SURGERY PRACTICAL 1.

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CASSETTE-CLINICS
OF
SURGERY

MP3 CD with E-BOOK

( Originally A Set Of Five Cassettes And A Book )

By

Dr. Ghanashyam M. Vaidya

Distributors :
Bhalani Medical Book House,
11, Mavawala Building, Parel,
Mumbai – 400012
(CASSETTE-CLINICS OF DR. GHANASHYAM VAIDYA)

Case No. 3!ULCER

(H/O Symptoms)
A 65 yrs. old male Hindu patient, Shamlal, staying in Parel a retired factory worker, comes
with c/o
Ulcer on the sole of left foot - 2 mths.
The patient was apparently alright 2 mths back, when he first noticed the ulcer on the sole
with slight pain. It increased in size for 5 days, & is constant in size since then.

(H/O Complications)
There was mild purulent discharge, but no H/O pain & fever.
No H/O Bleeding,
No H/O Discharge of bony pieces or sulphur granules.
No H/O Inguinal pain & swelling.

(H/O Etiology!of the ulcer)

At the onset, there was no H/O any apparent trauma.
No H/O Swelling preceding the ulcer.

(H/O Etiology!of chronicity of the ulcer)

There is H/O numbness in the distal part of both the feet, but he can feel the chappals & the
ground while walking.
No H/O Loss of sensations anywhere else on the body.
No H/O Varicosities, edema or dragging pain in the legs.
No H/O Fever, with Calf pain & swelling.
No H/O Intermittent claudications or rest pain.
No H/O Polyuria, polydipsia. Patient is not a known diabetic or hypertensive.
No H/O Evening rise of temperature, night sweats, cough, with expectoration &
hemoptysis, or contact with a known case of tuberculosis.
No H/O Repeated trauma to the site of the ulcer.
No H/O Recent weight loss, growth or bleeding in the ulcer.

(H/O Treatment taken )

No H/O Taking rest, immobllisation or regular dressing..
Family history is not contributory.
Personal history: Sleep, bladder & bowels habits normal. Non-alcoholic, but chronic smoker
Smokes 20 bidis per day for last 40 yrs.

On Examination
!1. General !2. Local !3. Focal!4. Systemic

On Local Examination.
On Inspection,
nd
A single oval ulcer, 3x2 cms, in size, situated on the sole of left foot, over the heads of 2 &
rd
3 metatarsals.
It has a well-defined, regular, white margin, with absence of the blue line of growing
epithelium.
The edge is punched outI all along the circumference.
The floor shows - scanty serous discharge.
- no slough,
- pale, flat granulation tissue.
The surrounding skin shows-
- no redness, edema, dilated veins, scars or sinuses.
- There is a zone of hypo-pigmentation.
-
On Palpation,

Cassette-Clinics of Dr Ghanashyam Vaidya 8

The surrounding skin showsIno local rise of temperature, no tenderness, edema or
induration. The edge is firm, non-tender, with no undermining. The granulation tissue is non-
tender & does not bleed on touch.
The base of the ulcer is formed by the underlying metatarsal to which the ulcer is fixed.

On Focal Examination,
1. The inguinal lymph nodes are enlarged, 1-3 cms. In size non-tender, discrete, and
mobile.
2. There is loss of touch and pain sensations surrounding the ulcer & anterior half of
soles of both the legs. The sensations over the rest of the leg & body are normal.
There is no palpable thickening of Posterior tibial, Ulnar and Greater auricular nerves.
There are no hypo-pigmented, anaesthetic patches over the body.
3. The pulsations of dorsalis pedis, posterior tibial, popliteal & femoral arteries on both
sides are well felt. No changes of chronic ischemia in the leg.
4. On examination in standing position, there is no varicosity of short or long saphenous
system, no ankle flare. No calf tenderness. Homan’s sign is negative.
5. The active and passive movements of the toes & ankle are not restricted.

On Systemic Examination.
No signs of malnutrition.
Spleen is not palpable. (Chronic leg ulcers in hemolytic anemias)

My Diagnosis is
Chronic non-healing ulcer on the sole of left foot, probably neurogenic.

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Case No. 4!PERIPHERAL VASCULAR DISEASE

(H/O Symptoms)
A 35 yrs. old Hindu male patient, Manoj, staying at Lalbaug working in a general store, comes
with c/o-
Pain in the legs on walkingI 2 yrs.
Continuous pain in right footI 1 mth.
nd
Blackening of right 2 toeI 10 days.

The patient was apparently alright 2 yrs back, when he started experiencing cramp like pains
in both the legs, on walking 1.5-2 kms, which compelled him to stop, and the pain
disappeared completely on resting for 3-5 mins.
The Claudication distance has diminished gradually, and at present it is 25-30 meters.
No H/O similar pain in thighs & buttocks.
Since last 1 month, he has continuous pain in right foot which is severe, continuous, interferes
with sleep, not relieved by analgesics and partially relieved by hanging the legs by the side of
the cot.
No H/O Numbness, paraethesiae or night cramps.

(H/O Complications)
The second toe of the right foot has blackened gradually since 10 days.
Before the onset of the gangrene, there was no H/O trauma, abrasion, ulceration or pustule
No H/O application of any irritants or excessive heat (for precipitating factor)
No H/O edema, fever or foul smelling discharge (for infection or wet gangrene)

(H/O Etiology)
Patient is a chronic smoker,Ismokes 15-20 cigarettes per day, for last 20 yrs.
He does not consume tobacco in any other form.
No H/O Raynaud’s phenomenon.
No H/O Fever with redness & pain in front of the legs.. (Buerger’s disease)
No H/O Chest pain on exertion . (Angina)
No H/O Giddiness, syncopal attacks, or stroke (Atherosclerosis).
No H/O Exposure to venereal diseases, & sore on penis.
No H/O Polyuria, polydipsia. Not a known diabetic or hypertensive.
No H/O Taking ergots..for headache.
No H/O Working with vibrating machines.

(H/O Treatment taken)

No H/O Taking any drugs, other than analgesics for the present complaints.
No H/O Any surgery on the legs or abdomen. (Lumbar sympathectomy, amputations)

Family historyImarried with 2 children.

No H/O impotence (Lerische’s syndrome)

On General Examination,

On Local Examination,
On inspection in standing & lying down position, The second toe showsIblack discoloration
& shriveled-up mummified appearance extending upto the P.I.P joint where it ends into a
zone of hyperemia & normal looking skin. No ulceration or discharge .

The proximal part of the foot and limb shows-

No redness, ulcerations, scars or sinuses,
Colour – no pallor or congestion of the limb.
no black coloured patches or skip areas.
Veins - the veins on the dorsum of the foot are Well filled in lying down position.

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 The skin over the lower part of the leg and skin –is thin and shiny, with scanty hair
and
with very little of sub-cutaneous fat.
The nails show transverse ridges
No varicositles of short or long saphenous system.
Limb girth 8 cms below the knee joint is less by 2 cms.

On Palpation :
The skin of the second toe is cold, nontender, hard and greasy, with loss of sensations.
The proximal limb is cold upto the knee.
no edema or crepitations.
no tenderness in line of the arteries.
There is no significant enlargement of Inguinal lymph nodes.

Movements : All movements of the second toe are lost. Flexion & extension of other toes
are normal. All movements at the ankle are normal.

Pulsations : DP & PT are not palpable on both the sides.

Right popliteal is not palpable, not demonstrable by Fuschig’s test.
Left Popliteal is feeble.
Femorals are well felt on both sides.
There is no tenderness along the vessels, the vessels walls are not palpably thickened.
Radial, brachial, subclavian & carotids are well palpable and equal on both sides.

On Auscultation :
No bruit is auscultable... along the course of the arteries in the legs,.. over the femorals,
abdominal aorta... & carotids.

Burger’s test is positive. The Burger’s angle of circulatory-sufficiency is 30 degrees.

My Diagnosis is
Dry gangrene..of right second toe..with developing line of demarcation ..due to peripheral
vascular disease. Of distal type..probably T.A.O.. (smoker’s arteritis).

Cassette-Clinics of Dr Ghanashyam Vaidya 11

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Case no!.8. VARICOSE VEINS

(H/O Symptoms)
A 30 yrsIold IHinduImale patient I SitaramI staying in Parel,I working in a factory,I
comes with c/o
Tortuous swelling in left lower limbI 5 yrs.
Dragging pain on walkingI..2 mths.
The patient was apparently alright 5 yrs. back, when he first noticed the swellingI.It was
painless & seen only on standingIIt has gradually increased in size since then to the present
size.
The dragging painIappears on walking a few hundred meters; it is never sharp
shootingIand is always relieved by rest and elevation of the limb
No. H/O intermittent claudications and rest pain.

(H/O Complications)
No H/O itching, oozing or ulceration in the lower third of the leg.
No H/O edema towards the evening
No H/O bleeding from the swelling
No H/O attacks of redness and pain along the swelling with fever.

(H/O Associated Pathologies)

No H/O similar swelling in the opposite leg.
No H/O bleeding per rectum.
No H/O scrotal swelling, dragging pain in the scrotum on prolonged standing.

(H/O Etiology)
There is H/O working in standing position, Iwithout elastic stockingsI 8 hours a dayIfor
last 10 years.
No H/O fever with calf pain and swelling.
No H/O prolonged recumbency, recent fracture or operation.
No H/O bladder or bowel disturbances.
(In females - H/O menstrual disturbances.
- H/O recent or present pregnancy.
- H/O taking contraceptive pills)
No H/O various veins in the family.

(H/O Treatment Taken)

No H/O taking any treatment for the swelling.

On General examination!..

On Local examination,
On Inspection,
There is a tortuous, dilated, non-pulsatile vessel, extending from in front of the medial
malleolus, along the medial aspect of the leg and thigh. No dilatation of the short saphenous
system. There is no ankle flareIno blow-outIno saphena varixIno dilated veins over the
lower abdomen. The skin over the lower third of the legIis pigmented & scaly – no oozing,
ulceration or edemaI no deformity of foot.

On Palpation,
No local rise of temperature... no tenderness over the vein. It is collapsible, no cord like
thickening or nodules along the vein.

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Special tests :
1) No pit is palpable along the vein-by
Fegan’s Method
2) Brodie Trendlenburg test!.is positive with
both – maintained pressure, as well as immediate release of pressure i.e.
Positive – Positive
3) Oschner-Mahorner’s differential tourniquet test
shows incompetency of S.F valve, ankle & below knee perforator. (3-tourniqurnt)
4) The cough Impulse test is positive
5) Moris test is positive
6) Schwartz test is positive

On Examination for deep vein thrombosis.

No swelling of the calf.
No tenderness along the line of posterior tibial, popliteal and femoral veins.
Homan’s sign and Mose’s sign are negative. Perthe’s test is negative.

No enlargement of the inguinal lymph nodes

No lump palpable per abdomen
There is no scrotal swelling –cord structures are normal.
I would like to do Per Rectal examination and Proctoscopy to rule out presence of
hemorrhoids.

My Diagnosis is,
Primary-uncomplicated – varicosities of the – right – long saphenous system –
-with incompetence of sapheno – femoral valve, ankle & below knee perforators.

Cassette-Clinics of Dr Ghanashyam Vaidya 21

(CASSETTE CLINICS OF DR.GHANASHYAM VAIDYA)

Case No.6 THYROID SWELLING

(H/O Symptoms)
A 20 yrs. old Hindu female housewife, Kamala staying in a village in Thane district comes with
c/o-
Swelling in the neck – 2 yrs.
The patient was apparently alright 2 yrs. back, when she first noticed a swelling in the middle
on the neck, to the right of the midline, with no accompanying pain or fever.
The swelling has gradually increased in size since then.
No H/O Regression in size.
No H/O Rapid increase in size with pain.
No H/O Appearance of new swelling elsewhere in the neck,

(Is it Thyroid ?)
No H/O Discharge or sinus from the swelling.
No H/O Evening rise of temperature, loss of weight, cough with expectoration &
hemoptysis, or contact with a known case of tuberculosis.
No H/O Swelling elsewhere in the body, bone pains, or bleeding gums.
No H/O Swelling in the cavity, dysphagia, dyspnoea or change in voice.
The above part may be summarized as
No H/O History suggestive of lymph node swelling.

(H/O Complications)

A. Pressure symptoms
No H/O Dysphagia, dyspnoea or hoarseness of voice.
No H/O Nocturnal dyspnoea.
No H/O Syncopal attacks.
B. Malignant change
No H/O Recent weight loss bone pains, swelling in the scalp or lateral part of the
neck.
No H/O Irradiation to neck in childhood. (If significant in the given case)
C. Thyrotoxicosis
No H/O Chest pain, palpitations or exertional dyspnoea.
No H/O Tremors, exitability, insomnia & excessive sweating.
Patient has not noticed any enlargement of eyeballs.
No H/O Increased apetite with loss of weight
No H/O Diarrhoea or menstrual disturbances.
D. Myxoedema
No H/O Mental lethargy, edema of feet & face, with hoarseness of voice.

(H/O Etiology)
No H/O Similar swelling in the family or village, at the onset,
No H/O Pain and fever,
No H/O Puberty or pregnancy.
Menarchy at 13 yrs.
M.C. regular, 4/28, with moderate flow
No H/O Taking anti-TB Treatment.

(H/O Treatment Taken)

No H/O Previous medical or surgical treatment for the swelling.

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On Examination -
On General Examination
The patient is averagely built, fairly nourished. There is no pallor, cyanosis, icterus or
clubbing. No generalized lymphadenopathy
Pulse- 80/m in., regular, good volume, with no water hammer character.
Blood pressure is 120/80 mm of mercury in right upper arm, in supine position.
Respiratory rate is 20/min, regular.
R.S. & C.V.S. are normal

On Local Examination
On Inspection,
A single oval swelling, 3x2x2 cms in size, to the right of middle of the neck, ½ cm from the
midline, 1 cm above the medial end of the clavicle, It has a smooth surface, and well-defined
margin. The over-lying skin is normal.. no scars, sinuses, fistulae
The swelling rises with deglutition,
but not on protrusion of tongue.
There are no visible pulsations.

On Palpation from behind, by Standard method and by Lahey’s method

No local rise of temperature no tenderness.
The swelling has a smooth surfaceI firm consistencyIand a well – defined border.
Borders : The lateral border is deep to sternomastoid.
The lower border is 1 cm. above the clavicle, and tracheal rings can be
palpated
in the suprasternal notch below the isthmus.
The rest of the thyroid gland is not palpable.
No fixity to the skin, Platysma sign is negative, No restriction of mobility in horizontal or
vertical direction.
No palpable thrill.
The trachea is slightly displaced to the left. Kocher’s sign is negative.
Carotid artery pulsations are well felt and equal on both the sides, but displaced slightly
backwards on right side (Berry’s sign)

On Percussion,
The note over manubrium sternii is resonant

On Auscultation
No systolic bruit over the swelling & over the upper poles of thyroid.

There are no signs of Thyro-toxicosis : i.e

- No true or apparent exophthalmos.
- Von Graffe’s and Joffroy’s signs are negative.
- No tremors of the out-stretched hands or protruded tongue.
- The skin is normal
- Pulse is not fast, irregular or bounding.

There are no signs of Myxoedema: i.e

- No thickening of skin,.. edema of face and legs,.. hoarseness of voice,.. or
mental lethargy.

Cassette-Clinics of Dr Ghanashyam Vaidya 15

There are no signs of retrosternal extension : i.e.
On inspection , no dilated veins over the chest wall.
no puffiness of face.
On palpation, tracheal rings are palpable in the suprasternal notch
On percussion, no dullness over manubrium sternii.
Elevation of both arms above the head..does not produce respiratory distress or
congestion of face.
No evidence of Horner’s syndrome.

There are no signs of metastasis : i.e.

Cervical lymph nodes are not enlarged.
No hard swelling over the skull.
Chest is normal.
No bony tenderness or deformity.
Per abdomen, Liver is not palpable, no free fluid

My Diagnosis is
Benign,Inon-toxic,IsolitaryIThyroid noduleIwith no retro-sternal extentionI.and no air
way obstruction.

Signs of thyro-toxicosis In the eyeballs:

Mild - Von Graffe’s sign of lid lag.

- lid retraction with widening of palpable fissure.

Moderate - True exophthalmos –as seen by Nafziger’s method of examination-

Positive Joffroy’s sign.

Severe - Further bulging of eyeballs.

- Intra-orbital congestion.
- Ophthalmoplagia..with positive Mobius’ sign
- Raised intra-ocular tension.

Progressive - Chemosis.
Diminished acuity of vision.
Impaired corneal sensations, corneal ulcers.
- Exophthamic ophthalmoplegia.

Cassette-Clinics of Dr Ghanashyam Vaidya 16

(CASSETTE CLINICS OF DR.GHANASHYAM VAIDYA)

Case No.5.. BREAST SWELLING

(H/O Symptoms)
A 50 yrs. old..Hindu..female..house-wife..Shantibai staying in Parel..comes with c/o
Lump in right breast..since 3 mths.
The patient was apparently alright 3 mths. back, when she first noticed a small lump in her
right breast without any other symptoms.
It has gradually increased in size since than.
It does not shift its position within the breast.
No H/O Pain
No H/O Pain before menstruation.
No H/O Blood or purulent discharge through the nipple.

(H/O Complications)
No H/O Fever, pain & pus. (For infective pathology)
No H/O Ulceration over the swelling or recent changes in the nipple (retraction).
No H/O Recent weight loss..swelling in the axilla or neck.
No H/O Pain in shoulder or back..or abdominal lump. (For Secondaries)

(H/O Associated Pathologies)

No H/O Swelling in the opposite breast

(H/O Etiology)
No H/O Trauma at the onset
No H/O Fever & pain – at the onset
No H/O Breast malignancy in mother or sister
No H/O Taking contraceptive pills
No H/O Recent lactation or breast feeding.
Patient is a multipara-with 4 children –with the last delivery 15 yrs. back
H/O Breast-feeding all the children

(H/O Treatment taken)

No H/O Taking any definitive treatment for the swelling.

On General Examination !.

On Local Examination,
A. Of both breasts together -
On examination in sitting position:
-right nipple is at a slightly higher level than the left.
-there is asymmetry of the breasts due to a diffuse bulge in the upper & outer
quadrant of right breast.
On bending forwards,
-right breast falls forwards less than left.
On raising the arms fully above the head, (Auchincloss’ method)
-right nipple rises less than the left.
-the swelling in the right breast becomes more prominent.
-skin over the swelling becomes puckered.
-no visible swelling in the axilla.

Cassette-Clinics of Dr Ghanashyam Vaidya 12

B. Local Examination of the affected breast –
On inspection of the right breast,
There is a diffuse swelling in the upper & outer quadrant.
The nipple is- displaced upwards & outwards, and deviated to the left.
It is not prominent flattened or retracted
There is no discharge, crack or fissure
The areola is of normal size,
no cracks or fissures,
no redness, shininess,
edema or engorged veins,
no dimpling, retraction or puckering
no Peau d’orange appearance,
nodules or ulceration.

The left breast appears normal. The arms are not swollen.

On Palpation
The left breast : no local rise of temperature, no tenderness.
A single lump, is palpable with flat hand in the upper & outer quadrant, 4x4x3 cms in size. It is
globular with an irregular surface & ill-defined margin merging into the breast tissue.
The consistency is hard, throughout the lump, and there is no blood or discharge through the
nipple on compressing it.
The lump is tethered to the skin, .. but not fixed to it. It is fixed to the breast tissue & to the
pectoral muscle, but not to the chest wall.

On Examination of right axilla,

Single, mobile, hard lymph node, 3x2 cms in size –is palpable in the medial chain,
No other lymph nodes are palpable in both axillae & neck.

On Systemic Examination,
Chest is normal
Liver is not enlarged.
No evidence of free fluid in the abdomen
I would like to do P.V & P.R. examination for pelvic deposits.

My Diagnosis is,
Malignant tumor- of upper & outer quadrant- right breast- probably carcinoma- stage lll of
Manchester classification.

If you have presented the case upto diagnosis-you have already passed. Now is your
chance to score. The Manchester staging - the investigation profile - the plan of treatment for
the different stages – the arguments in favour of the treatment chosen – and of course-the
standard discussion on elicitation and interpretation of various clinical signs – You will find it
all in the accompanying audio clinics.

Cassette-Clinics of Dr Ghanashyam Vaidya 13

(CASSETTE CLINICS OF DR.GHANASHYAM VAIDYA)

Case No. 1!..SCROTAL SWELLING

(H/o Symptoms)
A 40 yrs. Old male Hindu patient, Ramlal, staying in Parel, a Manual labourer, comes
with c/o-
Swelling in the scrotum since 2 yrs.

The patient was apparently alright 2 yrs. back, when he first accidently noticed a
swelling in the Right side of the scrotum. It gradually increased in size for 1 yr. and is constant
in size since then.
It does not increase in size on straining. Or decrease on lying down / compressing it.
No H/O Rapid increase in size.

(H/O Complications)
No H/O Pain & fever
No H/O Vesicles / exudation from the skin.
No H/O Ulceration / discharging sinuses.
No H/O Difficulty in micturition / intercourse.

(H/O Treatment Taken)

No H/O Tapping, or any operation in relation to the swelling.

Family history & Personal history are not contributory.

(On Examination -)

On General Examination,
The patient is averagely built, fairly nourished.
There is no pallor, cyanosis, icterus or clubbing.
no significant lymphadenopathy.
Pulse is 80/min., regular, good volume.
Blood pressure is 120/80 mm. of mercury, in Rt. upper arm in supine position.
Respiratory rate is 24/mm, regular.
R.S. & C.V.S. are normal.

On Local Examination,
On Inspection in standing position,
A single swelling in the Right side of the scrotum, 10x8x5 cms. in size.
It is a well defined globular swelling, with a smooth surface and a slight constriction around its
middle portion.
The overlying skin shows,
Diminished rugosities, no thickening.
No redness, edema. No vesicles, ulcers or sinuses.
No scar of previous surgery or infection.
On coughing there is no visible expansile impulse in the swelling or over the inguinal canal.

On Palpation,
No local rise of temperature, no tenderness. The top of the swelling can be reached, & only
the cord structures are palpable below the external ring.
The swelling is well defined, with a smooth surface and cystic consistency.
It is not reducible, or compressible.
But it is fluctuant & transilluminant.
There is no palpable impulse on coughing.
The Testis can be palpated with difficulty in the posterior part of the swelling, but size &
shape cannot be assessed,
The Spermatic cord is slightly thickened, but no nodularity of vas or bag of worms feel.

Cassette-Clinics of Dr Ghanashyam Vaidya 4

The Inguinal lymph nodes of the superficial chain on both sides are enlarged, 1/2-1cms. In
size, firm non-tender discrete, and mobile.
The opposite testis is normal, no expansile impulse in the opposite groin.
Per abdomen, no palpable lump in the epigastrium, Virchow’s lymph nodes are not enlarged.
I would like to do Per Rectal examination for hard & nodular seminal vesicles.

My Diagnosis is,
Uncomplicated right primary vaginal hydrocele.

Investigations :
Complete hemogram (CBC, ESR), Urine & X-ray chest.
HIV test, HbsAg.
If the patient is more than 35 yrs. oldIBUN, Blood sugar & ECG.

Operations :
A Thin & small sac : 1. Simple eversion of the sac.
2. Lord’s placation operation,
3. Sharma & Jhaver’s subdartos pouch.
B. Large sac : Jaboulay’s operation of partial excision and eversion of the sac.
C. Very thick sac : Sub-total excision of the sac and under running the edge for
hemostasis.

Cassette-Clinics of Dr Ghanashyam Vaidya 5

(CASSETTE-CLINICS OF DR. GHANASHYAM VAIDYA)

Case no!2 INGUINO-SCROTAL SWELLING

(H/O Symptoms)
A 45 yrs. old Hindu male patient, Dhanji a manual labourer, staying at Lalbaug, comes with
c/o-
Swelling in the left groin since 10 mths. The patient was apparently alright 10 mths.
back, when he accidently noticed a swelling in the left groin, which appeared on straining and
disappeared on lying down. It was painless, and gradually increased in size & extended into
the scrotum over the last 10 mths.
At present, it does not reduce automatically on lying down, but with manipulation the
patient can always reduce it.

(H/O Complications)
No H/O attack of irreducibility with severe pain, distention of abdomen, vomiting & absolute
Constipation.

(H/O Associated Pathologies)

No H/O similar swelling in the opposite groin, or anywhere else over the abdomen.

(H/O Etiology)
1. For hernia-
There is H/O Strenuous work, Patient is a manual labourer.
No H/O Chronic cough, excessive smoking.
No H/O Difficulty in micturition, night frequency,
Poor stream or terminal dribbling.
No H/O Chronic constipation or straining at stools.
No H/O Massive distension of abdomen.
No H/O Operation on the affected side of the abdomen.
2. No H/O Trauma (Cord hematoma)
3. No H/O Fever with chills, with simultaneous pain and enlargement of the swelling. (Filarial
funiculitis)

(H/O Treatment Taken)

No H/O use of truss, or any operation in relation to the swelling

Family history & personal history are not contributory.

On Examination -

On General Examination,
The patient is averagely built, fairly nourished.
There is no pallor, cyanosis, icterus or clubbing.
no significant lymphadenopathy.
Pulse is 80/min., regular, good volume.
Blood pressure is 120/80 mm. of mercury, in Rt. upper arm in supine position.
Respiratory rate is 24/mm, regular.
R.S. & C.V.S. are normal.

On Local Examination,
On Inspection in standing position,

A single swelling situated above the medial half of the inguinal ligament, extending into the
scrotum, but not reaching its base.
It is a pyriform swelling 8x3x2 cms in size, pushing the penis to the opposite side.
The skin over the swelling shows-
no redness, edema, dilated veins.
no scar of any surgery or infection.

Cassette-Clinics of Dr Ghanashyam Vaidya 6

 no hypo-or hyper-pigmentation.
There are no visible peristalsis.
There is a distinct visible expansile impulse on coughing

On Palpation,
There is no local rise of temperature, no tenderness. It is not possible to reach the top of the
swelling in the scrotum.
The top of the swelling lies entirely above the medial half of the inguinal ligament & the public
tubercle is palpable lateral to it.
The lower limit stops just above the testis, which can be felt separate from the swelling.
The swelling is soft and elastic,I no bag of worms feel.
It is reducible with a gurgling sound, reduction being difficult in the initial part & easy
thereafter.
There is a palpable expansile impulse on coughing over the external ring.
Internal ring occlusion test is positive.
On invagination test,
The external ring admits 2 fingertips,
The finger goes upwards, backwards & outwards,
The superior ramus of os pubis is not bare,
And on coughing,
1. Expansile impulse is felt by the tip of the finger,
2. Sphincter strength of the conjoint tendon is good.

On Percussion, the swelling is resonant.

On Auscultation, no sounds were heard.

The testis, epididymis & spermatic cord are normal.

No evidence of hydrocele,
No evidence of hernia on the opposite side.
No meatal stenosis or palpable stricture of urethra.

The tone of the abdominal wall muscles is goodI

1. No undue protrusion of lower abdominal wall on standing.
2. No Molgaigne’s bulgings on Valsalva’s maneuver or on raising the neck.
3. Sphincteric strength of the conjoint tendon on invagination test is good.

O/E of the abdomen, no palpable lump, no scar,

no evidence of free fluid.

O/E of the chest, no evidence of chronic bronchitis.

I would like to do P.R. examination for enlarged prostate.

My Diagnosis is :
Left sided, uncomplicated, acquired, reducible, indirect, complete, inguinal, enterocele,
with good abdominal muscle tone,
with strenuous work as the possible etiological factor.

FOR INVESTIGATIONS & OPERATIONS! in order of their importance and preference in a

given caseIlisten to the cassette carefully.

Cassette-Clinics of Dr Ghanashyam Vaidya 7

(CASSETTE CLINICS OF DR.GHANASHYAM VAIDYA)

Case No. 7!LUMP IN ABDOMEN

(H/O Symptoms)
A 65 yrs. oldIHinduImaleIpatientIDagadu,Icar driver by occupation,I staying at
MahimI comes with c/o
Pain in abdomenI.2 mths.
Lump in abdomenI.2 mths.
Vomiting after foodI.6 wks.
The patient was apparently alright 2 mths. back, when he first experienced belching and
fullness of stomach after food. After 2 wks., it was replaced by pain & vomiting after food.
Simultaneously, he noticed a lump above the umbilicus, which has slightly increased in size
since then.
The pain is felt in the epigastrium, dull-aching in character,I present throughout the day, but
not disturbing sleep. It increases and becomes sharp shooting..on taking food. It radiates to
the angle of left scapula, since last 1 wk, it was experienced with all types of food, including
milk, & waterIand is followed by vomiting.. But vomiting does not relieve the pain.
Vomiting is preceded by nausea, it is non projectile, non-bilious, containing undigested food.
No hemetemesis.

(From this point the history aims at eliminating the possible lumps that can arise in the
organs in that region. Here I have also added the organs not found in epigastrium, for the
sake of completion.)

Stomach : 1. Ca stomach 2. peri-gastric abscess 3. Trichobezoar

1. Positive H/O anorexia, recent weight loss
2. No H/O Malena or hemetemesis.
3. No H/O Pain related to food in the past. (preexisting ulcer)
4. No H/O Habit of eating hair.

Liver : 1.hepatoma 2.amoebic liver abcess 3.hydatid cyst.

1. No H/O chronic alcoholism, recent weight loss, with,Ijaundice, distension of
abdomen, edema feet importance, or breast swelling.
2. No H/O blood & mucous in the stool in the past.
No H/O high fever with chills, with pain in right hypochondrium and lower chest...
& pain on coughing.
3. No H/O Close contact with dogs.

Gall-bladder : 1 Calculous cholecystitis with mucocele or empyema..2. malignant CBD

obstruction.
1. No H/O flatulent dyspepsia, billiary colic, high fever with chills and rigors.
2. No H/O jaundice, with itching & white stools

Pancreas : 1. pseudo-pancreatic cyst or abcess.

1. No H/O severe epigastric pain, radiating to the back with vomiting and retching.
No H/O diarrhoea with frothy offensive stools

Lymph nodes : 1. filariasis.. 2. tuberculosis.. 3. metastasis.. 4. generalized lymph-

adenopathy.
1. No H/O fever with chills,..with pain and enlargement of the swelling..or pain in the
inguinal region.
2. No H/O Suggestive of pulmonary tuberculosis.. or contact with a known case of
tuberculosis.
3. No H/O scrotal swelling.
4. No H/O swelling in the neck, axilla or groin.

Intestines & colon :1 ca colon.. 2 obstructive pathologies..3. round-worm bolus.

Cassette-Clinics of Dr Ghanashyam Vaidya 17

1 No H/O altered bowel habits,Ior alternate diarhoea and constipation.. with blood in
the stools.
2. No H/O borboygmi, colicky pains, vomiting and constipation.
3. No H/O passage of roundworms in stools or vomit.

Kidneys 1. hydro-or pyo-nephrosis..due to calculus or tuberculosis' 2. malignant

tumour.
No H/O pain in the loin..or ureteric colic
No H/O edema of feet ..or large amount of urine..with decrease in the size of the
swelling, (Dietle’s crisis)

Spleen : 1. malaria, typhoid' 2 leukemia'3'lymphoma.. 4. Hemolytic anemia,

hyper-splenism.. 5. portal hypertension.
1. No H/O intermittent fever..with rigors or continuous fever.
2. No H/O recent weight loss with bleeding gums, bone pains, or repeated
infections.
3. No H/O swelling in the neck, axilla or groin.
4. No H/O jaundice and bleeding tendencies.
5. No H/O hemetemesis. If yes..
H/O peptic ulcer like pain.
H/O drug ingestion prior to hemetenmesis..esp. aspirin. The amount,
Colour hospitalization, number of blood transfusions.
H/O jaundice or disturbed consciousness after the episode.
No H/O abdominal distension & liver cell failure.
Etiology of the portal hypertension. a. children, b. adult
a. No H/O umbilical sepsis or home delivery.
No H/O severe diarrhoea or any major illness in childhood.
No H/O jaundice or blood transfusions
b. No H/O chronic alcoholism.
No H/O jaundice or blood transfusions

Family history – Personal historyI not contributory.

(to be mentioned in detail)

On General Examination:

On Local Examination of Abdomen,

On Inspection,
The contour of the abdomen is scaphoid.
No generalized distension.
A diffuse bulge in the Epigastrium, which, diminishes on raising the neck.
The skin shows no dilated veins..no scars or sinuses,
Umbilicus is normal in position and shape,
The abdomen moves well with respiration.. no visible peristalsis or pulsations in the
epigastrium or over the lump.
Hernial sites are normal.
No scrotal swelling.
No deformity of spine or fullness in renal angle.
No swelling in left supra-clavicular fossa.

On Palpation,
No local rise of temperature.
There is mild tenderness 2 cms, below xiphisternum.
No rebound tenderness, guarding or rigidity.

On Deep Palpation,
A single..intra-abdominal lump..is palpable in the epigastrium extending into umbilical & right
Hypochondriac regions.
The lump is firm non-indentable slightly tender.. with a smooth surface and a margin which
Is well-defined in the lower half, but is hidden under the costal margin in upper half. Fingers,

Cassette-Clinics of Dr Ghanashyam Vaidya 18

can be insinuated between the lump & costal margin.
It is fixed in all directions & does not move on respiration.
It exhibits transmitted pulsations of the aorta, which disappear in knee-elbow position.
Bimanual palpation and ballotment do not apply in epigastrium.

On Palpation of the rest of the abdomen,

The liver spleen..and kidneys are not palpable,
No other lump in the abdomen.
No colonic tenderness, no inter-costal tenderness.
No Expansile impulse over the hernial sites on coughing.
Both the testis are in the scrotum, normal in size, & consistency, Testicular sensations are
present.
No tenderness or deformity of the spine.
No paraspinal muscle spasm.
No renal angle tenderness.
Left supra-clavicular lymph nodes are not palpable.

On Percussion,
Dull note over the lumpInot continuous with the liver dullness, which is normal in
th
size, upper border lying in 6 ICS, as confirmed by tidal percussion. Splenic dullness is
normal.
No evidence of free fluid in abdomen.

On Auscultation, normal peristalsisIno bruit.

I would like to do P.R. examinationI for pelvic deposits.

My Diagnosis is,
An intra-abdominalI lump in epigastrium, I would like to give a differential diagnosisI
1. Carcinoma of stomach
2. Malignant lymph nodes..or lymphoma

Listen to the Cassette-Clinics presentation...a discussion that simplifies this so called ‘difficult’
case Ia clarification of the ‘basic’ points and step by step analysis of every sign and
symptom...that will drive the fear out of your mind, Iand will make you ask for a case of
abdominal lump.

Cassette-Clinics of Dr Ghanashyam Vaidya 19

(CASSETTE CLINICS OF DR.GHANASHYAM VAIDYA)

Case No!.9 TUBERCULOSIS OF SPINE

(H/O Symptoms)
A 26 years old, Hindu, male patient, Chotelal, clerk by – occupation, staying in Satara, come
with c/o –
Low backache – 8 months
Swelling in right groin – 2 weeks
The patient was apparently alright 8 months back, when he started experiencing stiffness in
the lower back with mild pain relieved by rest.
The pain was dull, continuous, localized to the lumbar region – with no radiation to the
buttocks, thighs or legs. It is aggravated by bending and jogging.
-but not increased by coughing or sneezing.
The patient has noticed as swelling in the right groin, two weeks back. It is painless & has
gradually increased in size over the last 15 days.

(H/O Complications)
No H/O tingling – numbness.
No H/O weakness of the limbs-like difficulty in walking upstairs, or slipping of chappals while
walking.
No H/O bladder or bowel disturbances.
No H/O swelling over the back, loin or in the abdomen.
There is a swelling in the right groin, since 2 weeks.
No H/O rupture or discharge from the swelling.

(H/O Etiology)
The onset was gradual with.
No H/O lifting heavy weights.
No H/O direct or indirect trauma.
There is H/O evening rise of temperature, night sweating, and weight loss.
No H/O cough with expectoration, and hemoptysis.
There is H/O painless slow growing swelling on the left side of the neck for the last 1 year.
No H/O recent weight loss with -abdominal distension, bleeding per rectum, bowel or bladder
symptoms.

Regarding the groin swelling,

No H/O trauma or infective lesion on the leg, penis or scrotum.
No H/O pain and fever
No H/O straining factors or increase in size on coughing.

(H/O Treatment taken)

No H/O taking any specific treatment except analgesics.
No H/O taking anti-tuberculous drugs in the past.

On Examination :
A. General examination.
B. Examination of the spine.
C. Examination of the swelling – local & focal.

A. General examination,
Matted lymph-adenopathy in right cervical region involving upper jugular lymph nodes.
Per abdomen, there is no mesenteric lump, no renal lump.
Epididymis and vas are normal.

B. On Examination of the spine

Cassette-Clinics of Dr Ghanashyam Vaidya 22

On Inspection,
The gait is cautious. The patient walks on toes, with short steps avoiding jerks.
There is a gibbus over the upper lumbar spineI
No scoliosis.
No para-spinal swelling.
Para-spinal muscles are prominent.
The skin over then swelling, the back, the abdomen, and the groin shows no scars, sinuses or
ulceration.

On Palpation
There is no local warmth.
There is tendernessI over the 2nd & 3rd lumbar spinesIwhich are prominentIforming a
gibbus deformity. Para-spinal muscle spasm is present.

On Testing the movements :

Flexion of the lumbar spine is markedly, restricted extension and lateral flexion are also
restricted.
The movements of the cervical & thoracic spine are normal.
Compression test for sacro iliac jointsI is painless.
Right hip jointIshows fixed flexion deformity of 10 degrees.
All other movements of the hip are normal.
On flexing the hip, rotations of the joint are painless.

On Neurological Examination,
No muscle wasting.
Power of all the muscle groups is grade 5.
Sensations are normal.
Superficial and deep reflexes are normal on both sides. Bladder & bowel movements and
sensations are normal.

C. On Focal Examination
1. No swelling in the para-spinal and lumbar regions.
2. There is a single, oval swelling, 5x8 cms. in size, just below the central part of the
inguinal ligament. It has a smooth surface, and ill-defined border. The overlying skin
shows no redness, edema, Dilated veins, Scars, sinuses or pigmentation.
There are no visible pulsations, but there is an expansile impulse on coughing.
On palpation,
No local warmth or tenderness. Size shape & position of the swelling confirmed it is
soft fluctuant,
Partially reducible, non-pulsatile with an expansile impulse on coughing.
On auscultation, there is no bruit.
On focal examination,
No evidence of trauma, infective lesion or ulcer over leg, penis or scrotum.
3. Right hipIas already mentionedIshows a fixed flexion deformityIdue to extra
articular pathology.
4. Per abdomenIthere is painless, soft, diffuse, fixed, retro-peritoneal swelling in the
right iliac fossa. Which cross-fluctuates with the inguinal swelling.

My Diagnosis is
Tuberculosis...of lumbar spine...with a gibbus at L2-3,
- with right psoas abcess pointing in the groin,
- with no neurological deficit-
- with a possible primary focus in left cervical lymph nodes.

Investigations :
Complete blood count with ESR, ..BUN IBlood Sugar Iurine
X-ray chest with sputum AFB.
X-ray lumbo-sacral & dorsal spine-AP & Lateral views.
Cervical lymph node biopsy

Cassette-Clinics of Dr Ghanashyam Vaidya 23

Guidelines for Treatment :

Will you operate? The criteria,

1) Absolute indication, progressive neurological deficit.
2) Generally accepted indications :
a) Presence of neurological deficit.
b) Presence of large cold abscess.
c) Presence of a deformity.
3) In the absence of the above 3 factors, there are 2 optionsIthe choice depending on
the
surgeons’ individual preference-
1) Conservative treatmentIconsidering surgery only if this fails to control the
progress the lesion.
2) Early surgery.

What are the advantages of your operation and the steps-?

What will be the aim of early surgery?
For the various indications?
What are the pre-operative precautions to be taken?
How will you approach the spine at various levels?
What is the conservative line of treatment? And the one-line answer to all these questions-
Listen to the Audio presentation for the Answers.

Cassette-Clinics of Dr Ghanashyam Vaidya 24