)) Palpation: No Local rise of temperature An IA mass +ve On deep palpation tenderness +ve (Mild)over sweling with epigastrium as point of max tenderness Size & shape : collaborative Surface: Smooth Margins Well defined (lower: 10cm above pubic symphysis & lateral margin 6cm to right of umbilicus) Uniformly firm consistency Skin over swelling is N . HTN. Lean & adequately nourished with N facies & P (-) I (-) C (-) C (-) K (-) L (-) E (-) Attitude: N & Decubitus : N & Supine Vitals – afebrile. No engorged veins Skin over abdomen Normal expect that brand marks are seen periumbilically A sweeling is seen in epigastrium region. epilepsy. TB. Insidous in onset. HR: 82/min. tangential & End of bed views where appropriate (B) Local examination (Abdominal)– 1)) Oral cavity:Tongue. DM. Sleep: disturbed Addictions: Non smoker / alcoholic. Right iliac fossa: Normal Spine. Continous.Not pits on pressure Not freely mobile NO rebound tenderness/Abdominal wall rigidity NO hyperesthesia over swelling NO fluid thrill Plane of selling – Intraabdominal (Carnett/s test) Exhibiting Transmitted Pulsations & do not fall in .Pain from 2months. & rhythm No RR/RF delay No vessel wall thickening BP: 116/82 mm hg RUL: supine. Umbilicus N (midline & inverted) & all quadrants move equally with respiration . faecal pillars. lateral. appetite: reduced B/B: reducved/regular. extending into uimbilical. with free hernial orifices. character. epigastric pulsations +ve (probably aortic) No visible peristalsis. Progressive. Dull aching type. RR: 14/min Patient is exposed from nipple to midthigh & was examined in supine. chest pain / Jaundice & bleeding disorders Treatment H/O: No H/O any surgical procedures / Long term medical treatment Personal H/O: Diet: mixed. sitting.Abdomen is Asymmetrically distended.N in volume. by looking from side. pharynx. with indistinct margins surface of swelling is N. R hypochondrial & Lumbar regions Irregular in shape. Knee elbow postions. Teeth . No Shift / radiation of Pain No H/O Trauma No H/O fever with Chills / rigor / evening rise with cough No H/O Bloating No H/O Vomiting / hemetemesis / Indigestion No H/O excessive beching No H/O Loss of apetite No H/O yellowish discolouration of eyes No H/O Passage of Tarry / Pale / Mucus Containg / Blood containing Stools No H/O Oliguria / hemeturia No H/O Change in bowel habits No H/O Significant loss of weight No H/O Swellings in neck No H/O Alchoholism Past H/O: NO H/O similar complaints in past. tonsils : Normal 2)) Abdomen: a)) Inspection: Contour . No pan/gutka Family H/O: No H/O similar complaint in family & No H/O any chronic illness Page 80 Physical examination (A) General survey – Patient is C/C/C.

No H/O swelling of knee No H/O giving away while walking No H/O locking/unlocking of knee No H/O Any Click sound from knee during activity No H/O massage No H/O fever Past H/O: No H/o similar complaint in past.A 60 Yr old male presented with a Retroperitoneal swelling probably a)) Pseudocyst of pancreas b)) Para aortic LN enlargement Discussion: Abdominal pain crisis • Little’s Crisis • Ruptured aneurismal pain • HyperParathyroidism • Tabes dorsalis spine crisis • Hepatic neuralgia • Sickel cell anemia IDK Shanker /21 /M /Hindu/ Student /hyderabad C/C: Pain in right knee during running & Climbing up stairs & downstairs – 1 week H/C/C: Patient was apparently assymptomatic 1 week back then one day while he was running there is twisting of leg after which he developed pain in R knee on outer aspect. relived on rest & medication partially. Pain – continous. No H/O suggestive of HTN/DM/TB/Bleeding disorders . aggravted on running & Climbing up stairs & downstairs & also on standing on outer aspect of foot. aching type.knee elbow position Liver & Spleen: Not palpable (fingers can be insuniated below coastal margins) Renal angle : No fullness / tenderness No palpable LN in SC area Hernial orifices: No expansile impulse / free Genitals N Supraclavicular fossa: N Spine & paraspinal Area: N c)) Percussion: Swelling in dull on percussion Not continuous with the liver dullness Shifting dullness -ve Liver upper border: 5 th ICS in MCL (liver span: 14cm) Traube’s space:.Tympanitic No IC tenderness / punch tenderness d)) Auscultation: Bowel sounds heard & Normal pitch & No venous Hums heard / Bruie heard PR: Not done 1)) Respiratory system: Midline trachea with BLAE: N & N vesicular sounds heard NO adventitious sounds 2)) Cardiovascular system: Apex – Normal & Heart sound 1 & 2: Heard & normal No murmurs heard 6cm Page 81 10 cm Diagnosis:. No radiation of pain & Not disturbing sleep.

(After Knee flexed at 900 if Not Extending from that position with continued pressure on that point) 4)) Post to TCL . tendons & areolar tissue) -Lower end of femur – Normal. 3)) Midway between Ligm patellae & TCL – Torn ANT. condyles & fibular head has no tenderness / irregularity (Springing test –ve) Mcmurray test: M/L SLC (Pain + CLICK in joint line imp) Lurchmann test: ACL Anterior drawer test: ACL posterior drawer test: PCL Appley’s grinding test: M/L SLC Appley’s distraction test: M/L CL Abduction & adduction stress tests: (performed knee flex at 200 – 300) M/L CL . horn of MALC 5)) Either said of LgPtl – Nipped of INFRAPATELLAR PAD OF FAT} -Patella: No tenderness / Crepitus (OA & Chondromalacia patellae)/ irregularity & there are NO gaps in its Borders & Its articular surfaces are Normal with No tenderness Push Under (for articular surfaces) palpate (For Demonstrating effusion of knee Joint: Moderate effusion: Patellar tap in supine & Fluctuation tests (Thickened synovium +ve On either sides & above patella) Smaller amounts: Hollow refilling sign & Patellar tap in standing position (Thickened synovium –ve) If bursa is palpable – Consistency. Both patella are facing Upwards & slightly outwards & toes facing roof) {In arthritis is assume moderate flexion – Maximum volm – to Accommodate fluid Late stages TRIPLE DISPLACEMENT – destruction of CRUCIATE & COLLATERAL LIGM} Gait: Normal NO knee swelling/ swellings around knee – Parapatellar fossa & Suprapatellar pouch are free (Usually knee effusion: horseshoe shaped swelling due to accumulation above patella & sides of patella & Ligm patellae. No Tenderness / irregularity -Upper ends of tibia & head of fibula – Normal. There is no tenderness at other Points. Bil effusion – Clutton’s joints & haemophilia) { Swelling around knee: Semimembranous (ABOVE joint line) / Prepatellar/ Infrapatellar / Suprapatellar / bicipital bursa swellings / Morrant bakers cyst (Herniation through Oblique popliteal ligm below joint line) Cysts of SL cartilage (lateral side cmn – lateral to Ligm patellae) popliteal aneurysm midline } NO thigh / calf muscle wasting (usually obvious in Thigh) Skin over knee is normal No scars/sinuses (B)Palpation: Page 82 NO local rise of temperature NO joint line tenderness.Torn POST. mobility & translucency are determined. 2)) In joint line – MSLC & rarely MCL deep fibers. There is tenderness of lateral side between femur & Fibula head. horn of MALC.Local examination (A)Inspection: (Examined in standing from front & behind (Popliteal fossa) then seated position then Supine lastly Prone (Popliteal fossa)) Attitude of limb: Normal (Both the ASIS are at same level. Compressable swellings – Baker’s cyst & Popliteal aneurysm ) -Popliteal fossa Normal (in flexed position – Prone: VAN. Tibial tubercle . No Joint effusion No synovial membrane thickening (boggy feel) {Tenderness Points – 1)) Medialy at femoral attachment – MCL. relation with tendon.

(respective displacements) Flattening of shoulder (Inward displacement of Humoral head. vertebral border. No sleep disturbance H/O loss of shoulder function H/O massaging at local bone setter No H/O fever No H/O swelling of shoulder No H/O repeated similar episodes in past No H/O suggestive of TB Page 83 Local examination (A) Inspection: Attitude: Supporting his L flexed elbow with R hand No swelling at shoulder. fracture of neck of scapula.Loss of resistance (If pain – supra spinatus tendinitis / GTb fracture) Palpation of Neck & shaft of humerus is normal. No irregularity / swelling seen of bony arch (formed by Clavicle Ant. Abduction & adduction (Knee flexed partially) – N range on Both sides Abnormal: Absent (Clutton joints) ANTEROIR DISLOCATION OF SHOULDER Yadayya / 40 / M / Hindu / Farmer/ Adilabad C/C: Inability to move his left Shoulder from 10 days Pain in outer aspect of shoulder from 10 days H/P/I: Patient was apparently asymptomatic 10 days back then on 1 day he was travelling in bullock cart & fell down from it with his left arm outstretched from which he developed Inability to move his left Shoulder & Pain in outer aspect of shoulder. Pain is outer aspect of Shoulder. -Palpation just below acromian process (G tuberosity) . Continuous. tip of Acromian (below is the superior aspect of shoulder ) & Greater Tuberosity In Codman’s method of palpation (R hand for left shoulder & left hand grasp L flexed elbow) Thumb lies below spine of scapula. rotation (hip & knee flexed at 900 ). Acromian process lat & spine of scapula post. No discontinuity / Swelling / Local bony tenderness (direction normally Medial epicondyle – Head & lateral epicondyle – G tuberosity ) -Transmitted movements to upper part is +ve (No fracture dislocation) -Spinous process. not disturbing sleep. aching .) are Normal. No radiation aggravated on attempted Shoulder movement relived partially on medication. axillary border & inferior angle of scapula – Normal -Relative position of 3 bony points is altered on L side -Drop arm sign: -ve -Apprehension test [Three Bony points are important in palpation tip of coracoids (below is the Ant aspect of shoulder).(C)Measurements: Thigh circumference: ? Calf circumference: ? (D) Movements: Active: Flexion & extension: N range on R & L Passive: Flexion & extension. deltoid wasting due to Tb/Rmt/Osteo arthritis & Chronic rotator cuff lesions) & fullness is seen in Deltopectoral groove & there is lowering of Ant axillary fold.) (B) Palpation: (from behind the patient & keeping arm by the side with 1 hand & palpating with other hand from all aspects) No local rise of temperature & No Local tenderness No fullness in Axilla (inf aspect of joint is lax so fluid accumulation begins here) -SC joints (if +ve ANT displ). other 3 fingers on clavicle ] . clavicle & AC joints (if +ve UP displ. tip of index finger just ant to acromian. No muscle wasting No scars / sinuses No Swelling at Clavicle At junction of L1/3 & M2/3 No shoulder drooping ( fracture of neck of scapula) No undue prominence of Acromial/sternal end of clavicle.

Extension – 45. Flexion – 90. M/L – quarter circle.3m NO H/O trauma NO H/O any swellings in hip region Local examination (A) Inspection: (in standing position from front & behind) -Attitude of limb: Left lower limb is Extended.1200 & additional 600 . rotations. initially more during night now continuous. Important movements are ER & ABDUCTION {At shoulder joint – 1000 . No radiation H/O fever with evening rise of temperature . examined from front & Back Scapula is incline 30 degrees forwards with coronal plane.800 by forward rotation of scapula but these occur simultaneously after initial 30 0 where Movement occur only at Shoulder then every 15 0 movement there is GH 100 & Scapular movement 5 0. circumduction) L: limitation Passive Dugas test: Not able to touch his R shoulder with left hand Page 84 (E) Distal NV status – Normal (F) Elbow & Wrist : Normal ( Which are also usually effected in this type of injury) (G) Axillary Lymph nodes – NOT palpable Diagnosis: Traumatic Anterior Subcoracoid Dislocation of left shoulder with No Associated fractures of humerus / Scapula with N Distal NV status HIP Rajayya / 50 / M / Hindu / Farmer/ Nizamabad C/C: Difficulty in walking – 3months Pain in left hip – 2months H/C/C: Patient was apparently asymptomatic 3months then he developed difficulty in walking & difficulty is more when he is climbing steps with NO H/O morning stiffness Pain in Hip – 2months insidious in onset . Aggravated on walking & relieved by taking rest & Progressive.e prevent tilting & R side pelvis is Raised – Evident by buttock on R sided raises) SO 1st patient is made to stand on normal side then on abnormal side (SO NORMAL SIDE SINKS – Gluteal folds & Iliac crest shoes this) {+ve test – Failure of OSSEO – MUSCULAR mechanism •Weak abductors . Disturbing sleep. During start of abduction see for any Shrugging at shoulder {complete rupture of Supraspinatus whose function is to start abduction so he bends affected side 30 0 so that deltoid can take over}) Active: R: Full range (Abduction – 180. Externally rotated Scoliosis of lumbar spine with convexity towards Left side & ASIS is lower on left side -Swellings / scars / sinuses: absent (femoral triangle / gluteal region) -Length: Apparent lengthening -NO muscular atrophy seen (loss of gluteal folds & Adductors) -Trendelenberg’s test (Normally if entire weight is bearing by Left leg with right leg flexed then Adductors on left side contracts & thus Lifting the pelvis i.4cm L: 15cm Vertical circumference of axilla: ??? (Increased in any shoulder dislocation & fracture of Neck of scapula / humerus) Test to know lowering of A/P axillary folds – Bryant’s test Hamilton’s Ruler test: +ve (Any shoulder dislocation) (D) Movements: (Exposed upto waist & compared on both sides.(C) Measurements Arm length (Angle of acromian {spine of scapula bends to form acromian} & lateral epicondyle): R: 32 cm L: 26cm (Increased in SUBGLENOID dislocation & fracture of NECK OF SCAPULA decreased in SUNCORACOID dislocation & fracture of NECK &/or SHAFT OF HUMERUS) Mid arm circumference: R: 15.

separation of upper femoral epiphysis B – reduced In Ant dislocation & Increases in post dislocation If ER +ve but Normal relation is maintained:Subtrochantric Fracture – Absence of Normal Transmitted movement 2)) Head of femur: (C)Measurements •Bryant’s triangle: •Nelton’s line: Most prominent part of ischial tuberosity to tip of ASIS .reduced on Superior migration of Head of femur: Femur fracture. ASIS & Line drawn vertically downwards from ASIS – BRYANT’S triangle +ve in this case -Any fixed deformaties (examined with patient lying in bed) 1)) Fixed Adduction / abduction deformity: The leg is held just above ankle & are abducted & adducted respectively until the ASIS become Normal & Thus Angle of deformity is calculated 2)) Fixed Flexion deformity: Compensated by lordosis of lumbar spine – HUGH OWEN THOMAS test – Sound thigh is flexed until the Compensation disappears (Not be forcibly continued) & Then angle between THIGH & BED is the Angle of flexion deformity 3)) Fixed M/L rotation deformity: It is always Revealed L spine cannot compensate this – Determined by Noting direction of Ant surface of patella / Tip of great toe with midline (normally slightly externally rotated – if midline it is medially rotated) {Tb hip arthritis: I – Apparent lengthening ( Flxn – concealed by – Lumbar lordosis & tilting pelvis forwards Abd – Tilting the pelvis downwards & Scoliosis of lumbar spine with convexity towards affected side II – Apparent Shortening Flxn – concealed by – Lumbar lordosis & tilting pelvis forwards Add – Tilting the pelvis Upwards & Scoliosis of lumbar spine with convexity towards Sound side III – Erosion – Real Shortening – similar to Stage 2 but they are exaggerated – Spasm of adductors causing erosion of upper part of acetabulum & thus femoral head get dislocated} (B)Palpation: Page 85 -No local rise of temperature -Tenderness: below the mid inguinal point (Any arthritis) & also on pressing greater Trochanter towards each other on L side –Bony points B A A – Shortest side .•C/P dislocation of hip •Fracture neck of femur •Coxa vara •Perthe’s disease •Hip arthritis} 1)) Greater Trochanter – NO tenderness {A triangle is formed by GT .normally 2 lines parallel but in Trochanter is raised it causes convergence on affected side •Length of lower limb (SOUND LIMB MUST BE PLACED IN SAME POSITION AS AFFECTED TO SAME EXTENT – INTERSPINAL LINE MUST BE HORIZONTAL LEVEL) From ASIS to medial maleolus (thigh only from ASIS to joint line of knee on medial side / Adductor tubercle / Upper border of patella) ONLY OBTURATOR TYPE OF ANT . Post Dislctn of Hip.Normally this touches the tip of GT – any upward displacement can thus be easily demonstratable •Shoemaker’s Line: Normally line from GT to ASIS will reach umbilicus – any upward displacement can thus be easily demonstratable •Morris bitrochantric Test: •Chiene’s test: 2 lines are drawn passing ASIS & GT .

sacroiliac joints are Normal (I) PR: Intrapelvic abscess & Detect Central dislocation of hip – NOT done .Hip is flexed at 90 & pelvis is fixed with 1 hand with other hand knee is grasped & pushes thigh downwards ALONG THE AXIS OF THIGH (other hand notes whether GT moves downwards) •Ortalani’s test • Barlow’s test (F) LN: Not palpable (G) Distal NV status: Normal Page 86 (H) Other Joints: Knee joint. Lumbosacral spine.DISLC: LENTGHENING •Limb girth : To identify muscle wasting Not seen on inspection & a point is made on affected Limb at a convenient distance from ASIS & this is made on N side also & Circumferences at that level are compared (D)Movements : (Both active & passive) – Pelvis has to be steadied by clinician •Flexion: Knee extended (90) knee flexed (120) •Extension: 15 (tested if there is no flexion deformity) •Adduction: 30 •Abduction: 40 •Rotation: ER: 45 & IR 30 (E) Stability tests: •Telescopic test: (+ve in C/P dislocation & in Charcots joint) .

any case can be in XM .1)) Nutritional value of foods 2)) Milesrones & SE classification 3)) Nephrotic syndrome 4)) Cerebellar ataxia 5 5)) Hydrocephalus 6)) Anemia & Splenomegaly PEDIATRICS 7)) Fever 8)) Seizures 9)) Traumatic neuritis 10)) Meningitis 11)) DMD 12)) Infantile hemiplegia Page 87 ** These cases are not exclusive.

9 4y – Copies Cross. 6 3y – Copies circle.Skip 3m. 3 Blcks 2y – Circular Stroke.face is lifted 90 6m – head + Chest lift 8m – Crawls** 12m .Creeps 6m -tripod 8m – Steady sitting** 10m – Pivot on sitting 9m – Stand (Support) 12m – Stand (Indpn)** 15m – Walks 18m – Runs 2y – walk back 3y – tricycle 4y – Hop 5y .Food Item Quantity Calories Tea One cup 52 Coffee One cup 90 milk (cow) One cup 67 milk (buffalo) One cup 117 Bread One slice 39 Biscuits (Glucose) One 25 Egg One 85 Samosa one 207 Upma 1-1/4 bowl 260 Idli Two 130 Sambar 1 bowl 81 Khichadi 1 plate 182 Masala Dosa One 192 Paratha Two 297 Phulka One 85 Puri 3 240 Rice 1 bowl 111 Dal 1 bowl 100 Potato Curry 3/4 bowl 131 Brinjal Potato 1 bowl 134 Curd 1 bowl 70 Banana One 116 Mango One 160 Mile Stones: Gross Motor Supine & pull to sit Ventral suspension Prone position Sitting Standing & walking Fine Motor Hand Eye Coordination Hand Mouth Coordination Advanced Hand skills 88 Dressing Page 6w – 20w 6w – Head horizontal 12w – above horizontal plane 1m – lifts the chin up 2m – face is lifted 45 3m .Radial 12m – Mature & Pincer 6m – ability to chew 12m – tries to feed 18m – feed himself well** 15m – Scribbles.Start to pull off 2y – Undress complt 3y – Dress & Undress complt 5y – Shoelaces Complt . 2 Blcks 18m – Strokes.Ulnar 9m . Bridge 5y – Copies triangle 1y .hand regard 4m – hands (midline) 6m .

11361 4556 . Plays.Bye Understand simple Q Point objects (Jargon) Domestic mimicry L / R Discrimination. Toilet alone** 3 steps . 4 colours 1m 2m 3m 6m 9m 12m 15m 18m 4y 5y Language Vocalizes with vowels Laugh loud Mono syllables Bi syllables. 2 Sentences Ask questions. Know name & gender** Says Song / Poem Ask word meaning** 2m 4m 6m 9m 12m 18m 2y 3y 4y 5y Hearing Turns his head towards Source Direct localization 4m 10m Vision Page 89 Fixate his mother Grasping with eye Binocular vision Adjust his position to follow obj Follow rapidly moving obj 1m 4m 6w – 4m 6m 1y ** To be Asked in History taking – Ideally Score 12 10 6 4 3 2 1 Income (Rs /-) 30375 15188 .15187 7594 .Personal & Social Development Intent regard Social smile Recognizes mother** Stranger anxiety & Vocalizes & Smile at image Bye .7593 1521 – 4555 1520 .30374 11362 . Imitate sounds 2 words 15 words 100 words.

H/O reduced urine output & frequency . after 1 day he developed swelling of legs (descending odema) & swelling of face is more in the morning. P (-) I (-) C (-) C (-) K (-) L (-) E (Both legs upto thigh pitting type) No scrotal edema Facies: N (Not steroid facies) Vitals – afebrile. TB. 10 mg Rantac & paracetmol patient is on No other treatment Page 90 Family history: No H/O of similar complaint in family No H/O dialysis. Bloody diarrhea. or renal transplantation in any family members No H/O DM/HTN/Tb/HIV in family Birth H/O: Mother is registered case in local hospital & Had regular ANC & IFA prophylaxis. hemetemesis / melena No H/O SOB before onset of symptoms No H/O Chronic diarrhoea No H/O fever with rash / cough with evening rise of temperature No H/O Sorethroat / pyoderma before onset of symptoms No H/O abdominal pain. HR: 83/min. Baby cried immediately & breast fed for 4m Immunization H/O: Immunized as per schedule. barber PCI – 1000 Socio economic class (K) – V (Lower) General examination: Physical examination (A) General survey – Patient is C/C/C. character. Abdominothoracic Anthropometry: Ht: Wt: 18kg midarm circumference – 12cm . regular. and vomiting before onset of Symptoms No H/O Skin rash with joint pains No H/O Blood transfusion No H/O fever with chills No H/O swellings in neck & weight loss No H/O Abdominal / Flank pain / Abd mass No H/O Any bleeding manifestations Past H/O: NO H/O similar complaints in past.15 days No H/O passage of red coloured urine No H/O jaundice. Received 2 doses of TT. No H/O HTN. Pregnancy is uneventful & had FTNVD at home by local dai. DM. & rhythm No RR/RF delay No vessel wall thickening BP: 100/70 mm hg RUL: supine RR: 28/min regular. bleeding disorders Treatment H/O: H/O 1 ascitic tap 2 days back. & patient is on prednisolone tab. No post immunization hosptalization Developmental H/O: Gross motor & fine motor milestones achieved normally Dietary H/O: Breast fed 2 yrs (exclusively – 5m) 2 idli & ½ cup milk: Rice – (4cups): Dal – (2 cups): 1 banana: Socioeconomic H/O: father – Uneducated.Nephrotic syndrome Sreenivas / 5 / Hindu/ karimnagar brought by his mother a reliable informant with a C/C: of Swelling of entire body from 15 days Decreased urine output & frequency From 15 days H/P/I: Patient was apparently asymptomatic 15 days back then he developed swelling of eyes which later involved entire face within 2 days he developed swelling of his abdomen.N in volume. OPV & SIP is also taken.

bleeding disorders Treatment H/O: Family H/O: No H/O of similar complaint in family No H/O DM/HTN/Tb/HIV in family . use of antimotility agents and antibiotics is believed to worsen the disease. Vomiting or an exanthem Before onset of symptoms No H/O of Slurring of Speech No H/O similar episodes in past No H/O loss of consciousness NO H/O head trauma NO H/O headache. leukemia Wilms & PheoChromocytoma DB HS purpura H/O H/O Sorethroat / pyoderma before onset of symptoms H/O fever with rash H/O Blood transfusion Family H/O HIV H/O fever with chills H/O Skin rash with joint pains H/O Blood transfusion No H/O swellings in neck & weight loss Page 91 Ataxia Pavithra / 9 yrs / F / Student of 5 th class / Hindu / Sainikpuri. & irregular eye movements No H/O Any discharge from ear / Ear ringing No H/O Any drug intake before onset of symptoms No H/O of Contact with Tb patient No H/O of similar complaint in siblings/family No H/O of increasing head circumference No H/O of Diarrhea / passage of floating foul smelling stools No H/O jaundice / abd pain No H/O Significant weight loss / night blindness Past H/O: NO H/O similar complaints in past. TB. Neurologic problems. No H/O HTN. Some cases. hyderbad brought by his mother a reliable informant with a C/C: of Inability to walk properly – 15 days Unsteadiness in reaching out for objects – 15 days H/P/I: Patient was apparently asymptomatic 15 days back then she developed Inability to walk properly & Unsteadiness in reaching out for objects along with difficulty in sitting H/O fever – 1month back. followed by hemolysis and renal failure. low grade subsided on medication not associated with chills/rigor No H/O Cough. projectile vomiting NO H/O seizures NO H/O memory loss / behavioural changes NO H/O symptoms suggestive of cranial nerves involvement No H/O weakness of UL & LL NO H/O Involuntary movements No H/O of Difficulty in feeling ground No H/O of Any bowel / bladder symptoms No H/O of Slurring of Speech No H/O child in constant motion while awake. abdominal pain.Discussion: 1)) Spontaneous renal vein thrombosis has been associated with membranous glomerulonephropathy. DM. particularly seizures. Nephrotic syndrome may either cause or result from renal vein thrombosis . Timely dialysis improves the prognosis.Renal vein thrombosis in newborns is generally characterized by the sudden development of an abdominal mass 2)) Hemolytic-uremic syndrome is the most common glomerular vascular cause of acute renal failure in childhood. Bloody diarrhea is the usual presenting complaint. plasma infusion or plasmapheresis Cause Streptococcal grp A Varicella infection Hepatitis B Infection HIV Infection Malaria SLE / RA Sickle cell disease Lymphoma.

Govt emply PCI – 3000 Socio economic class (K) – II General examination: Page 92 Physical examination (A) General survey – Patient is C/C/C. P (-) I (-) C (-) C (-) K (-) L (-) No Bulbar/dermal telengectasia No NC markers No Xanthomas / Xanthalesma No Chicken pox scars (Pock marks) Facies: N Vitals – afebrile.Birth H/O: Mother is registered case in local hospital & had regular ANC & IFA prophylaxis. Immunization H/O: Immunized as per schedule. No post immunization hosptalization . No admission of baby in NICU Baby cried immediately & breast fed for 8m. character. Pregnancy is uneventful & had FTNVD in hosp.Graduate.N in volume. & rhythm No RR/RF delay No vessel wall thickening BP: 110/80 mm hg RUL: supine RR: 18/min regular. OPV & SIP is also taken.VI Nystagmus V Sensory Motor VII VIII Vestibular Auditory IX & X XI XII Normal Normal Normal Normal Normal +ve Normal Normal +ve Normal Normal normal Normal Normal Normal Normal Normal normal Normal normal 3)) Motor System: A)) Inspection No Gross Muscle wasting / Hypertrophy seen No involuntary Movements B)) Palpation Bulk UL LL Tone UL LL Power UL LL Involuntary 16cms 24cms 16cms 24cms Normal Normal Normal Normal 4/5 4/5 . Thoracoabdominal (B)Anthropometry: Ht: Wt: 18kg midarm circumference – 12cm Local examination (CNS): 1)) Higher functions Handedness: R Level of consciousness: Fully consiousness Orientation: +ve Emotional state: Normal Memory: preserved Speech: Articulation disturbed 2)) Cranial nerve Examination: I II Visual acuity Visual fields Colour vision III. Received 2 doses of TT.IV. regular. HR: 86/min. BCG mark seen Developmental H/O: Gross motor & fine motor milestones achieved normally Dietary H/O: Breast fed 2 yrs (exclusively – 5m) 2 idli & ½ cup milk: Rice – (4cups): Dal – (2 cups): 1 banana: Socioeconomic H/O: father – educated .

T. mumps. Bacterial: scarlet fever ) Drug induced (phenytoin) Wilsons disease Refsum’s disease Chilhood degenerative diseases Extrapyramidal Cause Spinocerebellar degerative diseases 1. abdominal pain.T.A: + ? Absent 5)) Sensory system: Proprioceptive Exteroceptive Cortical Present & N Present & N Present & N Present & N Present & N Present & N GAIT: tandem walking ABSENT CEREBELLAR: +ve ANS: No abnormal sweating. constipation RAISED ICT SIGNS: Absent MENINGEAL IRRITATION SIGNS: -ve SKULL & SPINE: Normal PERIPHERAL NERVES: Normal Page 93 (C) Systemic examination: 1)) Abdominal examination: Umbilicus is midline NO Lumps palpable / Palpable organomegaly NO free fluid 2)) Respiratory system: BLAE: N & N vesicular sounds heard Cause / etiology Malignancy (SOL) Benign paroxysmal vertigo of children / basilar artery migraine Acute cerebellar ataxia (varicella.UL LL Co ordination UL LL Absent Absent Knee heel & finger nose test –ve dysmetria +ve dysdiadokokinesia +ve NO adventitious sounds 3)) Cardiovascular system: Heart sound 1 & 2: Heard & No murmurs heard Diagnosis: A case of acquired ataxia of cerebellar origin with infective etiology (Acute cerebellar ataxia) 4)) Reflexes: Superficial reflexes Abdominal Plantar Deep tendon reflexes Jaw jerk Upper limb Lower Limb Visceral reflexes Released reflexes Discussion present Present ? B. rubella.BR: + K. headache No H/O similar episodes in past No H/O fever. deafness H/O Memory loss H/O Invol movements H/O similar complaint in family H/O Difficulty in feeling ground (Involv of Dorsal . Cough. Dominant ataxia Abetalipoproteinemia Dandey walker syndrome Cerebellar abscess H/O H/O weight loss . influenza. Pyrm.BR: + K. Spinocerebellar tracts) H/O of Diarrhea / passage of floating foul smelling stools Xanthomas H/O of increasing head circumference H/O of Contact with Tb patient . echovirus poliomyelitis. Friedreich ataxia (AR) 2.A: + ? Absent ? B. Vomiting or an exanthem Before onset of symptoms No H/O Any drug intake before onset of symptoms H/O jaundice / abd pain H/O Night blindness .

PolymyoclonusOpsoclonus Syndrome
of Childhood
(Infantile Myoclonic
Encephalopathy)
Louis-Bar Syndrome /
ataxia - telengectasia

H/O fever with chills &
rigors
H/O child in constant
motion while awake. &
irregular eye movements
No Bulbar/dermal
telengectasia

cardiac disease and diabetes
- Death occurs, usually from heart failure or
dysrhythmias, in the third or fourth decade
4)) Treating underlying conditions
Refsums
Wilson’s
Malignancy
Drug induced

Dietary
Cu chelation
removal
Drug withdrawl / Replcm

Management:
1)) Investigations:
Acute cerebellar ataxia
• CSF: slight lymphocytosis.
• CT : normal
• MRI: cerebellar postinfectious demyelinating
lesions.
• EEG: normal or may show nonspecific slowing.
• Friedreich ataxia : GAA trinucleotide repeats on
chromosome 9 can be used for laboratory diagnosis
•Mt test & X ray chest: Tb
2)) Treatment

Cerebral palsy
Discussion
The term cerebral palsy is a nonspecific term used to
describe a chronic, static impairment of muscle tone,
strength, coordination, or movements. The term
implies that the condition is nonprogressive and
originated from some type of cerebral insult or
injury before birth, during delivery, or in the
perinatal period.

1)) Acute cerebellar ataxia:
Treatment is supportive. Corticosteroids have not
been shown to be of benefit; IVIG has been used.

Page

94

** Between 80% and 90% of children with acute
cerebellar ataxia not secondary to drug toxicity
recover without sequelae within 6–8 weeks. In the
remainder, neurologic disturbances, including
disorders of behavior and of learning , persist for
months or years, and recovery may remain
incomplete.
2)) Polymyoclonus-Opsoclonus Syndrome :
- Respond variably to ACTH or to IVIG.
- Plasmapheresis has been successful.
- Usually the underlying neural crest tumor is benign
(ganglioneuroblastoma); surgical excision may be
the only oncologic therapy needed.
3)) Friedreich ataxia :
- Surgery for scoliosis and intervention as needed for

Seizures (Epilepsy)
DMD
Kannaraju / 10 yrs / M / Student of 6th class / Hindu
/ Karimnagar, brought by his mother a reliable
informant with a
C/C:

of

Meningitis
Vivek/ 7 yrs / M / Student of 3 rd class / Hindu /
narayanguda, Hyderbad brought by his mother a
reliable informant with a
C/C:

of

H/O of fever - 7days
H/O headache – 5 days
H/O hyperirritability – 5 days

• G/E Findings to rule out Genetic Syndromes

H/C/C:
Patient was apparently asymptomatic 15 days back
then the patient developed Headache

Congenital heart disease
Suman / 10 yrs / M / Student of 6th class / Hindu /
Malkajgiri, hyderbad brought by his mother a
reliable informant with a
C/C:

Genetic
Syndrome
Down

Associated
Cardiac Defect
A & VSD

Turner

Bicuspid AV,
COA, AS

Noonan
WilliamsBeuren
Marfan

HCM
AS, PPS

Fetal
alcohol
Maternal
rubella

MVP, MR,
Tall stature,
dil. aortic root, High arched palate,
VSD, ASD
PDA, PPS

of

Discussion

Stroke

Most congenital defects lead either to decreased
pulmonary blood flow or increased pulmonary
blood flow with pulmonary congestion. Symptoms
vary accordingly
Decreased

Increased
Infant/Toddler

Cyanosis
Squatting
Loss of
consciousness

Tachypnea with activity/feeds
Diaphoresis
Poor weight gain

95

Dizziness
Syncope

Risk Factors for stroke

Cardiac disorders
Cyanotic heart disease
Valvular disease
Vascular occlusive disorders
Arterial trauma (carotid dissections)
Homocystinuria/homocystinemia
Vasculitis
Human immunodeficiency virus

Older Child

Page

Flat facies
Flat nasal bridge,
Eyes Upward slant,
Small ears
Clinodactyly
Simian crease
Short stature,
Wide Carrying angle,
Webbed neck,
Short 4rth metacarpal

Exercise intolerance
Dyspnea on exertion,
diaphoresis

Diabetes
Nephrotic syndrome
Systemic hypertension
Dural sinus and cerebral venous thrombosis
Hematologic disorders

Iron deficiency anemia
Polycythemia
Thrombotic thrombocytopenia
Thrombocytopenic purpura
Hemoglobinopathies
Sickle cell disease
Coagulation defects
Protein C and S deficiencies
Leukemia
Intracranial vascular anomalies
Arteriovenous malformation
Arterial aneurysm
Carotid-cavernous fistula
Transient cerebral arteriopathy

Family H/O: No H/O of similar complaint in family
No H/O DM/HTN/Tb/HIV in family
Birth H/O:
Mother is registered case in local hospital & had
regular ANC & IFA prophylaxis.
No other drugs taken / infections
Received 2 doses of TT, Pregnancy is uneventful &
had FTNVD in hosp.
No dystocia / Instrumentation
No admission of baby in NICU
Baby cried immediately & breast fed.
Immunization H/O:
Immunized as per schedule.
No post immunization hosptalization
BCG mark seen
Developmental H/O: recognizes Mother &
Vocalizes Sounds But Not able to loft hos head in
prone position

Hydrocephalus
Raju / 4months/ M / Hindu / Shankarmatt,
hyderbad brought by his mother a reliable
informant with a

Page

96

C/C: of
Progressive enlargement of head from birth with
H/O headache, nausea, Vomiting from 2 months
H/O Poor feeding from birth
H/C/C:
Patient is born with Normal head & has NO
difficulty in labour later then he slowly developed
Enlargement of head to reach present size.
H/O poor feeding from birth
H/O Headche , nausea & Vomiting - 2months NO
H/O trauma
NO H/O fever
NO H/O Swelling at back
NO H/O Involuntary movements
NO H/O unresponsiveness to loud Sounds
NO H/O Convulsions
NO H/O Altered Sensorium / Weakness of limbs

Dietary H/O:
Breast fed NO supplementary feeds Giving
Socioeconomic H/O:
Socio economic class (K) – 3
General examination:
Physical examination
(A) General survey –
Patient is C.
P (-) I (-) C (-) C (-) K (-) L (-)
Enlargement of head particularly frontal region
Buldging Ant fontanalle (NON pulsatile)
High pitched Cry
NONC markers
NO shunt
NO neck stiffness
Scalp veins NOT prominent
Sunsetting sign +ve (Loss of upward conjugate
gaze)
Craniotabes +ve
(Macewen Sign): resonant on percussion /
Crack – pot sign +ve
Facies: N (No dysmorphic features)

Erosion of post clenoid process •USG (V/P ratio: Ventricular dimater at middle portion of ventricles by Bi parietal diameter >0.33 •CT / MRI brain •Lumbar puncture •ICF pressure monitoring •Slit lamp (Chorioretinitis) •PET & Angiography Internal /Obstructive / NON communicating (Monro formen / Acqudect of sylvius) External /NON Obstructive / communicating (Archanoid villi / Basal cistern) Treatment 1)) Mannitol / Furosemide / Acetazolamide 2)) Ventricular tapping 3)) Ventriculo Peritoneal / atrial shunts OR Thecoperitoneal Shunts •Shunt block & infection •Ventricular collapse •Slit ventricle syndrome 4)) Ventriculosty 5)) Choroid plexotomy 6)) Treating underlying condition if possible •Steroids for TBM •AB for PM •Clot / SOL removal Discussion: Increase in size of ventricles due to excessive CSF (Over production / Deficient Absorption / Obstruction) Page 97 Antenatal •Chromosoal Abnormality •NT defects •Arnold chiari 2 Malformation •Dandy walker Malformation •Congenital Craniosynostosis •Congenital Aqueductal stenosis Acquired •Pyogenic meningitis & TORCH •Post Haemorrhagic (SAH) •SOL • Arnold chiari 1 Malformation Sunsetting sign +ve because Dilated suprapenial recess Pressess against tectum producing supranuclear palsy DMD Prem kumar / 8 yrs / M / Hindu / nizamabad brought by his mother a reliable informant with a C/C of H/C/C: Family H/O: No H/O of similar complaint in family No H/O DM/HTN/Tb/HIV in family Birth H/O: Mother is registered case in local hospital & had regular ANC & IFA prophylaxis.N in volume. No dystocia / Instrumentation No admission of baby in NICU Baby cried immediately & breast fed. & rhythm No RR/RF delay No vessel wall thickening BP: 110/80 mm hg RUL: supine RR: 25/min regular (B)Anthropometry: Length: Wt: 4kg midarm circumference – 9cm HC: 40cm Investigations: •X ray skull (Copper beaten appearance) – Separation of cranial sutures – Lacunae in cranium – Bone thinning . character. regular. No other drugs taken / infections Received 2 doses of TT. HR: 96/min.Vitals – afebrile. . Pregnancy is uneventful & had FTNVD in hosp.

No post immunization hosptalization BCG mark seen Developmental H/O: recognizes Mother & Vocalizes Sounds But Not able to loft hos head in prone position Dietary H/O: Breast fed NO supplementary feeds Giving Socioeconomic H/O: Socio economic class (K) – 3 General examination: Page 98 Physical examination (A) General survey – Patient is C.Immunization H/O: Immunized as per schedule. P (-) I (-) C (-) C (-) K (-) L (-) .