Basic Tips in Clinical Surgery

Basic Tips in
Clinical Surgery
Basic Tips in
Clinical Surgery
Nilesh Patel
MP Shah Medical College
Jamnagar
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Basic Tips in Clinical Surgery
© 2003, Nilesh Patel
All rights reserved. No part of this publication should be reproduced,

stored in a retrieval system, or transmitted in any form or by any means:
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prior written permission of the author and the publisher.
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First Edition : 2003
Publishing Director: RK Yadav
ISBN 81-8061-058-6
Typeset at JPBMP typesetting unit

Printed at Lordson Publishers (P) Ltd., C-5/19, RP Bagh, Delhi 110 007
Preface
The aim of this handbook is an humble attempt to help the

undergraduate medical students to grasp the basic
concepts of clinical surgery. The tips are written in simple
language and in chronological order. Much of the
information is substantiated by the real-time interaction with
the patients in the hospital.
I have seen students having very good knowledge of
theory of their practical cases but scoring less in viva due
to lack of eliciting proper history and tactfulness in giving
viva. I have tried to simplify and clear the basics behind
each phenomenon of disease process.
I would like to point out that the handbook will act as a
“starter” for the clinical surgery to the students. It is
suggested that student must constantly consult textbooks
of his choice.
Even a small endeavour like this has a strong support
from professors of my college and my colleagues. I am
confident that the handbook will relieve lot of confusion
and doubts of undergraduate students.
I have tried to remain as truthful and complete as
possible. However I do not have any authority regarding
the authenticity of material contained. If you find any pitfalls,
kindly draw my attention to them. I welcome suggestions
for improvement from student fraternity.
I am thankful to my parents Narmadaben, Shankarbhai,
my brother Akhil, teachers and my colleagues. My special
thanks to Mr RK Yadav, Director (Publishing) of M/s Jaypee
Brothers Medical Publishers, New Delhi for his sincere
efforts to give decent shape to this handbook.
Nilesh Patel
Contents
1. Be a Good Doctor! ....................................... 1
2. Ulcer ............................................................ 13
3. Swelling ...................................................... 23
4. Hernia .......................................................... 35
5. Lump in Breast ........................................... 47
6. Thyroid Swelling ........................................ 59
7. Varicose Vein ............................................. 75
8. Tips for Viva ............................................... 80
Index ............................................................ 83
One
Be a
Good Doctor!
HOW TO TAKE HISTORY?
INTRODUCTION
 I think this is the only thing that you want to be and
what society is expecting from you.
 So, I have tried all my knowledge and efforts to tell you
my opinion.
 The first step for success in practical exams is ability
to understand patient and examiner.
 Both of these things cannot be learned by reading
books, it needs experience.
 Experience of examiner will surely you have in exams.
But patients are the main source of your understanding
and digesting your theoretical knowledge.
 I believe: Perfect History only will make you a Perfect
Doctor.
TALK MORE, EXAMINE LESS

Why all students are not able to take good history ? Only
answer is ‘reading theory books not approaching patient.
Following are some steps to be good History-Taker:
1. Take at least 5 histories of all cases and show them
to residents and correct mistakes with red pen that
will concrete your mistakes to your brain. They will
not be repeated again.
2. Behave with a patient as he/she is your relative.
3. Putting hand on his shoulders, talking about his
family problems will make your patient comfortable
and he will trust on you.
The most important aspect of the history is your
confidence and patient’s trust on you.
4. Now, gradually start taking history and simul-
taneously watching patient’s reaction, behaviour -
suggestive of any disease:
• Like ‘blinking’ in primary thyrotoxicosis due to
tremors.
2 Basic Tips in Clinical Surgery
• Simultaneously, check mental status – confused,

anxious, irritable, depression, poverty of speech.
5. ODP means: Origin, Duration and Progress.
• It includes each stage from patient’s first curiosity
about symptoms or finding of lump till today.
• It includes all natural, pathological, clinical
changes like investigations, biopsy, treatment.
6. Other histories like past, family, personal and drug
should be taken according to ODP. It is not fair to
ask h/o HT to a child.
• ODP should direct all the steps from remaining
history to examination.
• ODP gives information of which drugs to be asked,
what is the affection of family history, which
findings may be possible in general examination,
which system has to be given more importance.
7. General examination should start from head towards
toe:
• Hair
• Eyebrow
• Eyes – conjunctiva, sclera, eyelid
• Mouth – tongue, cheeks, lymphnodes
• Neck lymphnodes
• JVP, pulsation, veins in neck
• Prominence of sternomastold
• Supraclavicular nodes
• Nail of upper arm
• Thorax
• Abdomen
• Vertebral column
• Inguinal lymphnodes
• Limb edema
• Nails of toe
• Bone, joint, spine movement
Signs of :
• Anemia
• Jaundice
• Cyanosis
8. Vital data:
Make patient comfortable while talking to him and
check for TPR, BP because anxiety can significantly
distract your findings.
9. Local examination:
• It is described in each case.
• General rules:
a. Proper light
b. Proper exposure
Be a Good Doctor! 3
c. Privacy
d. Position
• These points CAN’T BE LEARNED just by
reading. YOU WILL HAVE TO PRACTICE for
these.
• And lastly, after completing all this don’t forget
to:
a. Answer patient’s question about his disease /
medication.
b. Try to give him solution of any problem.
c. Advice him sympathetically to reduce risk factors
like smoking, alcohol etc.
d. If patient is a female; advice her about importance
of family planning.
e. Always be thankful to the patient.
• These are not for scoring in examinations but for
SCORING IN GOD’s VIVA. If patient helps you
to learn something, it is your duty to help him and
give right advice.
ODP
 In this chapter, I will tell you how to describe each
symptom?
 Remember, in C/C write symptoms in CHRONO-
LOGICAL order.
 For C / C, ask patient “What brought you to the hospital”?
 If patient says exact date of symptom - write “c/o pain
SINCE 28th december”.
 If he says some duration of symptom - write “c/o pain
FOR 10 days”.
 Then start ODP with sentence “Patient was relatively
asymptotic before some days / months”.
 ODP should include all events in detail till now.
 ODP will lead you to the provisional diagnosis.
 So, it includes following :
1. Describing each symptom
2. Ruling out etiology
3. Identifying precipitating (or relieving) factors
4. Ruling out complication
5. To know about associated disease that may affect
mode of treatment like Asthma, HT, DM.
6. You should know about “Drug Interaction”.
 Let the patient begin by the story in his own words
without interrupting. Afterwards ask specific questions
to clarify symptoms.
 Try to avoid leading questions because patient may tell
yes/no and may misdirect your history. But sometimes
they become necessary.

 If there is doubt in reliability of patient, confirm by asking
his relatives.
 While taking ODP, talk to patient about his social
problems. What does he like? Make him happy. He
will give very good history.
 After completion of examination, I have compared my
histories with other students, who have same patients
as mine. And I found that many described very super-
ficially because almost all AVERAGE students ask only
symptoms the patient have. They were weak in eliciting
good NEGATIVE history.
 ODP is more important because, if, sir will not come
out from ODP viva within 2 – 3 mins, he will not reach to
methods of examination”.
 In general it is said that if you can bring sir upto
examination, it is sure you have gained passing marks.
 Upto treatment – leads to above average mark
 Some bonus questions – higher scoring
 Thus remember: to score higher marks, you will have
to take complete and good history, so that examiner
will get impressed and will not ask you baseline
questions that decide from which category student
come. He will directly go above average questions.
 The more talking on ‘giving VIVA’ will be done in last
chapter.
 Now, we will see some symptoms.
PAIN
 Reflex that protects us.
 It varies with disease process and tissue involved.
 It may be characteristic and diagnostic.
 Each patient describes different severity according to
his pain threshold.
 Pain means ‘Poena’ means penalty (F.M.)
 Following points have to be included in describing pain:
1. Site:
• Ask patient where the pain is and to point to the
area of maximum intensity.
a. FOCAL Pain can be indicated with one finger.
• Usually, pain arising from skin and subcutaneous
tissue can be localised well.
• Pain of injury is usually localised.
b. Diffuse pain is shown by whole hand moving
on large area.
• Pain arising from deeper structures is usually of
diffuse type.
Be a Good Doctor! 5
• Rest pain may be localised involving only forefoot

or diffuse involving whole limb.
• Severe limb Ischaemia gives rise to diffuse pain.
• Importance: Gives idea about anatomical
structure involved like if in rt hypochondrium–
pathology in gallbladder, epigastric region –
peptic ulcer, left hypochondrium–spleen,
pancreas pathology.
2. Type: (Quality)
a. Vague aching Pain:
• Non-specific
• Mild continous pain
• Usually due to influence of deeper organs.
b. Burning Pain
• Like something heating inside body
• Peptic ulcer and reflux oesophagitis (chemical
burn by peptic acid)
c. Throbbing Pain:
• It implies tense, sensitive area with increase
of tension with each heart beat
• Seen in
i. Vascular tumour:
Pain due to rush of blood in each systole
ii. Intracranial pressure
iii. Aneurysm
iv. Inflammation } Mechanism same
as above
v. Pyogenic abcess – due to accumulation
of pus causing distension of tense cavity.
d. Scalding Pain:
• Variant of burning pain but felt during
micturition.
• Due to cystitis, pyelonephritis, urethritis.
e. Colic:
• Sudden rhythmic bouts of pain with pain free
interval in between them.
• Occurs when hollow muscular organ tries to
force certain content of tube out of it. In
obstructions.
f. Sharp, stabbing:
• Sudden, severe pain.
• Mostly seen in wounds but also in perforations
of ulcer.
g. Compressing:
• Like something is encircling and compressing
from each side.
h. Distending:
• Like feeling of tightness.
• Associated with distension of viscera involved.

Importance: Shows type of disease process
(inflammation, perforation, obstruction).
3. Severity:
• Mild, Moderate or Severe.
• Individuals vary extensively in their pain tolerance
and this is further influenced by anxiety with fear
of the possible implications of pain.
• A useful indicator is the influence of pain on
patient’s life style.
• Enquire whether they have had to stop work or
go to bed and whether they are losing their sleep
through pain.
Importance: Shows severity of disease
process and gives idea about treatment and
dose of analgesic required.
4. ODP:
a. Onset:
i. Sudden Onset :
– Patient can describe precise time of onset.
– Typically seen in
– Injury
– Blocking (obstruction) – MI, intestinal
– Rupture – Aneurysm, Ulcer, Appendix
ii. Gradual Onset:
– Time varies considerably
– Acute inflammation progress in a day or
overnight but degenerative disorders like
claudication or osteoarthritis take months
to develop.
b. Duration :
• Gives idea about the level at which disease
may have progressed.
c. Progress :
• Note progress of current attack.
• It may
– Increase
– Decrease
– Become continuous –plateu phase
– Fluctuate
• Ask about any change in the character of pain
• Like after perforation previously localised pain
becomes diffuse due to irritation of peri-
toneum.
d. Offset:
• Relief of pain usually indicates improvement
of disease or removal of precipitating factor.
Be a Good Doctor! 7
• Very occasionally, it is bad sign e.g. rupture of

tense abscess in cerebral ventricles or
peritoneal cavity.
5. Radiation, Referred, Shifting:
I have seen many students who know these terms
but fail to explain to examiner.
a. Radiation:
• Pain begins in one area and progress to
involve another area and present on both area
simultaneously.
• Pain in epigastric and hypochondrium. After
some time pain in above region plus on the
back. This is pain from pathology of
retroperitoneal structure like pancreas.
• Explain to your examiner such example.
• Others are:
– renal colic
– Gallbladder pain radiating to shoulder
blades
– Myocardial infarction.
b. Referred:
• Pain occurring at a site far away from the organ
involved.
• Classic example is pain over tip of shoulder
from disease under diaphragm
• Visceral nerve–phrenic nerve, Somatic
dermatome – C4.
c. Shifting:
• Pain begins in one area, subsides there and
begins in another area.
• Example is appendicitis
• First due to involvement of appendix which is
a part of midgut that have sharing of umbilical
dermatome – pain is felt in umbilical region.
• But gradually due to extension of infln. There
is involvement of peritoneum over appendix
leading to pain in that anatomical area – rt.
iliac fossa.
• There is tenderness at Mcburney’s point where
base of appendix is situated.
• REMEMBER: pain is symptom and tenderness
is sign.
• Do you know signs of appendix?
1. Macburney’s sign
2. Rovsing’s sign
3. Blumberg’s sign (positive release sign)
4. Cope’s psoas sign
5. Obturator sign
6. Baldwig’s sign.
This is the way how examiner can roam in world
of surgery. Simply from pain he can take you to
sky of appendix. But if you will practice you can
take him wherever you want by giving answers
tactfully. That we will discuss afterwards.
6. Factor Affecting:
a. Aggravating:
• Eating
– Spicy foods in peptic ulcers
– Fatty foods in biliary diseases.
• Movements
– such as coughing in peritonitis
– Osteoarthritis
• Raising legs in Ischaemia or sacral root
compression
• Lying down in pancreatitis
• Pressure over inflamed area
• Walking in claudication
b. Relieving :
• Analgesics or antacids
• Leaning forward in pancreatitis(namaz
position) (also in pericarditis)
• Eating food in duodenal ulcer
• Resting limb in infln. and injury
• Hanging limb in Ischaemia
7. Associated Symptoms Like:
• Fever (infln.)
• Vomiting, constipation (intestinal)
• Relative bradycardia – (typhoid)
• Bloody diarrhoea (dysentries)
Now, how to write?
Pain of intestinal obstruction :
Sudden, severe, colicky pain over the whole
abdomen is present for 8 hours. Previously it
remained for 30 – 40 secs. With a frequency of 3
– 4 per 5 min. Gradually increased in severity
and duration. Not radiating, shifting or referred.
Aggravated by movement and deep respiration.
Associated with profuse vomiting, patient has not
passed stool for 8 hours.
VOMITTING
 Remember, vomiting is a very common symptom.
 It may occur due to-
• irritation of GIT
Be a Good Doctor! 9
• Irritation of CNS
• Septicemia, toxemia
• Septicemia of ear and vestibular systems
• Ketoacidosis, pregnancy
• Even by severe colicky pain
• Drugs like morphin, quinine
 In surgery important causes are
• Peptic ulcer
• Pyloric stenosis
• Intestinal obstruction
• Cholecystitis
• Pancreatitis
 Now what to ask?
1. Amount
• Some common parlance terms of measurement
like “Katori, Bowl “ are used.
• Patient cannot tell amount in mililitres.
2. Colour and Taste
• Recently ingested material without acid = obstruc-
tion in oesophagas e.g. achalasia
• Ingested material and Acid – obstruction in gastric
outlet. e.g. pyloric stenosis.
• Yellow and bitter
– Presence of bile
– Obstruction beyond papilla of water.
• Green colour
– Contents of jejunum
• Brown and faecal odour—Contents of ileum
• Faeces: Gastrocolic fistula.
• Blood : causes of hemetemesis
3. Whether associated with blood or not
4. Frequency
5. Projectile or not
• Ask “Does it come with force and fall far away
from you? “
6. Association with constipation, fever
• To rule out intestinal obstruction, infection.
7. What is situation at present ?
• Subsided or not
• Any change in the pattern.
Write Like this:
Patient is having yellow, bitter, projectile vomit having
amount enough to fill one bowl and 5 times upto
now. It is not associated with blood, fever or consti-
pation. At present he is feeling well.
FEVER
Refer PJ Mehta Medicine for. Types of fever are:
1. Continuous
2. Remittent
3. Intermittent
4. Pel ebstein fever-hodgkins lymphoma
5. Relapsing
6. Stepladder-typhoid
What to ask ?
1. Onset and Timing :
• When does fever come?
• Sudden onset – acute malarial, pyogenic or viral
infections.
• Gradual onset– subacute infection like – TB,
brucellosis.
2. Severity :
• Whether it is high /medium/low grade fever?
3. Type:
• Whether it remains for whole day or at particular
time?
• Is there any specific pattern?
4. Frequency:
How many times in a day?
5. Whether associated with chills and rigors ?
6. Any specific pattern
• Like malaria, Hodgkin’s lymphoma
Write like:
• Mild, intermittent, evening fever not associated
with chills and rigors.
Mechanism of Fever :
Exogenous Pyrogens (Infections)
↓
Stimulate lymphoreticular Cells
e.g. monocytes, histocytes, liver kupffer cells
alveolar macrophages, splenic sinusoids
↓
Release Endogenous Pyrogens (IL2, IL8)
↓
Release Prostaglandins in hypothalamus
↓
Reset thermoregulatory centre to sense a normal

Surrounding temp. as above normal.
—So antiprostaglandins act as antipyretic.

Be a Good Doctor! 11
DIARRHOEA
What is to ask ?
1. Do you have diarrhoea?
2. Frequency and amount
• How many time and what is amount of stool?
3. Consistency
• Thin/Watery/Thick/Sticky
4. Colour
5. Steatorrhea:
• Sticky and frothy, there may be large amount.
6. Blood:
• Whether associated with blood?
• How much blood comes?
• What is colour of blood-bright red/black/clots?
• Above questions relating to blood should be asked
also in case of bloody vomiting.
• Passage of fresh blood in stool - hematochazia.
• Passage of clotted blood in stool – maleana.
• Coffee ground blood occurs due to action of HCl on
blood forming hematin crystals.
Types :
1. Watery:
• Traveller’s diarrhoea caused by enterotoxigenic
— Salmonella
— Staphylococcal gastroenteritis
— Cl. perfringens
— Campylobacter jejuni.
• Mechanism: Entropathogen
↓
Enterotoxin
↓
Acts on cAMP
↓
Secretion and decreased absorption
2. Bloody : (Dysenteries)
• Bacillary dysentery (Shigella- dysentriae, sonnei,
flexneri, boydi)
• Entero invasive E.coli, Entero Pathogenic
• Yersinia
• Amoebiasis
• Pseudomembranous colitis
Mechanism: Destruction of mucosa by cytotoxins
↓
Passage of Mucous, pus
↓
3. Fatty: malabsorption syndromes

• Frothy, sticky, large, pale, offensive, stool
Mechanism : Malabsorption.
WEIGHT LOSS
Ask the patient:
• Does his old clothes seem loose now?
• Since how long?
ANOREXIA
• Ask about reduction of appetite.
• Since how long ?
MALAISE
• Ask for increased tiredness/increased resting.
For other symptoms, we will discuss in each case. (other
histories like past, personal, family and examination).
Two
Ulcer
 Ulcer is a breach in the continuity of skin or mucosa

associated with molecular death of tissue.
 Surgical incision or wound is not ulcer but after few hours
molecular death sets in and then it becomes ulcer.
C/C: C/O ulcer on the right dorsum of foot for 15 days.
C/O discharge for 10 days.
C/O pain for 10 days.
ODP: Patient was relatively asymptomatic before 15
days:
Now we will talk how to take ODP:
1. Describe Ulcer ODP:
a. There may be trauma
• Then describe how trauma has occurred and
when ?
• What was done after trauma ?
• Was any local treatment given ?
• What was size at that time ?
• Was there slough, discharge, bleeding ?
• When did patient come to hospital ?
• What treatment was given ?
• How is condition now ?
or
b. May be due to rupture of abscess.
• Define abscess: cavity containing pus lined
by pyogenic membrane.
• There will be h/o swelling.
• Ask about initial size of swelling.
• What was change in size of swelling?
• Any discharge of pus or blood.
• Final size of swelling.
• Swelling associated with fever, pain.
• How did rupture occur ?
– Surgically by doctor
– Spontaneous
– By patient
• Any action taken from local doctor.
• When did he come to hospital?
• Treatment taken and present situation.
So, the only skill required for complete ODP is:

a. Ability to think, which consequence can occur from
‘A’ to Z’
b. What may be associated symptoms?
c. What can be possible etiology?
d. What can be complications?
2. Describe Pain:
• As in Chapter - 2
• Usually throbbing, sharp or burning
• Inflammed ulcer -painful,
• Tuberculous—Slightly painful.
Syphilitic
jeprotic,
neuropathic
} painless due to loss of sensory nerves.
[Tabes dorsalis,Transverse myelitis, Neuritis]-

3. Describe discharge.
• Amount
• Colour
• Smell
• Association with blood
4. Fever:
Usually mild due to inflammation.
5. Etiology:
a. Infective:
• Discharge
• Fever
• Infection in other part of body
• Residence in tropical area
• Signs of Inflammation.
– rubor, calor, dolor, tumour, functio de plasia
b. Arterial:
• Claudication / rest pain (pain on walking/sleeping)
• Blackening
• Paraesthesia, pins and needles
• Tingling
• Visual impairment (atherosclerosis)
c. Diabetes:
• Polydypsia, Polyurea, Polyphagia
• Visual impairment (diabetic retinopathy)
• Slipping of CHAMPALS
– Never forget to speak this, examiner likes to
hear this ”Recurrent slipping of champals
during walking” (diabetic neuropathy)
– “Loss of sensation of foot”
– “Does urinated place attract ants?”
(Glycosuria)
Ulcer 15
d. Varicose ulcer:
• Dull aching pain
• Dilated and tortuous veins
• Pigmentation
• Occupation - Surgeon, policeman, conductor
e. Tropical:
• Residence in tropical area
f. Trophic:
• Paraesthesia, Anaesthesia
• Tingling sensation
• Callus Formation (Thickening of skin of sole)
(Callus gives rise to invasion of micro-organism
and there is proliferation, so there is development
of small abscesses which burst on increased
pressure leading to ulcer in almost all neuro-
pathics. Science for treatment of callus is called
chiropody.
g. H/O Sexual exposure
• Syphillitic Ulcer
• Ask for sexual relation out of marrige
• Ask for presence of disease in his wife.
h. Traumatic:
There will be H/O trauma
i. Tuberculous Ulcer-mild evening fever, cough, weight
loss, anorexia, malaise, GIT symptoms.
6. Complications:
• Increased discharge
• Bleeding
• Non-healing
• Continuous pain leading to deformity.
Here examiner may go on for complications of healing;
– Painful scar
– Marjolin’s Ulcer
– Pigmentation etc.
}
– Hypertrophic scar you should
– Keloid know the details
of these.
PAST HISTORY
1. TB, Syphilis - recurrence is more
2. Ask for presence of factors leading to non-healing like
malnutrition, subacute infection.
3. HT - Martorell ulcer
4. DM - Leads to ulcer in following way
a. Diabetic neuropathy
• Motor nerves - clawing of toe leading to pressure
and ulcer
• Sensory nerves - patient ignores minor trauma
with subsequent turn into disastrous ulcer.
• Autonomic nerves-decreased sweating + callous

formation.
b. Provision of nutrition - Glucose
c. Diabetic microangiopathy tending to decreased
blood supply.
Family H/O:
• For infective ulcers
– Tuberculous
– Syphilitic
– Chancre
Personal H/O:
Usually not significant but
• Loss of appetite
• Inadequate diet
• Diarrhea
• Smoking→ →atheroscelerosis
}Leading to malnutrition
which lead to decreased
healing
↓
Ischaemic ulcer
GENERAL EXAMINATION
Look for: - Malnutrition
- Anemia
- Cyanosis
- Jaundice
- Lymphnodes
- Syphilitic stigma and other signs
of arterial disease
1. In acute inflammed ulcer :
• Lymph nodes are enlarged and tender
• Later on softens to form abscess
2. In Tuberculosis:
• Lymph nodes are enlarged, matted, nontender
• Later on cold abscess develops
3. In Hunterian Chancre:
Lymph nodes remain descrete and firm
4. Malignancy - stony hard and fixed to neighbour.
LOCAL EXAMINATION
A. INSPECTION:
1. Number:
Multiple in
— TB
Ulcer 17
— Gummatous
— Varicose Ulcer
— Bedsores
• Neuropathic
• Soft Chancre
2. Size
• Gives information about severity and need for skin
grafting.
• Ulcer more than 5 cm. usually needs skin grafting.
• If in ulcer of 8 × 10 cm. size SSG is not done, what
can happen ?
→ It will heal by secondary union leading to ugly scar
which may contract leading to deformities. There
may be painful scar, keloid, marjolins ulcer.
• What is rate of healing of ulcer?
→ It is 1mm. per day
• So, how much time will be taken for ulcer of 1 cm?
→ Yes, it takes 5 days not 10 {common sense}
• Use word approximately because by inspection you
cannot measure exactly.
• Always in 3 dimensions.
3. Shape:
Not so significant.
a. TB → initially oval but their fusion may give irregular
crescentic edge
b. Syphillitic→→ circular but may unite to form
serpingeous ulcer
c. Venous → oval
d. Carcinoma→ → always irregular.
4. Site:
a. Over tips of toes or in between toes:
• Ischaemic ulcer
• In farthest area of blood supply.
b. Heel or ball of the foot:
• Trophic, diabetic ulcers
• Bares maximum weight of body so prone to
develop ulcer.
c. Medial malleolus of lower limb:
• Venous ulcer
• Due to presence of incompetant perforators and
gravity
d. Shin of tibia:
• Syphillitic ulcers are more common on subcuta-
neous bones like tibia, sternum, skull.
• Traumatic because skin is susceptible to direct
trauma. Furthermore, tibia is subcutaneous and
lack of underlying muscle means skin’s blood

supply is reduced and poor healing potential.
e. External genitalia:
• Hunterian and soft chancre
• Spread by sexual contact
f. Back:
• Pressure sore
• In bed ridden patients
g. Neck and Axilla:
• Tuberculous
h. Rodent Ulcer:
• Above line joining angle of mouth to lobule of ear.
• Frequently near inner canthus of eye thus called
‘TEAR DROP CARCINOMA.’.
5. Edge:
• Edge is area between margin and floor of ulcer
• Following points are included :
a. Colour:
Red – Inflammation
Pale / cyanosed – Ischaemia
Pigmented – Venous / malignant
melanoma
Pearly white – Rodent ulcer
b. Oedema:
In inflammed and spreading ulcer
c. Shape:
i. Undermined edge:
• In TB, amoebiasis and pressure sore over
buttocks.
• There is large destruction of subcutaneous
tissue as compared to skin leading to
undermined edge.
• In TB there is development of subcutaneous
abscess which gradually causes necrosis of
small portion of skin due to increased
tension leading to undermined edge.
ii. Punched out:
• When there is equal destruction of all layers
• Seen in syphillitic, tropical, leprotic
iii. Sloping Edge:
• In healing ulcer because granulation tissue
heals more rapidly than skin, leading to
sloping edge.
• May be in varicose and septic ulcers.
iv. Raised and pearly white beaded :
• Rodent ulcer
Ulcer 19
v. Raised and everted :

Squamous-cell carcinoma
vi. Describe healing edge ;
• Regular, well-defined with 3 zones
• Inner red due to granulation tissue
• Middle blue due to reflection of light
• Outer white due to epithelium.
6. Floor:
• It is exposed surface of ulcer i.e. covering of base of
ulcer.
a. — Healing floor → Pink granulation tissue with
red dots at sites of capillary loops.
— Velvety due to protruding capillary loops
surrounded by fibrous tissue.
— Non-tender
— No slough or pus
— Bleeds on touch
• Is bleeding on touch is good sign ?
– Not always, seen in malignancy too.
b. Non-healing floor :
— Pale and smooth granulation tissue
— Presence of slough and discharge
c. Wash leather slough :
— Gummatous Ulcer
— May be in post-irradiation ulcer.
d. Bluish granulation tissue :
— Tuberculosis
e. Slough:
— Dead piece of tissue yet to be separated from
healthy tissue
— Yellow adherent surface, made of dead tissue
and inflammatory cells.
f. Black mass on floor - malignant melanoma
7. Discharge:
• Note:
— Character
— Amount
— Smell
• For inspection see gauzepiece for discharge.
a. Character:
i. Serous - chronic non healing
ii. Serosanguinous - healing
iii. Sanguinous -malignancy
iv. Thick yellow -staphylococcal
v. Thin yellow -streptococci.
Thin due to action of DNAse enzyme causing
liquefaction of inflammatory exudate.
vi. Yellow granules - actinomycosis

vii. Blue / green - Pseudomonas
• Due to pigment pyocyanin.
viii. Dark red/maroon—klebsiella
ix. Anchovy sause like - amoebiasis.
b. Amount:
• Profuse in ulcer associated with edema.
• Scanty in ischaemic ulcers.
More blood → more formation of transudate/
exudate.
c. Smell:
• Faeculent smell on infection with faecal
organism like E. Coli. (normal resident of
intestine).
• Foul smelling in anaerobic infection/
gangreen— malignancy.
8. Surrounding area:
a. Glossy, red, edematous surrounding area suggest
acute inflammation.
b. Induration of surrounding skin may be due to :
i. Inflammatory response to trauma, malignancy
ii. Direct invasion of malignant cells
c. Blood Vessels may be prominent due to increased
blood supply and venous drainage as inflam-
matory response.
d. Pigmentation and eczema in varicose ulcer.
e. Hypopigmentation in leprosy.
f. Scars due to previous ulcer.
B. PALPATION:
1. Temperature:
• Checked with back of hand first on normal area than
on area surrounding ulcer.
• Increased in inflammation.
2. Tenderness:
• Acute inflammation → tender
• Chronic Ulcer → slightly tender
• Neoplastic → nontender
3. Size:
• Measure in 3 dimensions
• Depth is measured by making wick of cotton and
described in mm.
• For other dimensions press fresh gauzepiece on
ulcer, remove it and measure linings marked by ulcer
on gauzepiece.
Ulcer 21
• In venous ulcers there may be full or partial thickness

skin loss but usually do not extend beyond
subcutaneous tissue.
• Usually inflammatory ulcer extends in subcutaneous
tissue but may communicate with deep abscess
cavity.
• Carcinoma spread circumferentially but as bulk
increases there is vertical penetration with fixation
to fascia, muscles or bones.
4. Edge and Margin:
• Margin is junction of ulcer with normal healthy
epithelium.
• Edge will be tender in
— Arterial ulcer due to Ischaemia of surrounding
— Vasculitic Ulcer
• Induration is seen in :
— Carcinoma
(anaplasia) } due to tight packing of cells
— Chronic Ulcer } due to inflammatory cells

5. Base:
• On which ulcer rests and better felt than seen.
• If an attempt is made to pick up ulcer between thumb
and index finger base will be felt.
• Slight induration of base is felt in chronic ulcer but
marked induration is important feature of squamous
cell carcinoma and hunterian chancre.
6. Bleeding:
• Press ulcer with cotton gauze and watch for bleeding.
• Common feature of malignant ulcer:
7. Surrounding skin:
• Check for edema, temperature, tenderness
8. Relation to deeper structure:
• Gummatous ulcer may be fixed to tibia or sternum.
• Carcinoma may be fixed to adjacent structures by
infiltration.
NEVER FORGET TO EXAMINE FOLLOWING:

1. Lymph nodes:
2. Vein — As varicose vein
+
Artery (VAN) — Pulsation
+
Nerve — Sensation (fine, crude,
vibration, temp., Joint sense).
3. Joint
Diagnosis:
Write like this:
Patient is having healing ulcer because [write criteria of
healing ulcer] on right dorsum of foot with probable etiology
of trauma supervened by diabetes.
If there is time and examiner is not in hurry, tell him
positive points favouring your diagnosis and negative points
ruling out other etiologies.
INVESTIGATIONS:
1. Routine-Hb.TC, DC, FSR
2. Blood Sugar, Urine Sugar
3. Syphillis - VDRL test or W.R. and Kahn test
4. Culture sensitivity and antibiogram
→ Specific for ulcer.
• How to take Culture?
— By autoclaved sterile swab, pus from ulcer is taken
and sent in test tube.
5. Test of tuberculosis.
6. Biopsy to rule out malignancy.
• Biopsy is taken at junction of normal and diseased
area b’cuase it it is easy to compare between normal
and abnormal.
7. X-ray of bone and joint :
• If ulcer is near bone or joint
• Gummatous ulcer causes new bone formation and
‘Sabre Tibia’.
8. Contrast radiography, duplex scan.
• For arterial ulcer.
9. Radioactive fibrinogen test, venography
• Deep vein thrombosis.
1. What is debridement?
→ Removal of dead necrotic tissue and slogh.
2. In advanced hospitals, what is used instead of Humbey’s
knife?
→ Electrodermatome.
3. Absolute contraindication for skin grafting?
→ Infection with B-hemolytic streptococus which causes
hemolysis and rejection of graft.
4. Which graft is better full thickness or partial thickness?
→ Full thickness graft is accepted rapidly due to presence
of blood supply in it.
→ Partial thickness graft gets nourishment from serum
stored inside it and gradually anastomosis develops. So
chances of rejection are more. But it is cosmetically better.
Three
Swelling
WHAT IS SWELLING ?
 Swelling denotes any enlargement or protuberance in
the body. Beware of term “lump” – it is a mass of tissue.
It can be called invisible swelling.
 Lump is palpatory finding, more than inspectory one
and usually seen in abdomen, breast.
Now we will move to C/C.
C/C : Swelling on ____ for __ day(s)
Pain for __ day(s)
Fever for __ day(s)
Mostly pain is presenting symptom and bring the patient
to hospital.
ODP: We will follow order same as of ulcer.
1. ODP OF SWELLING:
a. First ask – when did the patient first notice it ?
b. What did bring attention to it ?
Answer are like while bathing, shaving or shown by
some other person.
c. Mode of onset → “How did it start?”
d. Now ask size of swelling when seen first.
Describe like size of bare, lemon, apple, ball.
e. Ask whether there is change in the size of swelling ?
Usually ;
i. Inflammatory swellings increase rapidly and subside
gradually, so they decrease in size.
ii. Tumours:
• Benign → Gradually increase → But sudden
increase, if haemorrhage occurs in tumour.
• Malignant → rapid growth
• Malignant on benign growth→ But sudden
acceleration of slow growing swelling.
iii. Traumatic :
Sudden increase and maintain same size for some
period due to hematoma formation and then
gradually decrease.
iv. Fluctuating Swellings :
• Obstructed partotid gland enlarges on eating.
• Hernia → reducing on lying and increasing on

coughing.
• Blood filled or fluid filled lumps like varicose veins,
varicocele, and hydrocele.
f. Ask patient whether there is anything he can do to make
the lump bigger or smaller ?
g. Progress of swelling ?
• Any treatment taken.
• Present size of swelling.
2. PAIN:
Describe as written previously.
Inflammatory (throbbing pain)
Painful Lumps Traumatic
Malignant on Expansion
Infiltration
Breaking down
Pain precedes swelling in inflammation and vice versa
in malignancy.
3. FEVER:
Seen with inflammatory swelling.
Remember: “Whenever there is inflammation, there will
be fever”.
Pyrogens released from neutrophils and macrophages
reset hypothalamic thermoregulators.
Def. Inflammation is the body’s response to injury and
is an attempt to eliminate or minimize the harmful effect.
Criteria for diagnosis of inflammation:
i. Temp. > 38ºC or <36ºC
ii. Heart rate > 90 / min.
iii. Respiratory rate > 20 / min.
iv. Total WBCs > 12,000 / Cumm. Or < 4,000 / Cumm.
4. DISCHARGE:
 Quantity
 Colour
 Consistency
 Smell
• Putty, toothpaste like in sebaceous cyst.
• Pus in inflammatory swelling.
• Foul smelling on anaerobic infection.
Swelling 25
5. PRESENCE OF OTHER LUMPS:

For multiple swellings like :
• Neurofibromatosis
• Lipomatosis
• Hodgkins lymphoma
• Tuberculosis
• Empyema Neccessitance
Remember suffix ”matosis” shows multiple.
6. LOSS OF BODY WEIGHT:

In chronic inflammatory or neoplastic swellings due to factor
TNF-@.
7. ETIOLOGY:
a. Inflammatory : Onset, progress of swell is rapid,
Pain, fever
b. Neoplastic : Slow growing, painless
c. Traumatic : H/o trauma
d. Congenital : Present since birth
: Associated with other congenital
abnormalities
8. PRECIPITATING / RELEIVING FACTORS:

a. Increasing or decreasing pressure :
• In abdomen
• Hernia, abdominal swellings
• Increase in size of laryngocele on blowing.
b. On movement of joint :
• In swellings communicating with bursae
c. On contracting muscles.
9. COMPLICATIONS:
a. In swelling itself.
• Secondary changes like
— hemorrhage
— ulceration
— fungation
b. Due to pressure on surroundings :
• Difficulty in moving joint
• Pain due to compression of nerve, artery
• Edema due to compression of vein
• Difficulty in breathing due to compression of trachea
• Difficulty in swallowing due to compression of
oesophagus.
• Deformity – deviation from normal size and shape
c. Systemic :
• Septicaemia, toxaemia
• Weight loss
• Secondary malignancy
Past History:
a. • H/o similar swelling in past and its treatment.
• Malignant swelling may recur.
• Recurrent fibroid of Paget.
b. H/o HT, TB, DM, Syphillis.
c. H/o any operation.
Family History:
a. • Congenital swellings
• Some malignancies (like cancer of breast)
• Tuberculosis (cold abscess)
• Syphillis
• Von Recklinghausen’s disease.
Personal History:
a. • Try to identify any risk factor for malignancy.
Addiction → Smoking, tobacco chewing etc.
GENERAL EXAMINATION
1. Cachexia and malnutrition associated with malignancy
and cold abscesses.
2. Abnormal attitude /paresis/paralysis due to compressing
tumor/swelling.
3. Edema of distal limb due to compression of vein.
Vital data :
Temperature → in cases of acute inflammation.
Pulse → rapid in acute inflammation.
Respiratory rate → rapid in acute inflammation.
LOCAL EXAMINATION
First, understand that there are four areas to be covered
in case of swelling (even in ulcer) :
1. Site → In Both Inspection and Palpation.
2. External features →In Inspection
3. Internal features → In Palpation
4. Surrounding tissue → In Both
A. INSPECTION:
1. Site:
• Site is measured from fixed bony prominence such
as olecranon process, tibial tuberosity, manubrio-
sternal angel.
Swelling 27
• In inspection write area like – swelling in inner side

of left arm.
• But in palpation write exact distance as told before
like – swelling is 10 cm. distal to tibial tuberosity.
Importance :
a. Gives idea about :
i. Anatomical origin
ii. Anatomical plane in which it is
iii. Its relations with surrounding
b. Dermoid cysts are seen more in
i. Midline of body
ii. On line of fusion of embryonic process. e.g.
outer canthus of eye or behind ear.
2. Size :
On inspection write “about the size of lemon / apple”.
3. Shape:
Write like – ovoid, pear shaped, kidney shaped,
spherical, irregular, polypoid.
4. Surface:
• It is described in terms of smooth / rough / lobulated
and regular / irregular
• It is common sense that :
a. Lesions arising in epidermis may exhibit surface
abnormality. eg. punctum in sebaceous cyst.
Cauliflower surface in squamous cell
carcinoma.
b. Deeper lesions are usually covered by skin
which may be normal or inflammed.
5. Colour:
Same like surface, superficial lesion will exhibit their
own colour but deeply placed will be covered by normal
/ inflammed skin. e.g.
• Yellowish colour of xanthelasma due to fat
• White colour of gouty tophi due to calcium
• Red/Purple colour of hemangioma
• Red in hyperemia / inflammation
• Pale and Shinny in tissue edema
• Black pigmentation in malignant melanoma.
6. Number:
• Some are multiple like
— Neurofibromatosis
— Diaphyseal aclasis
• Remember in case of multiple swelling describe
one swelling in great detail and others only taking
positive points, if you have less time for history
taking.
7. Pulsation:
Seen in two types:
a. Transmitted pulsation:
• Swelling lying near artery
e.g. pancreatic mass over aorta
b. Expansile pulsation:
• Swelling arising from vessels
e.g. aortic aneurysm
vascular malformations
arteriovenous fistula
8. Peristalsis:
• Important only in abdominal lump.
• Watch for minimum ten mins.
• If still not visible -RUB abdomen for some time and
then watch. You will be able to see it now due to
stimulation of peristalsis.
• Seen in—congenital hypertrophic pyloric steno-
sis—carcinomas producing intestinal obstruction.
9. Movement with Respiration:
Swellings in upper abdomen movement with
respiration due to attachment of liver, spleen, stomach,
gallbladder, hepatic and splenic flexure of colon to
diaphragm.
10. Impulse on Coughing:
Present in all swellings which are in continuity with
abdominal cavity, pleural cavity, spinal canal or cranial
cavity.
11. Edge:
• Terms used are clearly defined /ill defined.
• If clearly defined then regular / irregular and round/
sharp.
12. Movement of Deglutition:
• Only in neck swellings
• Swellings fixed to trachea / larynx move
e.g. thyroid swellings, subhyoid bursitis, pretracheal
lymphadenopathy
13. Movement with protrusion of tongue
Swellings related to thyroid only move.
14. Skin over swelling:
• Red and oedematous in inflammation
• Tense, glossy with venous prominence in rapidly
growing sarcoma
• Punctum in sebaceous cyst.
• Peau-d-orange in Ca. breast.
15. Pressure effect on surrounding:
• Wasting due to trauma or paralysis by compression
of nerve or decreased blood supply.
Swelling 29
B. PALPATION:
1. Site :
• Exact measurement from bony prominence as
written before.
2. Temperature :
• Increased blood flow in superficial tissue increases
temperature which is seen in :
— Inflammation
— Tumours with rich blood supply
— Tumours of vascular tissue.
• Compare the local temp. with that of adjacent skin
and equivalent site on other side of body.
• Use dorsum of hand because :
— thinner skin
— rich nerve supply
— fewer sweat glands making it dry
3. Tenderness :
• Keep eyes on face of patient while eliciting
tenderness
• Seen in swellings due to trauma, inflammation,
malignant lumps
4. Size :
• Write in exact measures
• 3 dimension → horizontal, vertical, depth
• Gives idea about change in size whether increasing
or decreasing.
5. Surface:
With palmar surface of hand
Smooth – cyst
Lobulated – lipoma
Nodular —matted lymphnodes
Irregular —carcinoma.
6. Edge :
• It may be well-defined or ill-defined merging into
surrounding structures.
• Neoplasms and chronic inflammatory swellings
have well defined edge.
• Benign tumours – smooth and regular edge
Malignant tumours – irregular edge
Acute inflammatory swellings – ill-defined edge
• How to differentiate lipoma and cyst.
In lipoma – edge will slip away when you palpate.
In Cyst. – edge will not slip.
7. Consistency:
• Soft – like lips – Lipoma
Firm – like tip of nose – Fibroma
Hard – like forehead – Osteoma
Rubbery – slightly indentable – Chondroma

Spongy – squeezable
Stony hard – Carcinoma
Cystic – Cyst., chronic abscess
• Depends on contents of swelling.
• Now think what can be contents of swelling?
 Normal → increased in number and / or size.
A. Cells
 Due to alteration of local tissue.
  e.g. carcinoma.
Abnormal Invasion by other cells
e.g. inflammation, metastasis.
 Inflammation

B. Fluid Venous obstruction

Lymphatic obstruction

C. Gas Inguinal hernia (crepitus)

Surgical emphysema
8. Compressibility :
• Lumps are termed compressible when they can be
emptied by squeezing but reappear on releasing.
• Seen in cavernous hemangioma, lymphangioma,
narrow necked meningoceles.
9. Reducibility :
• Lump can be emptied by squeezing but does not
return spontaneously – this requires additional force
like coughing or effect of gravity
e.g. inguinal hernia
• Give example of having both 8 and 9 characrisitcs.
→ Saphena varix.
10. Indentation and Fluctuation:
• If contents of lump are solid or semi-solid and not
too tense they can be indented by pressure. e.g. in
lax sebaceous cyst. and large dermoid cyst.
• Now what is fluctuation ? Define it.
→ If pressure is applied to one side of fluid filled lump,
the fluid tends to protrude in all other directions
and provided it cannot escape in another compart-
ment, this bulging of rest of the wall can be
demonstrated the sign being termed fluctuation.
• Method :
The cyst is held between thumb and finger
(watching digits) of one hand and pressure applied
downwards between them with digit of another hand
(displacing digit). The watching digits can feel
expansion.
• Same expansion can be felt when muscles held
transversely but not longitudinally so ALWAYS do
in two planes right angle to each other.
Swelling 31
• ALWAYS FIX MOVABLE SWELLING FIRST and

THEN ELICIT the test otherwise it will give false
positive results.
• For small swellings there is PAGET’S test per-
formed by simply pressing in the centre. If centre
is soft, it may contain fluid and if firm it is solid
swelling.
FLUID SOLID
. .. .
. ... . .... ..
................ ...... ..
. .... . . ...
.. ... .
Centre – Soft - Firm
Periphery – Firm - Soft
Examples : hydrocele, spermatocele, abscess

• C/I of this test : tender abscess, branchial cyst.
• Why in lipoma, test is positive sometimes ?
→ Because at body temperature fat is semifluid and
test is positive in not too tensed lipoma.
11. Fluid Thrill: Write in (PERCUSSION)
• In fluid containing swelling percussion wave is seen
to be conducted to its other poles when one of its
pole is tapped as in percussion.
• In large swelling percuss at one pole with two
fingers of one hand and feel at other pole with
palmar aspect of other hand.
• In small swelling – ring and index finger on side
wall and middle finger on top. Tap with middle
finger and feel with other two fingers.
e.g. in hydatid – cyst.
12. Pulsation:
Two Types :
a. Expansile pulsation :
Fingers
Swelling
Artery
• Due to → swelling of artery e.g. aneursym.

→ swelling with rich blood supply e.g.
hemanginoma.
→ vascular malformations e.g.
arteriovenous fistula.
• Watching digits move updown and laterally also.
b. Transmitted Pulsation:
Fingers
Aneurysm
Artery
• In swelling near to artery.

e.g. pancreatic mass situated in front of abdominal
aorta.
• Digits move only up and down.
• Method :
By gently pressing a finger of each hand on either
side of the mass.
13. Impulse on coughing:
a. Method: Swelling is grasped with hand and patient
is asked to cough (after telling him to move face
on other side) and feel impulse which is due to
increased pressure in respective cavities.
b. Positive in swellings which are in continuation with
cavities like :
i. Abdominal—Hernia, Iliopsoas and lumbar
abscess.
ii. Pleural – Empyema neccessitans
iii. Cranial – Menigocele.
14. Transillumination:
• Clear fluid transmits light.
• A lump containing such fluid glows when the beam
from pen torch is shone across it.
• Trans means “through: so keep torch at one end
and card-board on another end with lump in
between.
• Card-board is used to cut off peripheral surrounding
glow to prevent false-positive results.
Swelling 33
• Water, serum, lymph, plasma and fat are trans-

illuminating. e.g. Hydrocele, Epididymal cyst,
Spermatocele, Meningocele, Cystic hygroma,
Branchial cyst, Bursae, Lipoma.
15. Expression and discharge:
• When skin over cystic lesion breaks down the
contents are discharged.
• Putty like granular in sebaceous cyst.
• Bad smell is common because of retaining and
moisturizing of dead cutaneous elements. Also,
seen in necrotic, degenerating, malignant lensions.
16. Fixity to overlying skin:
• Swelling originating from skin will be fixed to skin.
e.g. Sebaceous cyst. Papilloma, Epithelioma.
• They will move along with skin unless fixed to
unlderlying structures by infiltration (e.g.
Epithelioma)
• Methods :
a. Skin is made to move over swelling
b. Pinching of sking.
— Always in two DIRECTION right angle to
each other.
17. Relations to surrounding structures :
To find out :
a. Basic structure from which swelling is arising
b. To know whether there is any invasion.
• Swelling of skin – fixed to skin.
• Subcutaneous swelling – not fixed to skin or
muscle.
There may be puckering of skin in lipoma due to fibrous
strands extending from capsule to overlying skin.
Puckering due to
fibrous strands
• Swelling of fascia – like above one but decreased

mobility.
• Swelling of muscle – not fixed to skin but to
muscle.
— Can move horizontally when muscle is relaxed
but can’t when muscle is tight, check in two
directions.
• Tumour deep to muscle.
— Disappear on tightening of muscle.
• Tumour within muscle

— Decrease/Increase on tightening
• Tumour outside muscle
— Increase on tightening
• Tumour of tendon → same as muscle
• Tumour of nerve and vessel
— Does not move in longitudinal axis but slight
movement in horizontal axis.
• Swelling of bone → absolutely fixed.
LYMPH NODE EXAMINATION

Very important NEVER FORGET to palpate lymph nodes
draining the region of swelling :
Mainly 3 Groups :
1. Cervical
2. Axillary
3. Inguinal
C. PERCUSSION:
1. Fluid thrill – as in palpation.
2. Enlarged bladder, pregnant uterus or an ovarian cyst
are dull to percussion.
3. Obstructed intestine will be resonant.
4. Retrosternal goitre can be detected by dullness to
percussion over sternum.
D. AUSCULTATION:
1. Bowel sounds in hernia.
2. Bruit (murmur) over vascular lesions.
3. Crepitus over joint.
4. Friction rub over pleuritic or pericardial surface
5. Machinery murmur of arteriovenous fistula or enlarged
toxic thyroid gland.
Diagnosis:
Write all positive findings and keep D/D according to that.
Four
Hernia
DEFINITION
A hernia is protrusion of viscus, in part or in whole, through
normal or abnormal, congenital or acquired defect in the
wall that contains it.
First we will take history and examination after which
we will go to viva.
1. AGE:
Indirect hernia is more common in younger while direct
hernia in older patient.
2. OCCUPATION:
Strenuous work like weight lifting, cycle ridding.
3. C/C:
• It will be swelling for _____ days / months.
• Sometimes patient may present as emergency with
symptoms of intestinal obstruction or strangulation
like :
• severe pain over whole abdomen
• vomiting
• abdominal distension
• dehydration
• absolute constipation
4. ODP:
As usual,
A. ODP of Lump:
1. When did you notice it first time?
2. What were you doing when you saw swelling?
Like on standing, coughing, weight lifting.
3. What was size and shape at that time?
• Congenital hernia is larger than acquired one
at first appearance and progress more rapidly.
• Remember, congenital hernia may appear at
any time in life when precipitating factors
accumulate.
• Round shape– direct,

• Oblong/pear shape– indirect
4. Where does it reach?
• If above groin then inguinal.
• If below groin then femoral.
• If reaching to scrotum then indirect.
5. Does it get reduced automatically or by you?
• Direct hernia disappear rapidly on lying down
while indirect hernia needs manual reduction
usually.
6. • Does it increase on coughing?
• Diagnostic sign of hernia
• Direct hernia protrudes forward.
B. Pain:
As written earlier :
• Usually there is dragging pain (Due to protrusion
of omentum through small ring, producing
dragging sensation).
• But NEVER forget, painful and tender hernia is
sign of complication.
• Usually pain is present long before appearance
of lump
C. To rule out etiology:
1. Congenital Weakness:
• Persistence of processus inguinal
vaginalis
• Patent canal of nuck
} hernia
• Incomplete obliteration of umbillicus—

umbilical hernia
2. Acquired weakness:
i. Obesity
Fat separate muscle bundles and layers,
weakens apponeurosis and favours appea-
rance of paraumbillical, direct inguinal and
hiatus hernias.
ii. Repeated Pregnancy
iii. Muscle wasting d’s.
Like TB, myelopathies, ask symptoms of TB
and wasting.
iv. Infiltration of abdominal wall by intraabdominal
malignancy.
• Loss of weight
• Loosening of clothes
• Abdominal pain
• Past h/o carcinoma
Hernia 37
v. Poor wound healing:

• Postoperative complication
• This I will describe in detail later on.
vi. Iatrogenic:
Surgical incision may cause division of nerves
and causes muscle weakness e.g. McBurney’s
incision for appendicectomy may cause
divisions of subcostal or ileo-inguinal nerve
leading to right sided direct inguinal hernia.
3. Precipitating Factors :
I. Chronic cough : Ask symptoms of Chronic
Obstructive Lung Disease:
—Breathlessness,cough,fever
ii. Constipation
iii. Bladder out-flow obstruction:
• Difficulty in urination.
• Dribbling of urine.
• Burning micturition
Sometimes patient may be aware of enlarged
prostate. Ask him if he knows.
iv. Occupation
v. Parturition:
Ask for any recent delivery.
vi. Vomiting
vii. Ascites:
• Accumulation of fluid in abdomen.
D. Specific for incisional hernia which is dreadful case
for UG students. But don’t worry we will fight.
We have to ask detailed history of all previous
operations on abdomen.
1. • Number of operations done
• More operations at one site, more will be
weakness.
2. Reason for operation
• If done for some emergency indication like
intestinal obstruction or strangulation then due
to rapidity of operation there may not be proper
asepsis,haemostasis and closure leading to
hernia.
3. Where and which doctor did operation?
• ASEPSIS in O.T. and competent doctor are
necessary to reduce post-operative compli-
cations of hernia.
4. Was there formation of pus/bleeding from
incision?
• Release of pus due to postoperative infection.
5. Was there any fever after operation?

• Points to postoperative infection.
6. Any treatment taken for that.
• Dressing, drugs – antibiotic
• Resuturing
*Do you know importance of resuturing?
[bonus question]
→ Taking secondary suture causes better
apposition, early healing and increases
strength.
7. Was drain put to remove pus?
→ Source of infection, if put in same incision.
8. Did you feel breaking of stitches gradually?
9. Have you consulted any doctor for this?
E. Rule out complication:
Important one are strangulation and obstruction.
1. Strangulation:
• Ischaemic pain over whole abdomen
• Tenderness and redness of lump
• Hypovolemic symptoms
2. Obstruction:
• Vomiting
• Colicky abdominal pain
• Dehydration
• Absolute constipation
• Abdominal distension
3. Irreducibility:
• May be initiation of above two
• Whether swelling reducible or not?
• Reducibility is lost.
5. PAST HISTORY:
1. History of Hernia in past.
2. History of Operation.
3. History of TB, DM, HT.
GENERAL EXAMINATION
• Nothing is so particular
• See for – Obesity
– Ascites
– Pregnancy
}
Linea albicantes
– Signs of wasting
VITAL DATA:
Important when patient presents as emergency like in
strangulation or obstruction.
Hernia 39
• Pulse → Feeble and rapid due to hypovolemic shock.

• Temp. → If peritonitis and bacterial infection.
• BP → Decrease.
• Resp. rate → May increase
LOCAL EXAMINATIONS
AIMS : To find out following points:
1. Inguinal / femoral – type of hernia
2. Bilateral / Unilateral
3. Direct / Indirect, if inguinal
4. Descends in scrotum or not (complete /incomplete)
5. Reducible / Irreducible
All these points are written while putting diagnosis.
Most students do mistake in :
1. Proper exposure
From umbilicus to midthigh.
2. First examine in standing position and then in lying
down position because dimensions, shape, size all
get changed with position.
It also gives idea about reducibility.
NEVER forget to speak like – In standing position
findings are :
A. INSPECTION:
• Look carefully at both groins. Compare them.
• Check following points :
1. Swelling
a. Size and shape:
• Smaller and round in direct
• Larger and pyriform in indirect
• Spherical in femoral.
b. Site :
• Inguinal hernia – above groin crease
• Femoral hernia – below groin crease
* Define groin : [bonus]
—Groin is region 2.5 cm. above and below inguinal
ligament.
c. Extent:
• Indirect hernia descends in scrotum
• Direct does not
• Femoral hernia starts below inguinal
ligament and ascends over it.
d. Visible Peristalsis:
• Seen if coverings are thin as in recurrent
hernia or incisional hernia
• Never seen in femoral hernia
2. Skin over swelling:

• Uncomplicated – normal skin
• Strangulated – reddened
• If patient has used truss for long time there
may be pigmentation by hemosiderin.
• In recurrent hernia scar of previous operation
may be present
• Describe SCAR in detail for INCISIONAL
HERNIA.
a. Usually there will be shiny, lax skin with
crease.
b. Scar
}
— Vertical dimension
— Horizontal dimension
— Colour All should be
— Discharge described
— Regularity
— Surface
c. Wide, irregular, puckered scar shows

secondary healing.
Remember, to withstand viva of incisional hernia, your

basics regarding Healing must be very clear.
3. Impulse on Coughing :
Ask patient to turn his face away from clinician
and to cough – many students forget this in
examination anxiety.
Coughing → increased intra-abdominal pressure.
↓
Expansile impulse on coughing
• ‘EXPANSILE’ word is very important. Don’t
forget to speak it.
• If neck of sac is blocked by adhesions,
additional viscera will not get access into the
sac during coughing.
4. Position of penis:
Large hernia in scrotum will push penis to other
side.
B. PALPATION:
• Before palpation ask if there is any tenderness and
keep that in mind while palpation.
• All points like ‘SWELLING’ should be examined and
noted.
• I am describing particularly to Hernia.
Hernia 41
1. Position and extent:

(a) Femoral hernia - below inguinal ligament and
lateral to Pubic tubercle
(b) Inguinal hernia - Above inguinal ligament and
medial to Pubic tubercle.
• But large femoral hernia ascends superficial to
inguinal ligament though its base will still be below
ligament.
• In obese patient, it is difficult to palpate pubic
tubercle. In such case you can follow tendon of
adductor longus upwards to reach pubic tubercle.
2. To get above the swelling:
• In any case such words indicate whether you
can palpate normal structure or not.
• Root of scrotum is held between thumb in front
and other fingers behind in attempt to reach
above swelling.
• If one can palpate whip like structure– sper-
matic cord – it means you are able to get above
swelling and that is scrotal swelling.
• But in inguinoscrotal swelling you can not get
spermatic cord above swelling due to hernial
contents.
3. Consistency:
• Doughy and granular in omentocele
• Elastic in enterocele
• Tense and tender in strangulated hernia.
4. Relation of swelling to testis and spermatic
cord:
• Inguinal hernia remains in front and sides of
the spermatic cord and testis which remain
incorporated in swelling.
• If hernia is of acquired or funicular variety the
hernia stops just above testis.
5. Impulse on coughing:
• Always performed in standing position.
• When there is no swelling a finger is placed
on the superficial inguinal ring and the patient
is asked to cough.
• Root of scrotum also can be held by index
finger and thumb and felt for impulse on
coughing.
• Contents of hernia will force out through the
superficial inguinal ring and separate thumb
and index finger. This is an expansile impulse.
• Impulse on coughing will be absent in:
— Strangulated hernia
— Incarcerated hernia
— Adhesions in neck of sac.
Zieman’s Technique :
• Place index finger over deep inguinal ring (1/2
inch above mid-inguinal point), middle finger
over superficial inguinal ring and ring finger
over saphenous opening (4 cm below and
lateral to pubic tubercle).
• This can be applied only after complete
reduction of hernia.
• Now, patient is asked to cough or hold nose
and blow.
• Impulse at :
– Index Finger – indirect
– Middle Finger – direct
– Ring finger – femoral
6. Reducibility :
• Ask patient whether he can reduce hernia. In
most cases he will do by lying down or by
pressure.
• In other cases, patient is asked to lie down, to
flex the thigh of affected side and to adduct
and rotate it internally. This will relax pillars of
superficial inguinal ring and oblique muscles.
• Other method of reduction is TAXIS.
• It should NOT be attempted in presence of
intestinal obstruction, redness or oedema over
mass, since this factors suggest possibility of
dead wall in sac and this must not be returned
to abdominal cavity.
• Pressure on the fundus of the sac just pushes
the contents over the top of the neck rather
than through it.
• Therefore, thumb and finger of the examiner’s
hand lateral to the hernia is used to squeez
and narrow the sac contents adjacent to the
neck. Alternating this pressure with fundal
pressure.
• If sac is full of gut loops (enterocele) first part
is difficult to reduce but last part reduces easily
with GURGLING sound.
• In case of omentocele initial reduction of gut
loops is easy but difficult to reduce omentum.
7. Invagination test:
• This manoeuver is only required when hernia
is suspected but not identified by direct
palpation for lump and cough impulse.
Hernia 43
• Invagination must be gentle and pass deep to

the subcutaneous tissues of groin.
Method :
• Reduce hernia by above method
• Ask patient to lie down to reduce hernia
• Little or index finger can be used
• Invaginate the skin from the bottom of the
scrotum and finger is pushed up to palpate
the pubic tubercle.
• Right hand should be used for right side and
left hand for left side.
• The finger is then rotated and pushed further
up in to the superficial inguinal ring.
• The nail will be against the spermatic cord and
pulp will feel the ring.
• Normal ring is triangular slit when admits only
the tip of finger.
• If more than one finger can be introduced, it is
abnormally large.
• Patient is asked to cough.
• Normally examining finger will be squeezed
by approximation of two pillars.
• A palpable impulse will confirm diagnosis
• When the finger enters the ring – does it go
directly backwards (direct hernia) or upwards,
backwards and outwards (indirect hernia)
• The finger is again rotated so that pulp of finger
looks backward.
• If impulse on
→ Pulp of finger – Direct type
→ Tip of finger – Indirect type
8. Ring occlusion test :
• Reduce hernia and ask patient to stand and
put thumb over deep inguinal ring and then
ask patient to cough
• Indirect hernia comes through deep inguinal
ring so pressure by thumb will prevent
emergence of hernia while direct hernia will
show a bulge medial to the occluding finger.
• In case of femoral hernia, if pressure is exerted
over femoral canal the hernia will not be able
to come out. This is confirmatory test for
femoral hernia.
C. PERCUSSION:
Resonant Note→ enterocele
Dull Note→ omentum or extraperitoneal fat
D. AUSCULTATION:
Bowel sounds absent in omentocele or strangulation.
E. EXAMINATION OF TESTIS, EPIDIDYMIS AND SPER-
MATIC CORD:
F. EXAMINATION OF TONE OF ABDOMINAL MUS-
CLES:
To decide type of operation.
1. Observe patient in profile.
Undue protrusion of lower abdomen shows loss of
tone.
2. In lying down position ask pt. to raise legs or
shoulders against resistance and observe
abdominal wall.
There will be retraction in case of normal tone.
3. Do invagination test and check strength of two
pillar.
IN CASE OF CHILD:
Inguinal hernia is invisible due to presence of
thick pad of fat over inguinal region.
To make hernia visible , child is asked to jump or
run around or deliberately make it cry according
to age.
Now palpate spermatic cord as it emerges from
superficial inguinal ring.
If there is hernia the cord will be felt thicker than
its fellow on opposite side due to presence of
hernial sac.
If this fails perform GORNALL’S test.
Child is held from back by hands and abdomen
is pressed and child is lifted. This will make
hernia apparent.
• In case of incisional hernia
1. See the status of skin and scar by palpation
2. Measure gap in muscle in both direction. Describe
in terms of fingers like [two finger horizontally
and four fingers vertically]
3. Check strength of apposition of muscle
surrounding gap as in F-2 point ~ described above.
• Some things regarding viva:
1. Commonest hernia:
– Inguinal (80%) }
– Femoral (10%) } groin hernia (90%)
2. Stages of hernia:
a. Reducible
b. Irreducible(incarcerated)
• Due to adhesions of gut or omentum.
Hernia 45
• May be asympomatic
• May predispose or show onset of last stage.
c. Obstruction
• blocking passage of gut contents.
d. Strangulation
• blood supply is impaired leading to gangrene
and perforation.
3. Example of dangerous hernia:
Richter’s hernia because in this one side of loop
of gut gets trapped in sac. So strangulation without
obstruction can occur.
4. Diagnostic sign of hernia:
a. They occur at well recognised congenital or
acquired places of weakness in abdominal wall.
b. Reducible.
c. Palpable expansile cough impulse.
5. Boundary of Hesslbach’s triangle:
• laterally-Inferior epigastric artery.
• Medially-lateral border of rectus abdominis.
• Inferior-inguinal ligament.
6. Characteristic of direct hernia:
• Appear later in life and rare in women.
• Do not occur in children.
• Rarely descend in scrotum.
• Reduce easily.
• Emerge forward.
• Rarely strangulate.
7. What is Malgaigne’s bulge?
• In some thin subjects there can be an oval shaped
longitudinal bulge produced on straining at above
and parallel to medial half of inguinal ligament.
8. D/D of inguinal hernia:
a. Femoral hernia.
b. Communicating hydrocele→Transillumination
better.
c. Hydrocele of cord or canal of NUCK→grasp
lump,bring down and you can get above swelling.
d. Undescended testis.
e. Lipoma of cord.
9. Anatomy of femoral hernia:
→ Neck of femoral hernia lies between lacunar
ligament medially and femoral vein laterally and
the inguinal and pectineal ligaments antero-
posteriorly.
→ Sac descends in femoral sheath and become
superficial through sephanous opening.
10. Give name of lymph node in femoral canal
→ Cloquet’s node (It was my bonus question in

exam).
11. Irreducibility and obstruction is more common in
femoral due to narrow neck.
12. What is prevascular femoral hernia?
→ Arises in thigh, anterior to the femoral vessels in
femoral sheath.
→ It has wide neck and flattened wide sac so it is
reducible.
→ But surgical repair is tough.
13. D/D of femoral hernia:
a. Inguinal hernia.
b. Enlarged lymphnodes.
c. Saphena varix.
d. Ectopic testis.
e. Psoas abscess.
f. Psoas bursae.
g. Femoral aneurysm.
h. Lipoma.
i. Hydrocele of femoral hernial sac.
14. Mid-inguinal point—centre of pubic-symphysis and
ant. sup. iliac spine.
—Mid-point of inguinal ligament—centre of pubic
tubercle and ant. sup. ilic spine.
—To find ant. sup. iliac spine trace inguinal ligament
from centre to laterally.
15. For herniorrhapy monofilament suture is used like-
sutupack/prolene.
Five
Lump in Breast
Breast is modified sweat gland arising on mammary line.

• Normally overlies on 2nd to 6th rib.
• Why Ca. Breast is common ?
→ Acinar and ductul cells continuously undergo
proliferation during development and reproduction so
derangement of this process leading to neoplasm is
common.
Now we will go toward HISTORY.
1. Age :
a. Child bearing age :
Younger Older
Fibroadenoma Fibroadenosis
(nearing menopause)
(20 – 30 yrs.) (30 – 40 yrs.)
Hard Type Soft Type

(Breast mouse)
b. Lactating women → Mastitis
→ Lactational carcinomatosa
c. Pre and Post menopausal → Ca. Breast
2. Residence:
• Higher in England and Wales
• Rare in Japan
3. Social Status:
More in developed world and Higher social economic
class due to :
a. Unsuckled breast
b. Late marriage
c. Diet rich in saturated fatty acids
d. Tight brassieres
ODP:
Following all points should be included :
1. H/o Swelling:
a. When it was first noticed ?

• Usually while bathing
• Be aware of term ‘BSE’ – Breast Self Examination.
b. Origin, duration and progress like ‘swelling’
• Rate of enlargement of malignant lump is usually
progressive and not related to MENSTRUAL
Cycle.
• Bening lumps arise and disappear and repeatedly
if they are Cyst. and often related to MENSTRUAL
cycle.
c. Which is slow growing Ca. Breast ?
• Atrophic scirrhous Ca.
2. H/o Pain:
a. Usually Ca. are painless but pain without lump is
recognized feature of Ca. But pain is characteris-
tically fairly well localized and constant in contrast to
cyclic and diffuse discomfort of bening breast
diseases.
b. Painful lumps are :
• Acute mastitis (signs of inflammation present)
• Fibroadenosis (Pain related to menstrual cycle.)
3. Nipple discharge:
a. Clear, yellow, green — Benign breast diseases like
fibroadenosis
b. Milky – galactorrhea, galactocele, mammary duct
ectasia.
c. Bloody :
i. Fresh : Ca. Breast
ii. Dark, altered : duct papilloma
• Because obstruction retains blood inside which
becomes clotted and black
d. Purulent - mastitis and abscess.
4. Changes in Nipple:
• Like : Deviation, Distortion, Depression, Destruction,
Discolouration, Discharge, Retraction, Eczema,
Ulceration.
5. H/o swelling in opposite breast:
• Bilateral swellings are
– Fibroadenosis
– Multiple Fibroadenoma
– 3% of Ca. Breast
6. Ruling out etiology:
a. H/o trauma which may lead to hematoma or fat
necrosis.
— But sometimes trauma may draw attention to pre
existing lump.
Lump in Breast 49
b. Fever and pain for inflammatory changes (mastitis).

c. Oral contraceptives/HRT(hormone replacement
therapy)
d. Menstrual history–early menarche and late
menopause are risk factors of Ca. Breast.
e. Lactation :
i. Lactating breast
– Mastitis
– Retention of milk also produce firm lump
– Galactocele
– Lactational carcinoma
ii. Unsuckled breast - Ca. Breast
– Fibroadenosis
7. Ruling out complications:
a. Fever, pus discharge
b. Pain in back, shoulder – metastasis
c. Weight loss
d. Abdominal lump
e. Ulceration
f. Odema of arm
g. Peau d orange
8. H/o biopsy or any treatment for condition.
9. Present situation.
FAMILY HISTORY:
 Of mother, Sister
 Tuberculosis in case of suspected tuberculous mastitis.
PAST HISTORY:
 Similar complaints in past
 H/o recurrence-then take detail h/o treatment taken.
 P/h of any other breast diseases or T.B.
DETAILED MENSTRUAL AND OBSTETRIC H/O:

 Many students forget this point BUT IT IS VERY
IMPORTANT for Ca. Breast.
 Also ask lactational history.
 Ask for days of period regularity, LMP( last menstrual
period)
 Usually patient having Ca.breast have less children.
DRUG HISTORY:
OC Pills / HRT
GENERAL EXAMINATION
1. Cachexia
2. Chest → Consolidation, Collapse, Effusion
3. Spine → tenderness, decreased movement
4. Abdomen → Ascites, Lump
5. Odema of limbs
6. Sings of T.B.
LOCAL EXAMINATION
Points to be considered :
1. Adequate privacy
2. Well Exposure
3. Proper natural light
4. Various positions like
a. Sitting upright:
• Gives more information about level of nipple,
lump.
• For palpation of axillary lymphnodes
b. Bending forward:
• Shows fixity to chest wall.
c. Hand raising:
• Also called “OKINCLAUS EXAMINATION”
• Comparison of nipple level
• Under surface can be inspected
• Dimpling can be seen
d. Recumbent:
• For palpation of lump against chest wall.
Now some specific things for breast :
a. Consistency of breast varies from woman to woman
b. Size may change during development, normal
menstrual cycle, pregnancy, lactation and ageing.
c. Breasts are rarely symmetrical, so any recent
changes in symmetry should be noted.
1. INSPECTION:
Method:
1. First note all points given below in upright position
and describe in detail.
2. Now raise hand (above head) and see any new
changes like level of nipple, dimpling, under surface.
3. Now, arms are brought down to hips to contract
pectoral group of muscles to see any change of lump.
Lump in Breast 51
4. Now lean forward, so that breasts fall away from the

body.
5. During all these movements make note of any
differences in “freedom of movement of lump“.
Now points to be covered are:
A. BREAST:
1. Position, symmetry
2. Size and shape
3. Puckering / dimpling
4. Surface
5. Colour and texture of skin
• Warm, oedematous and red in mastitis and
rarely in mastitis carcinomatosa.
6. Peau d’s orange appearance
7. Engorged veins :
• Few veins are normally visible on skin, but
these venous patterns enlarge and become
prominent during pregnancy.
• Engorged veins arising outside pregnancy
suggest malignancy.
8. Ulceration :
• Seen in
— Cystosarcoma phylloides Due to pr.
— Rapidly growing adenoma } atrophy
— Ca. Breast due to infiltration of skin.
To differentiate these two there is PROBE TEST.
• Pass probe beneath skin.
If passed – benign (pressure atrophy)
Not passed – Malignancy (infiltration)
“Sarcoma fungates and carcinoma ulcerate”
Fungation occurs through ulcer.
B. NIPPLE:
1. Deviation:
• Change in direction of nipple
• Normally downward and outward
• First sign (earlier than displacement)
2. Displacement :
• Change in actual position
• Demonstrated by measuring from clavicle and
midline.
• Displacement to same side– malignancy
Opposite side – Benign
3. Discharge :
For inspection see undercloth.
4. Retraction :
• It may be
Congenital Acquired
– bilateral – unilateral
– due to failure of – In Ca. and chronic
evagination of nipple bud abscess
– due to fibrosis and
infiltration.
5. Redness, Oozing, destruction:
Eczema Paget’s d’s
- During lactation - Near menopause

- Bilateral - Unilateral (usually)
- Vesicles, Itching present - Vesicles, Itching - absent
- No destruction of nipple - Destruction of nipple
- Responsive to steroids - Treatment :
Bilateral - Chemotherapy
Unilateral - Surgery
C. AREOLA:
1. Colour : Young Pale Pink-

Adult Darker -
Pregnancy Brown -
2. Size : Increased -
Soft fibroadenoma
Sarcoma -
Decreased -
Scirrhous Ca.
(sometimes).
3 Surface : Ulceration, crack, eczema
D. LUMP : As described in swelling.
E. ARM AND THORAX:
• For edema
• Dilated veins
• Signs of metastasis as described in G/E:
F. AXILLA AND SUPRACLAVICULAR FOSSA:
• For secondaries in nodes.
2. PALPATION:
There are many confusions in methods of palpation. I hope
you will find my method easy and systematic.
First whole method of palpation.
A. For Small and Normal Breast :
Position :
Patient is asked to lie flat and then to put the hand of
the side to be examined behind her head and then
Lump in Breast 53
roll slightly to opposite side (You can put pillow under

scapula of same side), so that breast lies flat on
chestwall and easily palpable.
B. Large Breast:
Ask patient to lean slightly forward, so that breast
fall away from chest and do bimanual palpation.
C. Very Large Breast :
Mamography is essential.
Always palpate normal breast first because texture of
breast varies from woman to woman.
Normal breast gives firm lobulated impression and
nodularity.
First palpate with flat of finger and then with tips of finger
and thumb.
When difference of texture between lump and breast
tissue is more, it is easily felt by flat of hand which is less
sensitive. So, Ca. Breast is felt by flat of hand. While fibro-
adenosis has less difference so we need more sensitive
finger tips to palpate it.
In General :
“If felt by flat of hand – carcinoma and tip of hand –
benign breast d’s”
Now, always go methodically.
• Normal breast → all four quadrants like ‘round the
clock’
→ Retroareolar area.
→ Nipple
→ Axillary tail.
• Affected breast → same order as above.
— While palpating retroareolar area keep eye on nipple
to see escape of any discharge.
— Nipple is palpated between thumb and fingers for tissue
nodularity.
How to Check for Discharge?

• Stroke each quadrant of breast with fingers and then
press retroareolar area like milking of cow.
• Lastly check for fixity of lump. That is described later.
Other Positions for Palpation are:
1. Sitting
2. Semirecumbent
3. Arm above head.
Now Points that we have to Observe While Palpating:

→ Temperature and Tenderness:
• Warm and tender in acute mastitis and mastitis
carcinomatosa
• Normal in Ca. Breast and chronic abscess

(antibioma).
→ Situation of Lump:
Describe in this quadrant.
Ca. Breast and fibroadenosis
(more common)
Fibroadenoma
→ Number :
• Multiple in fibroadenosis.
→ Size:
• Describe in 3 dimensions
• Large in
— Soft fibroadenoma
— Cystosarcoma phylloides
— Ca.
— Brodie’s d’s. (type of cystosarcoma phylloide)
→ Shape:
• Globular in Fibroadenoma
• Irregular in Ca.
→ Surface :
• Smooth in benign
• Irregular in Ca.
→ Margin:
Ill-defined Well-defined
In fibroadenosis Due to difference in consistency

Because of it’s softness of lump and breast tissue
Fibroadenoma and Ca.
Regular and slip off Irregular and does not slip
- Fibroadenoma or
- Cyst. - Carcinoma
→ Consistency :
Soft → Cyst., Lipoma, Abscess
Firm → Fibroadenoma
Indiarubber, shotty, diffuse → Fibroadenosis
Varying → Sarcoma
Lump in Breast 55
→ Fluctuation:
• Stand behind patient pass your hand above her
shoulder and hold cyst. with one hand and tap in
centre with index finger of other hand.
• Positive in Cystic swelling.
→ Trans-illumination:
Fat is transparent but solid tissue are not.
→ Fixity to skin:
Two methods to check (like swelling)
a. Moving lump up and down and laterally
b. Pinching skin or moving skin over swell.
There are two terms:
a. Tethering:
• Lump is movable to some extent but dimples
at reaching extreme of movement when
pinching skin or raising hand.
• Shows infiltration of Astley Cooper’s ligament
joining glandular tissue to skin.
b. Fixity:
• Lump can not be moved independently of skin
or skin cannot be pinched.
• Shows infiltration of skin.
• Seen in
– Ca. Breast
– Fat necrosis
– Rarely in chronic abscess
• Tumour lying immediately beneath nipple will
be fixed to it whether benign or malignant
because ducts pass through it.
→ Fixity to breast tissue :
• With left hand fix breast tissue continuing lump
and with right hand check mobility at lump.
• Fixed in Ca. Breast
Moving in fibroadenoma (breast mouse)
→ Fixity to underlying fascia and muscles:
• Ask the patient to keep her hands on hips.
• Now, check mobility in two directions without
pressure.
• Then ask her to give pressure to hip to contract
pectoralis and again check for mobility.
• Compare results.
• Whether adequate pressure was given or not can
be checked by feeling ant. Axillary fold.
If swelling is in lower and outer quadrant it will overlie
on serratus anterior.
So ask her to push against your shoulder with

outstretched hand and compare change in mobility same
as before.
→ Fixity to Chest Wall:
Lump will be fixed irrespective of contraction.
→ Palpation of nipple:
→ Ulcer examination, if present.
3. LYMPH NODES:
Important lymphnodes are :
1. Apical
2. Medial
3. Ant. (pectoral)
4. Post. (subscapular)
5. Lateral (Brachial)
6. Supraclavicular
7. Deltopectoral (below clavicle)
Method :
• If patient’s left axilla is to be examined left arm is
taken and supported by left hand of examiner, so
that the muscles of shoulder girdle are relaxed to
allow easy access to axilla.
• Examiners right hand palpates ant. Axillary fold
and nodes between pectoral muscles.
• The hand is gradually introduced gently into apex
of the axilla to palpate the apical group of nodes
and passed down to palpate medial group and
then feel post. Group in post. Axillary fold.
• For lateral group of left side give support with right
hand and palpate with left hand.
• Or better option is to palpate post.and lateral
groups from posterior side which is more
informative.
What to see:
• Size
• Number
• Consistency
• Mobility
Other important mode is scalene node, behind insertion
of sternomastoid.
Other lymphatic organ examined is liver which is
common site of metastasis.
4. P/V AND P/R EXAMINATION:

For pelvic deposits.
* Why fat necrosis, fibradenosis and Ca. are more
common in left breast?
Lump in Breast 57
∗ Because male partners are usually right handed

causing more manipulation of left breast while
intercourse.
* Give order of involvement of nodes:
1. Axillary / Internal mammary nodes
2. Supraclavicular
3. Opposite breast
4. Mediastinal nodes
5. Other distant nodes
6. Sometimes liver: by lymphvessels through the
plexus over sheath of rectus abdominis communi-
cating with subdiaphragmatic lymphatic plexus and
through lympatics of falciform ligament.
* How to decide prognosis from nodes ?
a. No. of nodes involved :
No nodes - 75%
1 – 3 Nodes
> 4 nodes
- 50%
- 24% } for 10-year survival
b. Extent of disease in each node :

No involvement – Good
Micrometastosis – Moderate
Macrometastasis – Bad
c. Level of involvement :
1. Level I → 65%
• Nodes lateral to lateral border of Pectoralis
Minor (PM) – lower axilla.
2. Level II → 30%
• Nodes between medial and lateral border of
PM – Mid Axilla.
• ROTTER’s nodes
• Do you know about CLOQUET’S node?
• They are node in femoral canal.
3. Level III → 0%
• Nodes medial to medial border of PM
• Apical axilla.
* Which receptor are important for diagnosis of
Ca.breast?
• Progesteron receptors are more important than
eastrogen receptors.
• Normal value: > 10 femtomole/mg. Of cytosol
pressure
4 – 10 equivocal
< 4— diagnostic of carcinoma
• Measured in biopsy sent in normal saline.
* Special Ix for Ca.
a. FNAC
b. Trucut biopsy
c. If ulcer present —— discharge cytology

—— wedge biopsy
d. Rectum - Suction biopsy to rule out secondaries.
e. What is SENTINEL biopsy? (bonus question)
It is biopsy of first involved node which is decided by
introducing radioluscent dye.
Six
Thyroid Swelling
First, we will discuss some basic aspects about Thyroid :

1. Embryology:
• It is derived from evagination of pharyngeal
epithelium from pharyngeal pouch.
• If remnants are present in tongue, they lead to
development of lingual thyroid.
• Its communication with oral cavity is foramen,
caecum which is obliterated.
2. Anatomy:
Hyoid
Levator glandulae thyroidiae
Thyroid cartilage
Pyramidal lobe
Isthmus
Lateral lobes
3. Blood Supply :
a. Sup. Thyroid artery
b. Inf. Thyroid artery
c. Thyroidea Ima artery
4. Venous drainage:
a. Sup. Thyroid vein
b. Middle thyroid vein
c. Inf. Thyroid vein.
5. Nerve Supply:
Middle cervical ganglion.
6. Histology:
Parafollicular (C cells)
(secrete thyrocalcitonin)
Follicular cells
(secrete T3 and T4)
7. Physiology :
Hypothalamus -ve feedback



TRH
Peripheral
 organ
Pituitary -ve T3


TSH T4 → T3
GIT Iodine Causes

Hypertrophy
Hyperplasia
↑ function
} of
thyroid

Kidney I Na+ T3, T4

12 12
12
12
1212
12 
e
x
Iodide (I–) o

Iodotyrosine c
 y
se
ena t
og o
al
eh sis
D
Peroxidase T3, T4
Iodotyrosine

I0, I+

Tyrosine
Monoiodotyrosine (MIT)
Di iodotyrosine (DIT) } [ MIT + DIT
DIT + DIT
T3
T4
Iodotyrosine
Thyroid Swelling 61
Now, what to ask patients ?

1. Age:
a. Neonate:
i. Transmitted goitre – if mother is taking propyl-
thiouracil
ii. Grave’s d’s— if mother is thyrotoxic due to
transmission of thyroid hormones.
b. Neonate to Puberty :
i. Endemic cretinism → seen in goitre belt
ii. Enzyme deficiency
(a) Decreased or absent peroxidase.
• Pendred’s syndrome which includes
congenital deafness with juvenile goitre.
(b) Deficiency of Dehalogenase.
iii. Genetic defect in thyroglobulin synthesis.
c. Puberty :
• Physiological goitre due to hyperplasia due to
increased demand
• More common in female
• Upto 20 years.
d. 20 – 30 years :
• Chances of degeneration in hyperplasia
leading to colloidal goitre.
• Young girls are prone to develop papillary
carcinoma.
e. 25 – 35 yrs :
Primary thyrotoxicosis
f. 35 – 45 yrs :
i. Secondary thryotoxicosis
• End stage of colloidal goitre—occurs 10 –
15 year after colloid goitre.
ii. Follicular Ca.
iii. Hashimoto’s d’s
g. More than 45 Yrs.
Anaplastic medullary Ca.
h. Pregnancy :
2nd physiological goitre (for compensation of
fetus’ demand)
i. Menopause:
3rd physiological goitre to compensate decreased
oestrogen and progesterone.
2. Sex:
a. Thyrotoxicosis → F:M = 8:1
b. Thyroid Ca → F:M = 3:1
3. Occupation:
• Stressful jobs increase incidence.
4. Residence:
a. Goitre in Himalaya belt, Rocky mountain
b. Bharuch Iodine def. Goitre
c. Porbander }
– Stone
}
common
– G-6 PD def. (Bhanushali people)
disease
– Filariasis
in Sau-
– Hydatid d’s
rashtra
– Bronchial asthma (due to humidity)
Now towards C/C and ODP

Mostly C/C will be SWELLING in the neck since this much
days / months or one / more of symptoms described below.
ODP
1. Swelling:
a. When did you notice swelling?
Answer will be: During shaving/bathing/looking in
mirror.
b. What was the size of swelling when you noticed it?
Write size in terms of lemon, apple.
c. How did it increase?
1. Rapid increase
• Inflammation
• Malignancy
• Haemorrhage
2. Slow increase
• Benign tumour
2. Pain:
Total ODP as written in first chapter.
a. Do you have pain in neck/swelling?
b. Where do you feel pain?
c. What is the character of pain?
d. Whether it is continuous/intermittent?
e. Does it increase on swallowing water/food?
f. Does it radiate anywhere?
Usually pain is present in:
a. Haemorrhage in thyroid swelling.
b. Malignancy – due to infiltration of surrounding.
c. Inflammatory conditions except Riedel’s thyroiditis.
• Usually there is discomfort (not typical pain ) in
Hashimoto’s thyroditis.
• What is latent hyperthyroidism ?
– It is evolving phase. Swelling has not appeared
but symptoms are present.
Thyroid Swelling 63
3. CNS:
a. Irritability:
It means patient in bad mood even without stimulus.
b. Excitability :
• Bad mood due to some bad stimulus.
• It is exaggerated response.
c. Insomnia:
Patient’s sleep is disturbed at night.
d. Anxious:
• Patient talks more, moves more or anything as
students do while exams are on way.
• CNS symptoms are predominant in young people
and in primary thyrotoxicosis.
4. Neuromuscular:
a. Weakness of proximal muscles :
• Like getting fatigue on climbing stairs.
• Tremor of finger and tongue with hyperreflexia.
5. CVS :
These symptoms are predominant in secondary
thyrotoxicosis or old-age patient because in old-age
heart is weakened and burdened by atherosclerosis,
so they are prone to develop CVS symptoms.
a. Palpitation:
Abnormal awareness of heart beat.
b. Chest Pain
c. Dyspnea on exertion
d. Precipitation of angina / MI
Give some signs of CVS in thyrotoxicosis
a. Water hammer pulse
• Due to wide pulse pressure
b. Irregularly irregular pulse
• Due to atrial fibrillation.
c. Increased first heart sound
d. Systolic murmur (Functional murmur)
• Due to rapid flow of blood in heart chambers.
e. Means – Lerman scratch
• A to and fro high pitched sound audible at
pulmonic area and may simulate pericardial
friction rub.
6. Metabolic:
a. Voracious means increased appetite.
b. Weight loss
c. Sweating
d. Intolerance to heat
All are due to high Basal Metabolic Rate and
uncoupling of oxidative phosphorylation.
7. GIT:
Diarrhoea due to increased motility and secretion.
8. GUT:
In PREMENOPAUSAL woman :
• Oligomenorrhoea
• Amenorrhoea
9. Eye:
a. Widened palpebral fissure.
(When you see in the mirror do you feel your eyes
are widened?)
May be noticed by other persons.
b. Infrequent blinking.
May be noticed by other person.
c. Failure to wrinkle brow on upward gaze.
d. Excessive watering due to epiphora.
e. Double Vision
f. Eye Pain
g. Ulceration
h. Unable to close eye
} Exophthalmos
leading to infection
There are two types of Ophthalmopathy in thyro-

toxicosis.
a. Non-Infiltrative :
• Results from increased sympathetic activity
leading to retraction of upper eyelid. (Muller
muscles are hyperactive)
• This gives appearance of bulging staring eyes due
to widening of palpebral fissure.
• This can be made visible by `Von Graefe’s sign’
in which, when patient follows examiner’s finger
up and down. The upper lid is seen to lag behind
the corneoscleral limbus (lid lag).
b. Infiltrative :
• Due to cellular infiltration and mucopoly-
saccharide deposition by increased fibrinogen
resulting in oedema of orbital and periorbital
tissues.
• There is proptosis– actual protrusion of globes
which is usually but not always bilateral.
Thyroid Swelling 65
• Ophthalmoplegia develop particularly in superior

rectus or inf. Obligue muscles causing diploplla
which is mostly marked on upward and outward
gaze.
• There is weakness of convergence and loss of
co-ordinated eye movements.
• Visual acuity deteriorates with the development
of papilloedema, retinal edema, haemorrhage
with optic nerve damage.
• The last stage, malignant exophthalmos may lead
to blindness.
10. Skin:
• Warm, moist, velvety skin.
• There may be palmar erythema.
11. Nail:
• Separation of finger nail from nail bed, called
— Ochynolysis
— Plumer’s nail
• More seen in RING finger that is choice of finger in every
teenager, who is in search of LOVING Partner.
12. Hair:
• Fine and silky
• That is why incidence of thyrotoxicosis is more in girls
because they like silky hairs.
13. Pressure Symptoms:

 Seen in huge thyroid or retrosternal goitre.
a. Compression of trachea – Dyspnea.
• Compression should be more than 75% to develop
stridor.
b. Oesophagus – Dysphagia
c. Involvement of laryngeal nerve – hoarsness
• Not seen in simple goitre
• It suggests — Neoplasm
— Sudden haemorrhage in cyst.
— Thyroditis.
d. Involvement of sympathetic trunk
• Horner’s syndrome — Pseudoptosis
— Anhidrosis
— Miosis
— Enophthalmos
— Loss of ciliospinal reflex
• PAMELA ANDERSON
e. Compression of superior vena cavae.

• SVC Syndrome (flushing and suffusion of face).
* PEMBERTON Sign:
In retrosternal goitre when arms are raised above
head, they cause:
— Suffusion of face
— Giddiness
— Syncope
* What is ‘Jod Base Dow’ phenomenon?
In case of multinodular goitre, the ingestion of excess
lodine may result in development of thyrotoxicosis –
this is called ‘Jod Bas Dow’ phenomena.
PAST HISTORY:
1. H/o similar complaints in past.
2. H/o Rx for them in past.
If 1 tab. Daily was taken – hypothyroidism
2 -3 tab. daily was taken—hyperthyroidism
3. H/o goiterogenic drugs :
a. For diabetes– sulfonylurea
b. AKT – Paraminosaliylic acid
c. Antithyroid drugs
d. Antiarrhthmic – amiodarone
e. Iodide – expectorant
4. H/o Operation:
a. Partial thyroidectomy
b. Operation for thryoglossal fistula
In both of these, recurrence is common.
5. H/o irradiation in childhood:
• Papillary Ca.
6. H/o other d’s - DM, HT, TB
PERSONAL HISTORY:
1. Diet:
• about iodized salt
• excessive ingestion of cabbage (Brassica family) in
diet
• Goiterogens
2. Appetite – increased
3. Sleep—distrubed
4. Bladder / Bowel function—diarrhoea
5. Habit
FAMILY HISTORY:
• In case of genetic def. of enzymes and medullary Ca.
• Other d’s - TB, DM, HT
Thyroid Swelling 67
MENSTRUAL HISTORY:
About
• days of cycle
• days of bleeding
• any recent change in pattern
OBSTETRIC HISTORY:
Amenorrhea, Oligomenorrhea may lead to infertility.
GENERAL EXAMINATION
1. Anxious, lethargic, excitable
2. Exophthalmos
3. Puffy face
4. Pretibial myxedema
(Due to infiltration by mucopolysaccharides)
5. Hurry gait (anxiety)
6. Moist skin (Felt: while handshaking, due to increased
sweating)
7. Weakness (due to increased BMR)
8. Falling of lateral 2/3 of eyebrow in myxedema
9. JVP raised: If heart failure or fibrillation occurs.
VITAL DATA
1. Temperature: Normal/ Increased
2. Pulse: Tachycardia / flutter/ fibrillation / failure
Take two types of pulse
a. BASAL Pulse
• Pulse is taken at night arbitrarily at 12, 2, 4,6 a.m.
• During deep sleep pulse rate is slowest which is
taken as basal pulse.
b. CASUAL Pulse :
In OPD when patient comes, pulse is taken – casual
pulse.
• If both pulse increased – thyrotoxicosis
• If basal pulse normal but casual increase – anxiety
or anxiety disorder.
• Quality of pulse will be bounding and irregularly
irregular usually.
• If sir asks what examination you will perform when
patient is sleeping, say I will check pulse (Bonus
answer).
3. Resp rate: Normal/Increased
4. Blood pressure:
Systolic BP -→ Increased
Diastolic BP → Decreased
INCREASED BMR
INCREASED DEMAND
High sympathetic activity Dilatation of blood vessels
Increased Systolic BP Decreased TPR

(Total Peripheral Resistant)
Decreased Diastolic BP
So, pulse pressure (systolic – diastolic) → increased.

Therefore, there is wide pulse pressure and bounding
or water hammer pulse.
LOCAL EXAMINATION
A. INSPECTION:
• Don’t try to touch the patient. Just give instructions and
observe.
• Patient should be in relaxed position. No flexion, no
extension except in case of short neck and obese person
where PIZZILO’s method is applied.
PIZILLO’s method: Ask patient to press her occiput
back on to her clasped hands. This will make swelling
prominent.
• Points to inspect are same as in swelling:
1. Number, Site
2. Size
3. Shape
4. Extent
5. Surface and overlying skin
6. Margin
7. Movement with deglutition.
8. Movement with protrusion of tongue
9. Impulse on coughing and pulsations
10. Surrounding skin
11. Deviation of trachea.
Thyroid Swelling 69
Write Like this:

A single swelling situated in lower ant. neck, extending
from right sternomastoid to left sternomastoid, vertically
from suprasternal notch to thyroid prominence with butterfly
shape, smooth surface, normal skin, well defined margin
moving with deglutition and protrusion of tongue.
Surrounding skin is normal, no pulsation. No impulse on
coughing and no deviation of trachea.
Now some VIVA questions :
1. When thyroid swellings does not move with
deglutition
Due to size – Very large goitre
– Retrosternal Thyroid
Due to adhesions – Riedel’s thyroiditis
– Malignancy
– Previous neck operation like :
–tracheostomy
–radical neck dissection.
2. At which the level thyroglossal cyst is not in midline.
• At the level of thyroid cartilage because levator
glandulae thyroideae is on left side of thyroid
cartilage.
3. In suspected Retrosternal thyroid perform pemberton
test.
B. PALPATION:
The methods are:
1. Normal :
• Usually in flexed neck to relax muscles
• Stand behind patient
• Lower chin to relax muscles
• Put thumb behind neck and with fingers palpate
swelling
2. Pizzilo’s method:
• To make small nodules prominent by extending neck.
3. Lahey method:
For palpation of each lobe.
a. Examiner stands behind patient
For left lobe push it to left with the right hand and
palpate with left hand.
b. Stand in front of patient :
• Exactly opposite to above one.
• Left lobe is palpated by right hand.
4. Criles method:
• For very small swelling
• Palpate with thumb and ask patient for deglutition.
Now every points of PALPATION OF SWELLING should

be done. I am not writing those again.
Something particular to thyroid:
1. Consistency:
a. Firm:
• Primary / Secondary thyrotoxicosis
• Toxic adenoma
b. Cystic:
• Colloid goitre
• Multi nodular goitre without tension
• Thyroglossal cyst.
c. Hard:
• Malignancy
• Riedel’s thyroiditis
• Calcified Cyst.
• Tensed Cyst.
2. Mobility:
Restricted lateral mobility in malignancy
3. Pulsation over swelling:
• Usually at upper pole of thyroid swelling
• Apply light pressure to feel thrill in Grave’s disease
with two fingers.
4. Not getting below swelling:
If means trachea is not palpated below swelling
indicating it is extending behind sternum – retro-
sternal goitre.
C. PERCUSSION:
Dull note over sternum shows retrosternal goitre.
D. AUSCULTATION:
• In 70 percent cases of Grave’s d’s, bruit is heard over
swelling.
• Remember ‘Bruit’ is murmur in vessel.
• It is due to hypervascularisation of thyroid.
EYE SIGNS:
Show severity of toxicosis.
A. Mild:
1. Stellwag’s Sign :
• Infrequent blinking of eye lid.
• Due to tonic contraction of voluntary part of levator
palpebrae superiors.
• See this sign while taking history.
2. Von-Graefe’s sign:
• Lid lag
• Explained earlier in eye symptoms.
Thyroid Swelling 71
B. Moderate:
1. Joffroy’s Sign :
• No wrinkling of forehead on upward gaze with face
inclined downwards (Ask patient to see her feet
and then try to look upwards).
2. Naffzigar’s Sign :
• Two methods:
a. Ask patient to see fingers of leg toe i.e. flexion
of neck.
— Put your right hand on back of neck and
left hand over forehead.
— Now look in supraciliary plane, if eye ball is
seen, test is positive.
— Hand should not obstruct your field of vision.
b. Stand behind the patient and extend neck.
Seen in supraciliary plane.
C. Severe:
1. Corneal congestion
2. Watering of eye due to epiphora
• More in morning.
3. Mobeus sign :
• Difficulty in conversion
• Due to ophthalmoplegia where extraocular
muscles are affected.
• Upward – outward movement is lost.
• More described in eye symptoms.
D. Progressive : (Malignant Ophthalmoplegia)
1. Conjunctival chemosis
2. Corneal ulceration
3. Loss of vision
4. Distortion of eye ball
5. Retinal edema and haemorrhage
* Dalrympte’s Sign:
Upper sclera is visible due to retraction of upper eyelid.
* Gifford Sign:
• To differentiate exophthalmos with proptosis
• In exophthalmos you can not or only with difficulty
evert eyelid. While in proptosis you can easily evert.
• Because in first one there is infiltration in eyelid
leading to thickening and adhesion.
Causes of Proptosis :
• Optic nerve tumor
• Glioma
• Bone tumor
* When can you 100% say this is Grave’s d’s ?

• When both of below present:
1. Pretibial myxedema
2. Exophthalmos
• I have seen examiners confusing students in
the natural history of thyroid swellings, so we
will discuss that.
First of all classification of thyroid swellings:
1. Simple Goitre (euthyroid)
a. Diffuse hyperplastic
• Physiological
• Pubertal
• Pregnancy
b. Multinodular
2. Toxic:
a. Diffuse - Grave’s d’s
b. Multinodular
c. Toxic adenoma
3. Neoplastic:
a. Benign
b. Malignant
4. Inflammatory:
a. Autoimmune
• Chronic lymphocytic thyroiditis
• Hashimoto’s d’s
b. Granulomatous
• De Quervain’s thyroiditis
c. Fibrosing
• Riedel’s thyroiditis
d. Infective
• Acute (bacterial, viral)
• Chronic (TB, Syphillis)
e. Other
• Amlyoid
Natural History of Goitre :
• Iodine deficiency
• Enzyme deficiency
• Goitrogen
Decreased – T3, T4 Physiological

Hyperplasia
Feedback increase of TSH
Persistent growth, Stimulation

Causing Diffuse Hyperplasia
Thyroid Swelling 73
Diffuse hyperplastic Goitre
Gradually, stimulation by
TSH becomes fluctuating.
Causes some lobule to develop

more, leading to mixed pattern
of active and inactive lobules.
Active Lobules become more vascular.
Haemorrhage and necrosis occurs.
Leads to central necrosis leaving

surrounding rim of active follicle.
Necrotic lobules coalesce to

form colloid filled follicles-Colloid Goitre.
Continuation of this Process
Multinodular Goitre
Development of
Long acting Thyroid
Stimulating Antibody (TsAb)
Toxic Nodular Goitre One of nodule becomes

Autonomous (neoplasm)
and convert into
Also Called Toxic adenoma
Secondary thyrotoxicosis
seen in middle age
Simple Goitre:
• Patient is euthyroid
• Smooth, firm, Palpable nodule
• Painless
• Freely moving
• Hardness and irregularity may be due to calcification
simulating carcinoma.
• Pain and sudden enlargement may occur due to
haemorrhage.
Grave d’s:
• Diffuse vascular goitre appearing at same time as
hyperthyroidism.
• Younger woman
• Frequently associated with eye signs
• Also called primary thyrotoxicosis
• Due to stimulation by TsAb.
Toxic Nodular Goitre:

• Secondary thyrotoxicosis
• In Middle age
• Simple nodular goitre is present for long time before
thyrotoxic symptoms develop.
Two types :
a. Nodules are inactive, surrounding tissue is
hyperactive.
b. Nodules become converted into adenoma and
become hyperactive.
Toxic Adenoma:
• Due to autonomous growth of nodule
• Surrounding tissue is suppressed due to high T3, T4
level
* If single swelling (descrete swelling) is palpated then
there are two possibilities :
SOLITARY Nodule DOMINANT Nodule
Only one nodule, rest of Whole gland is enlarged

gland is normal. but one nodule is more prominent.
What is thyroid acropachy ?

• Grave d’s + clubbing + osteoarthropathy
Berry’s Sign:
The carotid arteries may be displaced backward by
neoplasm of thyroid.
Seven
Varicose Vein
First, we will see what to ask in history of varicose vein.

A. Occupational history:
It is seen in occupations involving long duration of erect
posture like:
• Surgeons
• Traffic police
• Conductor etc.
Continuos pressure load over veins in standing position
leads to incompetency of valves leading to the dilation,
elongation, tortuosity and sacculation of vein.
B. Chief Complaints:
1. Tortous swelling
2. Dragging pain
3. Cosmetic reason
4. Complications –
• Pigmentation of skin
• Eczema and ulceration
• Bleeding
• Itching
• Oedema in the evening
• Calcification of vein
• Talipes equines
• Superficial thrombophlebitis
C. Origin, Duration and Progress:
1. Detailing chief complaint : As I have told previously
go from ‘a’ to ‘z’.like this—Patient was relatively
asymptomatic before 6 months. Then he noticed
tortous swelling in left leg. It was painless and seen
only on standing.
It gradually increased in size to present dimensions.
Then he developed dragging pain which was never
sharp or shooting and relieved by elevation of leg.
2. Ruling out etiology:
a. Occupation
b. Deep vein thrombosis
• Blue discolouration of vein
• Fever with pain and swelling
• H/o – prolonged recumbancy
– Fracture
– Operation
– Subacute bacterial endocarditis

– Abdominal Sepsis
– Valvular Heart disease
• In females h/o oral contraceptives and leg pain
in postpartum period.
c. By pressures on vein: Abdominal pathologies may
compress inferior vena-cavae leading to rise in
pressure of lower legs and incompetency of
valves.
Ask h/o abdominal lump – Abdominal distension
– Bladder disturbances
– Bowel disturbances
h/o menstrual disturbances
h/o present or recent pregnancy
Q: What are the reasons for development of
varicosities in pregnancy?
1. Action of progesterone and relaxin producing
relaxation of smooth muscles of veins.
2. In last trimester uterus presses iliac vein.
3. Constipation leading to pressure by full rectum.
3. Complications:
a. Superficial thrombophlebitis
– attack of pain and redness on swelling
– fever
– significance: If it is present any injection or
surgery can aggravate it. They are postponed
for at least 3 months. It may also suggest
associated-
- Buerger’s disease
- Polyarteritis nodosa
- Polycythemia
b. Eczema:
It is noncontagious, inflammatory condition of the
skin in response to exogenous or endogenous
stimuli.
c. Ulcer :
Take detailed ODP of ulcer.
d. Bleeding :
Ask – amount
– associated discharge
– smell
– since when
e. Associated conditions:
1. H/o similar swelling in other limb.
2. H/o bleeding P/R
3. H/o scrotal swelling for
4. H/o dragging pain in scrotum } Varicocele
Varicose Vein 77
f. Pigmentation of skin:
It occurs due to backpressure in capillaries with
extravasation of RBC and high molecular-weight
proteins. Mechanism is shown below.
HAEMOGLOBIN
 
Haem Globin
 
Haemosiderin Biliverdin

Irritates nerve
 
Ingestion by dermal Produce 
macrophages Melanocyte ITCHING
reaction

PIGMENTATION
D. Past History:
Ask for any treatment taken and, as usual, about other
diseases.
E. Family History:
If present it suggests familial absence of first valve in
wall of iliac vein so that all back pressure is borne by
sephanofemoral junction which causes primary
varicosities.
For examination see standard books of surgery you are
referring.
Now, some VIVA questions:
1. What is Crovalier’s sign?
— If present it shows incompetency of sephano-
femoral valve and also differentiate sephana
varix from femoral hernia.
— In this, finger is kept at sephana virix and patient
is asked to cough . A tremor is felt as if jet of
water is entering and filling it.
2. Can varicose vein be pulsatile?
Yes, if they are secondary to AV fistula.
3. What is ankle flare?
— It is diffuse hemangiomatous swelling filling the
hollow between medial malleolus and the heel,
produced by the dilation of the delicate
cutaneous venules draining the ankle and the
heel.
— In this, finger is kept at sephana virix and patient
It shows incompetency of lower ankle perforator
so seen in varicose veins secondary to deep

vein thrombosis.
4. What is blow out ?
— The forcefull flow of blood from incompetent
perforators which is at right angle to sephanous
vein, produces dilatation of opposite wall of vein
like saccular aneurysm. This is called blow-out.
Blow-out at sephanous opening is termed
sephana varix.
5. How to differentiate between femoral hernia and
sephana varix?
Character Sephana varix Femoral Hernia
Consistency Soft Doughy
Colour Bluish No colour
Crovalier’s sign Impulse is expansile No impulse
Associated with Varicose vein Other hernia
6. What does negative-positive Trendlenberg test

means?
— On keeping pressure over sephanous opening
veins do not fill from below (negative) but on
releasing pressure it fills up quickly (positive).
— It indicates sephanofemoral incompetency.
— If test is positive-negative it suggests incompe-
tency of leg perforator.
7. Why is it called Brodie-Trendlenberg test?
It was invented by Sir Benjamin Brodie but
popularized by Fredrick Trendlenberg.
8. Do you know other Trendlenberg –s?
a. Trendlenberg position–head low and leg-up
position
b. Trendlenberg sign – for varicose vein
c. Trendlenberg gait – in waddling gait due to hip
instability suggesting weak
abduction at hip.
d. Trendlenberg sign – seen in congenital
dislocation of hip.
e. Trendlenberg operation – for varicose vein
9. Which signs will you look first when patient of
varicose vein comes to OPD?
— They are
a. Homan’s sign
b. Moses’ sign
— To rule-out deep vein thrombosis which is
emergency.
Varicose Vein 79
10. What does positive Perthe’s test indicate?

— It show that deep veins are blocked and
superficial veins are only route for venous
drainage of lower limb. So it contraindicates
surgery - if varicosed veins are removed it will
lead to catastrophe of venous gangrene due to
absence of drainage of blood.
11. Define varicose vein and common sites for them?
— It is a term applied to dilated, elongated and
tortous vein of superficial venous system.
— Common sites are: superficial veins of leg, lower
oesophageal veins, testicular veins, superior
haemorrhoidal plexus.
12. Give C/I to surgery:
These are:
— Deep vein thrombosis
— Supeficial thrombophlebitis
— Poor life expectancy
— Unwilling/unfit patient
13. Which swellings decrease on lying down?
a. Varicocele
b. Inguinal hernia especially, direct variety
c. Lymphvarix
d. Congenital hydrocele
e. Other hernias – umbilical, ventral, incisional
f. Varicose veins.
Eight
Tips for Viva
A. Proper dressing
1. Wear clean, ironed, simple and sober clothes
2. White, full-sleeve apron
3. Properly combed hair
4. Well-written exam number attached properly on
apron
5. Lastly, wear smile and confidence.
B. Make checklist to take all tools for exam.
• Two pens
• Few blank paper sheets
• Stetho
• Measuring tape
• Torch
• Roll made of X-ray / cardboard for transillumination
C. Be polite in exam hall.
D. If you have any confusion regarding case or exam
method get it cleared immediately.
E. Whenever you are given a case, go to the patient, make
him comfortable, behave friendly and take him in
confidence that you are not going to harm or bore him.
F. Tips while taking history:
1. Take history according to time.
2. In short case—you may get less time so, first take
ODP in short and give more importance to
examination.
3. Take interest in ‘talk’ of patient and simultaneously
also get from him what you want.
4. Take perfect history as I have written in earlier
chapters.
G. During examination following are MUST:
• Proper position
• Proper light
• Proper exposure
• Privacy
H. Don’t be perspirated on seeing examiner because his
most questions will require your common sense only.
I. Don’t forget to say ‘Good Morning! May I sit Sir, Thank
you Sir’.
Tips for Viva 81
J. If examiner asks you to speak history, try to speak

without seeing history from paper and have eye-contact
with Sir. So memorize history before viva starts.
K. Don’t alter history by yourself because he may cross
check you by asking to patient.
L. C/C and O.D.P. are spoken in chronological order.
M. After describing C/C in ODP say to examiner that:
To rule out etiology I have asked following C/O _______.
To rule out affecting factors I have asked following
C/O________ .
To rule out complications I have asked following
C/O __________.
N. If you want to divert your examiner to particular topic -
you have prepared perfectly. In Viva whenever point
regarding that topic comes take little rest. It will make
your examiner to ask further on that point & you will
win. This technique needs some practice so do it in
your ward exams not in University exam.
O. Try to avoid speaking words about which you don’t have
much knowledge e.g. rare syndromes, diseases.
Otherwise your viva may go on that topic and you may
get trapped.
P. While speaking keep proper speed - not very fast that
examiner cannot understand and not too slow that he
has time to think for difficult questions to ask you.
Q. If he asks you to say diagnosis, tell him `my diagnosis
is this _____’.
— If he asks favouring or opposing points say them
according to your history.
R. If you can’t diagnose perfectly (especially in swelling)
always put few D/Ds according to your findings.
S. Take care that no point in history should clash with other
point in history.
T. If you don’t know answer say “I don’t know, “Sir”. Don’t
stand dumb. It will save your time and he will move to
other question which you can answer.
U. Don’t try to make examiner fool by giving answers
unrelated to question.
And at last,
BEST OF LUCK!
Index
A Diarrhoea
traveller’s 11
Abscess 13
Ankle flare 77
E
Anorexia 12
Astley Cooper’s ligament 55 Eczema 52, 76
Electrodermatome 22
B
F
Berry’s sign 74
Blow out 78 Fever 10
Breast 47 Fibroadenoma 47, 48, 54, 55
areola 52 carcinoma 54
atrophic scirrhous 48 Fibroadenosis 47, 48, 49, 54
bening breast diseases
48 G
bening lumps 48 Gifford sign 71
breast mouse 47 Goitre 61
Ca breast 48, 49, 53 colloidal 61, 70
Ca. breast and follicular ca 61
fibroadenosis 54 Grave’s disease 70
fibroadenoma 52 Hashimoto’s d’s 61
fibroadenosis 48, 53 Hashimoto’s thyroditis 62
lactational carcinoma 49 papillary carcinoma 61
lactational carcinomatosa physiological 61
47 primary 70
malignant lump 48 primary thyrotoxicosis 61
mastitis 47-49, 51, 53 retrosternal 70
mastitis carcinomatosa Riedel’s thyroiditis 62, 70
51, 53 secondary thyrotoxicosis
nipple 51 61, 70
scirrhous ca 52 thyroid ca 61
Brodie’s d’s 54 thyrotoxicosis 61
Gornall’s test 44
C Grave’s d’s 61, 74
Callus 15 endemic cretinism 61
Chiropody 15
Cloquet’s node 45, 57 H
Criles method 69 Hernia 35
Crovalier’s sign 77 acquired weakness 36
congenital 35
D congenital weakness 36
Dalrympte’s sign 71 direct 43, 45
Debridement 22 femoral 41, 44, 45
Deep vein thrombosis 75 D/D of 46
Diabetic neuropathy 14, 15 incisional 37, 40, 44
indirect 43 O
inguinal 41, 44, 45
Ochynolysis 65
inguinal femoral 39
Okinclaus examination 50
irreducibility 38
Ophthalmopathy
irreducible 44
infiltrative 64
obstruction 38, 45
non-infiltrative 64
reducible 44 Ophthalmoplegia 65
reducible irreducible 39
resuturing 38 P
Richter’s 45
strangulated 41 Paget’s d’s 52
strangulation 38, 45 Paget’s test 31
Pain 4
Hesslbach’s triangle 45
burning 5
Horner’s syndrome 65
colic 5
compressing 5
I
diffuse 4, 5
Inflammation 24 distending 5
Invagination test 42 focal 4
poena 4
J radiation 7
referred 7
Jod base dow phenomenon
rest 5
66
scalding 5
Joffroy’s sign 71
sharp, stabbing 5
shifting 7
L throbbing 5
Lahey method 69 vague aching 5
Latent hyperthyroidism 62 Pemberton sign 66
Lymph nodes Pendred’s syndrome 61
apical 56 Perthes’ test 78
brachial 56 Pizzilo’s method 68, 69
deltopectoral 56 Plumer’s nail 65
hunterian chancre 16 Probe test 51
inflammed 16 Pulsation
malignancy 16 expansile 31
medial 56 transmitted 32
pectoral 56 Pulse
basal 67
subscapular 56
casual 67
supraclavicular 56
tuberculosis 16 R
M Relative bradycardia 8
Retrosternal thyroid 69
Malaise 12 Riedel’s thyroiditis 69
Malgaigne’s bulge 45 Ring occlusion test 43
Means-Lerman scratch 63 Rotter’s nodes 57
Mobeus sign 71
S
N Sabre tibia 22
Naffzigar’s sign 71 Scar
Index 85
Sentinel biopsy 58 subhyoid bursitis 28

Sephana varix 78 transmitted 28
Simple goitre 73 tuberculosis 25
Skin grafting 22
Stellwag’s sign 70 T
Superficial thrombophlebitis Tear drop carcinoma 18
76
Thyroid acropachy 74
Swelling 23 Thyroid swelling 59
acute inflammatory 29 classification of thyroid
axillary 34
swellings 72
benign 23 Grave’s d’s 72
benign tumours 29 natural history of goitre 72
bruit 34
Thyrotoxicosis
carcinoma 29 primary 63
cervical 34 secondary 63
chondroma 30
Toxic adenoma
chronic inflammatory 25, dominant nodule 74
29 solitary nodule 74
contents of 30
Toxic nodular goitre 74
cyst 29, 30 Trendelenberg test 78
dermoid cysts 27
diaphyseal aclasis 27 U
empyema necessitance
25, 32 Ulcer 13
expansile 28 actinomycosis 20
fibroma 29 amoebiasis 18, 20
Hodgkin’s lymphoma 25 arterial 14, 21, 22
hydatid cyst 31 bedsores 17
inflammatory 23, 24 carcinoma 17, 21
inguinal 34 cell carcinoma 21
laryngocele 25 chronic 21
lipoma 29, 33 complications 15
lipomatosis 25 diabetes 14, 17
lymphadenopathy 28 gummatous 17, 19, 21
malignant 23 healing 18
malignant melanoma 27 hunterian 18
malignant tumours 29 hunterian chancre 21
matted lymph nodes 29 infective 14
neoplasms 29 inflammatory 21
neoplastic 25 inflammed 14
neurofibromatosis 25, 27 ischaemic 17
osteoma 29 keloid 15, 17
pretracheal leprosy 20
pulsation 28 leprotic 14, 18
recurrent fibroid of Paget malignancy 22
26 malignant 21
retrosternal goitre 34 malignant melanoma 19
sebaceous cyst 24, 27, Marjolin’s 15, 17
28, 33 Martorell 15
squamous cell carcinoma neuropathic 14, 17
27 post-irradiation 19
pressure sore 18 varicose 15, 17, 18
rodent 18 vasculitic 21
septic 18 venous 17, 21
skin grafting 17
slough 19 V
soft chancre 17, 18 Varicose vein 75
squamous 21 Vomitting 8
squamous-cell carcinoma projectile 9
19 Von Graefe’s sign 64, 70
syphillis 22
W
syphillitic 14, 15, 17, 18
TB 16, 17, 18 Water hammer pulse 63
traumatic 15, 17 functional murmur 63
trophic 15, 17 Weight loss 12
tropical 15, 18
Z
tuberculosis 14, 19
tuberculous 15 Zieman’s technique 42
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Basic Tips in

Basic Tips in Clinical Surgery

© 2003, Nilesh Patel

All rights reserved. No part of this publication should be reproduced,

First Edition : 2003

Publishing Director: RK Yadav

Typeset at JPBMP typesetting unit

The aim of this handbook is an humble attempt to help the

1. Be a Good Doctor! ....................................... 1

5. Lump in Breast ........................................... 47

6. Thyroid Swelling ........................................ 59

7. Varicose Vein ............................................. 75

8. Tips for Viva ............................................... 80

HOW TO TAKE HISTORY?

TALK MORE, EXAMINE LESS

• Simultaneously, check mental status – confused,

they become necessary.

• Rest pain may be localised involving only forefoot

• Associated with distension of viscera involved.

• Very occasionally, it is bad sign e.g. rupture of

Exogenous Pyrogens (Infections)

Reset thermoregulatory centre to sense a normal

—So antiprostaglandins act as antipyretic.

3. Fatty: malabsorption syndromes

 Ulcer is a breach in the continuity of skin or mucosa

So, the only skill required for complete ODP is:

[Tabes dorsalis,Transverse myelitis, Neuritis]-

• Autonomic nerves-decreased sweating + callous

lack of underlying muscle means skin’s blood

v. Raised and everted :

vi. Yellow granules - actinomycosis

• In venous ulcers there may be full or partial thickness

— Chronic Ulcer } due to inflammatory cells

NEVER FORGET TO EXAMINE FOLLOWING:

• Hernia → reducing on lying and increasing on

Inflammatory (throbbing pain)

Painful Lumps Traumatic

5. PRESENCE OF OTHER LUMPS:

6. LOSS OF BODY WEIGHT:

8. PRECIPITATING / RELEIVING FACTORS:

• In inspection write area like – swelling in inner side

Rubbery – slightly indentable – Chondroma

• ALWAYS FIX MOVABLE SWELLING FIRST and

Examples : hydrocele, spermatocele, abscess

• Due to → swelling of artery e.g. aneursym.

• In swelling near to artery.

• Water, serum, lymph, plasma and fat are trans-

• Swelling of fascia – like above one but decreased

• Tumour within muscle

LYMPH NODE EXAMINATION

• Round shape– direct,

• Incomplete obliteration of umbillicus—

v. Poor wound healing:

5. Was there any fever after operation?

• Pulse → Feeble and rapid due to hypovolemic shock.

2. Skin over swelling:

c. Wide, irregular, puckered scar shows

Remember, to withstand viva of incisional hernia, your

1. Position and extent:

• Invagination must be gentle and pass deep to

→ Cloquet’s node (It was my bonus question in

Breast is modified sweat gland arising on mammary line.

a. Child bearing age :