SURGERY CASES MADE EASY Medicine
SURGERY CASES MADE EASY Medicine
SURGERY CASES MADE EASY Medicine
Chapter: /
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SURGERY CASES MADE EASY
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photocopying, recording or otherwise without the prior permission from the author.
ISBN - 978-9553-558701
Chapter: SURGERY CASES MADE EASY
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PREFACE
This book is designed to provide a concise yet comprehensive study guide to short
cases (OSCE) for undergraduate clinical examinations in the field of surgery. It covers
most of the surgical short cases commonly given at the final MBBS examination. Hence
medical students and ERPM candidates will be highly benefited referring to this book.
Carefully selected 32 common cases are included in the first edition of the book and
the distinctive feature of this book is that it offers a stepwise sequence of examination
which appears to be lacking in most of study materials. It also provides a sample
presentation, probable questions you might be asked as well as their answers along
with relevant images for each of the cases. There is a separate chapter consisting of
quick-review flash cards which would be perfect for a last minute revision before the
exam.
I would like to thank Dr. Gathika Kodithuwakku for providing invaluable specialist
inputs to the book.
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TABLE OF CONTENTS
CASE 01 - Examination of a Lump …………………………………………………………………….. 04-05
CASE 02 – Lipoma …………………………………………………………………………………………….. 06-07
CASE 03 - Sebaceous Cyst ………………………………………………………………………………… 08-09
CASE 04 - Dermoid Cyst ……………………………………………………………………………………. 10-11
CASE 05 - Ganglion …………………………………………………………………………………………… 12-13
CASE 06 - Ulcer Examination .…………………………………………………………………………… 14-16
CASE 07- Malignant Melanoma ……………………………………………………………………….. 17-19
CASE 08 - Thyroid Examination………………………………………………………………………….. 20-23
CASE 09 - Thyroidectomy Post-operative………………………………………………………….. 24-25
CASE 10 - Breast Examination ………………………………………………………………………….. 26-29
CASE 11 - Mastectomy Post-operative.……………………………………………………………… 30-31
CASE 12 - Post Mastectomy …………………………………………………………………………….. 32-34
CASE 13 - Gynaecomastia …………………………………………………………………………..……. 35-36
CASE 14 - Inguinal Hernia …………………………………………………………………………………. 37-39
CASE 15 - Femoral Hernia …………………………………………………………………………………. 40-41
CASE 16 - Paraumbilical Hernia ………………………………………………………………………… 42-44
CASE 17 - Parotid Tumours ………………………………………………………………………………. 45-46
CASE 18 - Submandibular Tumours ………………………………………………………………….. 47-48
CASE 19 - Vericose Veins ………………………………………………………………………………….. 49-51
CASE 20 - Scrotal Lumps …………………………………………………………………………………… 51-54
CASE 21 - Carpal Tunnel Syndrome ………………………………………………………………….. 55-57
CASE 22 - Radial Nerve Palsy ……………………………………………………………………………. 58-59
CASE 23 - Ulnar Nerve Palsy …………………………………………………………………………….. 60-62
CASE 24 - Trigger Finger …………………………………………………………………………………… 63-64
CASE 25 - Baker’s Cyst ……………………………………………………………………………………… 65-66
CASE 26 - Amputated Stump …………………………………………………………………………… 67-70
CASE 27 - Cellulitis ………………….……………………………………………………………………….. 71-73
Chapter: TABLE OF CONTENTS
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Examination of a lump is a component in almost every surgical clinical examination. Sometimes you
may be asked to spot diagnose a lump with just inspection. Given below is a rough guide to
examination of a lump.
EXAMINATION
Inspection
1. Site, Size and Shape (SSS).
2. Skin overlying the lump (Scars, Signs of Inflammation, Punctum).
Palpation
1. Surface (Smooth/ Irregular).
CASE 01
2. Edge (Well or poorly defined).
3. Tissue Plane/ Mobility /Fixity – Skin attachment and attachment to underlying structures.
4. Consistency (Soft, Firm or Hard).
5. Cross Fluctuation (Only if soft to firm).
6. Transillumination (Only if fluctuant).
7. Temperature and Tenderness.
8. Reducibility.
9. Pulsatility.
10. Palpable lymphnodes.
PRESENTATION
There is a hemispherical shaped lump, over the left lateral aspect of the neck, measuring 5cm x
5cm in size. The overlying skin looks normal. Its surface is smooth and the edge is well defined. It is
Chapter: EXAMINATION OF A LUMP
mobile and not attached to skin or the underlying structures. It is soft in consistency, fluctuant and
transilluminant. It is not reducible or pulsatile and there is no associated lymphadenopathy.
Tip: If you are confident enough, make sure that you give a rational presentation, excluding the
possibilities one by one for more marks.
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Fig 1.1 - A Lump in the scalp Fig 1.2 - A cystic hygroma in a child
CASE 01
QUESTION AND ANSWERS
1. How do you elicit the skin attachment of a lump?
Using the thumb of the examining hand, the skin over the lump is stretched in two directions
perpendicular to each other. If the skin is freely movable over the lump, the lump is not
attached to the skin.
2. Why “pinching” the skin over the lump is not the ideal way?
This method is not accurate as the lump may be attached to the skin in a point other than the
site of pinching.
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LIPOMA CASE 02
EXAMINATION
CASE 02
If the lump becomes prominent - a subcutaneous lipoma.
If the lump becomes less prominent - an intramural lipoma.
8. Consistency - Soft to firm depending on the nature of fat within it.
9. Fluctuance - Fluctuant (Pseudofluctuant).
10. Transillumination - May be transilluminant.
PRESENTATION
There is a hemispherical shaped lump, measuring 5 cm in diameter, over the right scapula. It is
not tender, the surface is lobulated and the edge is well defined. It is freely mobile and not attached
to skin or the underlying muscle. It is soft in consistency, fluctuant and transilluminant.
So my probable diagnosis is a lipoma and I would like to offer him surgical excision under LA if
it is cosmetically unacceptable.
Chapter: LIPOMA
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CASE 02
Fig 2.1 - A lipoma on the back of the chest
consent.
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EXAMINATION
1. Site - Commonly over the scalp and hairy areas, NOT in palms and soles.
2. Size -Medium to large.
3. Shape - Hemispherical.
4. Skin - Punctum (50%)? Infected (Erythema, Tenderness, Warmth)?
5. Surface -Smooth.
6. Edge - Well defined.
7. Tissue plane -Always attached to skin. Not attached to underlying structures.
8. Consistency - Soft to firm.
9. Fluctuance - Fluctuant.
10. Transillumination - Not transilluminant (Thick sebum).
CASE 03
11. Lymph nodes (Infected?)
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PRESENTATION
There is an oval shaped lump, measuring 5cm x 4cm in size, over the right side of the forehead
2 cm above the eyebrow. There is a punctum on the overlying skin and there is no surrounding
erythema or warmth. Its surface is smooth and edge is well defined. It is attached to the skin and
not attached to the underlying muscle. It is firm in consistency, fluctuant and not transilluminant.
So my diagnosis is an uncomplicated sebaceous cyst and I would like to offer him surgical
excision under Local anesthesia (LA). But if it is infected patient may need to undergo general
anesthesia (GA).
CASE 03
1. What are the histological types of sebaceous cysts?
1. Epidermal cysts.
2. Trichilemmal cysts.
If infected, incision and drainage is done ideally under GA (But some surgeons prefer local
anesthesia for small ones).
An elliptical incision is used encircling the punctum.
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EXAMINATION
1. Site - Commonly over the midline (forehead, neck, trunk), behind the ear (Posterior auricular
dermoid), over the lateral eye brow (External angular dermoid).
2. Size - Small to medium.
3. Shape - Hemispherical.
4. Skin - Overlying scar (Implanted dermoid), no punctum (Not a sebaceous cyst).
5. Surface - Smooth.
6. Edge - Well defined.
7. Tissue plane - Not attached to underlying structures. Congenital or inclusion dermoid cysts do
not attach to the skin. But acquired or implanted dermoid cysts are attached to the skin.
8. Consistency - Soft, indentable.
CASE 04
9. Fluctuance - May be fluctuant.
10. Transillumination- Not transilluminant.
Tip: If you are given an external angular dermoid, at the end of your examination, ask the
patient to blow forcefully while his mouth is sealed and nostrils are pinched and palpate the
lump for expansility. If it is expansile, it might indicate intracranial communication of the
dermoid cyst.
Fig 4.1 - Posterior auricular dermoid Fig 4.2 - External angular dermoid
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PRESENTATION
There is a hemispherical shaped lump, measuring 3cm x 3cm in size, bisecting lateral side of the
right eyebrow. There is no punctum or scars on overlying skin. Its surface is smooth and edge is well
defined. It is not attached to the skin or underlying muscle. It is soft in consistency, indentable,
fluctuant and not transilluminant. Clinically it does not increase in size with manoeuvres which
increase the intracranial pressure.
So my probable diagnosis is external angular dermoid and I would like to offer him surgical
excision under local anaesthesia (LA) after exclusion of intracranial extension with skull x-ray and CT
brain.
CASE 04
QUESTION AND ANSWERS
1. What is a dermoid cyst?
It is a skin lined cyst deep to the skin in the subcutaneous tissue.
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GANGLION CASE 05
EXAMINATION
1. Site - Commonly over the dorsum of the hand and foot near joints.
2. Size - Small.
3. Shape - Hemispherical.
4. Skin - Scar? (Recurrence?)
5. Surface - Smooth.
6. Edge - Well defined.
7. Tissue plane - Not attached to skin.
Check the mobility by contracting the underlying tendon (i.e. if the ganglion is on the dorsum of
the hand, ask the patient to maintain the fingers in extension while you are applying resistance
by downward pressure on extended fingers. Meanwhile assess the mobility of the lump both
CASE 05
vertically and horizontally).
Ganglion’s horizontal mobility (sideways movement to the tendon) is reduced when the muscle
of the relevant tendon is contracted.
8. Consistency - Soft to firm depending on the tension of fluid within it.
9. Fluctuance - Fluctuant (May be difficult elicit due to its size).
10. Transillumination - Brilliantly transilluminant (clear fluid).
Chapter: GANGLION
Fig 5.1 - Ganglion in an extensor tendon Fig 5.2 - Ganglion in a flexor tendon
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PRESENTATION
There is a hemispherical shaped lump, measuring 1cm in diameter, over the dorsum of the
right hand. Its surface is smooth and edge is well defined. It is not attached to the skin but to the
underlying extensor digitorum tendon. Its horizontal mobility is restricted when the tendon is
contracted. It is soft in consistency, fluctuant and brilliantly transilluminant.
So my diagnosis is a ganglion of extensor digitorum tendon and I would like to offer him
surgical excision under general anesthesia (GA) in a bloodless field.
CASE 05
It is a cystic swelling related to the synovial lining of the tendon sheath and it is believed to
occur due to myxomatous degeneration of the synovial sheath.
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EXAMINATION
Examination of an ulcer is more or less similar to an examination of a lump. But some additional
features have to be kept in mind.
Inspection
1. Site.
2. Size (Extent).
3. Margin (Shape) - Regular? Irregular?
4. Edge - Sloping? Punched-out? Undermined? Rolled-out? Everted?
5. Floor - Healthy? Granulation tissue? Slough?
6. Discharge? - Serous? Serosanguinous? Purulent? Amount and smell?
Palpation (Without gloves) - depending on the type of suspected ulcer from above
1. Temperature of the surrounding skin.
2. Regional lymphadenopathy.
3. Peripheral pulses.
4. Peripheral sensation and joint position sensations (JPS).
PRESENTATION
CASE 06
1) Venous Ulcer
There is an ulcer over the right ankle just
above the medial malleolus (Gaiter’s area). It is
oval in shape, approximately 2cm x 3cm in size.
Its margin is irregular, edge is sloping and floor
contains healthy granulation tissue. There is a
serous discharge from the ulcer. The ulcer is
Chapter: ULCER EXAMINATION
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PRESENTATION
2) Neuropathic Ulcer
There is an ulcer over the sole of right foot which
is oval in shape, approximately 3cm x 4cm in size.
Its margin is regular, edge is punched-out and
floor contains healthy granulation tissue. There is
no discharge from the ulcer. Ulcer is painless, base
contains flexor tendons of toes, surrounding skin
and peripheral pulses are normal. Peripheral
sensation to pain is absent up to ankles and joint
position sensation is impaired.
PRESENTATION
3) Ischemic Ulcer
There is an ulcer over the tip of the 2nd toe of right
foot which is round in shape, approximately 1cm x
1cm in size. Its margin is irregular, edge is punched-
out and floor contains slough. There is a purulent
discharge from the ulcer. The base contains bone of
the distal phalanx. The surrounding skin is colder and
blackish in colour. Dorsalis pedis and posterior tibial
pulses are absent and the femoral pulse is weak on
the right side. The peripheral sensations are normal
and there is no inguinal lymphadenopathy.
CASE 06
PRESENTATION
4) Malignant Ulcer
There is an ulcer over the dorsum of the right foot
Chapter: ULCER EXAMINATION
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3. What are the types of edges and examples for each one?
1. Sloping - Venous ulcer.
2. Punched-out - Ischemic ulcer.
3. Undermined - Tuberculous ulcer.
4. Rolled-out - Basal cell CA.
5. Everted - Squamous cell CA.
CASE 06
3. Vitamin B12 deficinecy.
4. Leprosy.
5. Vasculitis.
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EXAMINATION
Malignant Melanoma are usually found on the legs of young adults (more commonly in females).
But the site of the lesion and its characteristics may vary depending on the type of Melanoma.
Inspection is the most vital part of the examination.
1. Inspect carefully the lesion which is characteristically brownish or blackish in colour. They
are usually found on the legs and soles of young women and the back of the trunk in men.
Look for,
a. Marked variation of the colour within the lesion
b. Surface ulceration
c. A halo of brown pigment in the skin around the lesion
2. Palpate the lesion. They are usually palpable and have irregular margins.
CASE 07
3. Examine the draining lymphnodes. Look for inguinal lymphadenopathy (If positive - Stage III
disease).
4. Inspect carefully for “Satellite lesions” - along the pathway of lymphatic drainage for tumour
nodules.
5. Look for hepatomegally (If positive - Stage IV disease).
6. If you are given a chance to talk with the patient, ask for,
III. Smptoms that may indicative of malignancy
a. Rapid increase in size recently
b. Change in colour or shape of the lesion recently
c. Itching
d. Bleeding
PRESENTATION
I examined this 30 year old women who is having a brownish skin lesion on her left sole which
is 2 cm x 2 cm in size. There is marked variation in colour within the lesion and there is brownish
halo in the skin surrounding it. Its surface is ulcerated. It is palpable and has an irregualar margin.
There is left inguinal lymphadenopathy and I could notice satellite lesions along the lymph draining
pathway. So my probable diagnosis is a malignant melanoma.
18
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CASE 07
QUESTION AND ANSWERS
1. What is the most common type of malignant melanoma?
Superficial spreading melanoma.
2. Lentigo maligna.
3. Previous melanoma.
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CASE 07
FNAC of suspicious nodes and inguinal block dissection is done if node positive disease.
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EXAMINATION
Greet the patient and take consent. Make sure you have enough space behind the patient’s chair
before proceeding with the examination.
Examine from front,
1. Inspect – Offer a glass of water and ask to swallow on command & look for the lump moving
upwards with deglutition. Observe from the side.
2. Only if the lump is small and in the midline, ask the patient to put the tongue out while
stabilizing the jaw and look for the lump moving upwards.
3. Look for scars (previous lobectomy scar) and dialated neck veins.
4. Only if the lump is a large one, elicit Pemberton’s sign.
CASE 08
1. Palpate the thyroid gland from behind. Examine using one hand at a time while stabilizing the
gland from the other. Feel for the consistency and nodularity of the gland.
2. Examine for cervical lymphadenopathy.
PRESENTATION
This patient is having a lump in the antero-inferior aspect of the neck which moves up with
deglutition. There are no visible surgical scars in the neck or dilated neck veins and Pemberton’s sign
Chapter: THYROID EXAMINATION
is negative. Lump is firm in consistency and its surface is nodular with a prominent nodule in the
right upper lobe. There is no cervical lymphadenopathy. Its lower border can be felt, trachea is
deviated to the left side and the right carotid pulse is deviated posterolaterally. There is no bruit. She
is clinically euthyroid and there are no thyroid eye signs.
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CASE 08
Fig 8.1 - Diffuse goiter
(Grave’s disease)
2. What are the differential diagnosis for a solitary nodule of thyroid (SNT)?
1. Prominent nodule of a MNG.
2. Hemorrhage into a colloid cyst.
3. Thyroid adenoma.
4. Thyroid carcinoma.
5. Foci of thyroiditis.
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3. What would be the next management option, if the histology of a SNT comes as follicular
neoplasm?
Thyroid lobectomy and look for the histology to decide on further management. If the histology
is malignant, other lobe is also removed later.
CASE 08
3. Deviated trachea.
4. Displaced carotid pulse.
3. Exophthalmos..
4. Proptosis.
5. Opthalmoplegia.
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13. What are the indications for thyroidectomy for a multinodular goiter (MNG)?
1. Cosmetically unacceptable (Patient’s wish).
2. Compressive symptoms.
3. Secondary thyrotoxicosis.
4. Suspected or proven malignancy.
CASE 08
Fig 8.3 - Solitary thyroid nodule (STN)
Chapter: THYROID EXAMINATION
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EXAMINATION
1. Look for stridor.
2. Talk to the patient and ask how she feels now and look for horseness of voice.
3. Ask the patient when the drainage was last emptied and comment on its colour and volume
and check whether it is functioning.
4. Inspect / Offer to inspect the scar.
5. Elicit Chvostek’s sign to detect hypoglycemia.
PRESENTATION
I examined this patient who had undergone a thyroidetomy one day before. Her general
condition is good and has no stridor or hoarseness of voice. The drain has been last emptied eight
hours before and it has about 2ml of drainage and is functioning. Chvostek’s sign is negative. I would
like to remove the dressing to inspect the surgical scar.
Fig 9.1 - Drain inserted after Fig 9.2 - Scar of collar incision
thyroidectomy
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4. What are the effects of different types of recurrent laryngeal nerves injuries?
1. Unilateral partial - Asymptomatic.
2. Unilateral complete - Hoarseness of voice.
3. Bilateral partial - Severe stridor.
4. Bilateral complete - Aphonia.
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EXAMINATION
Take consent. Provide adequate Privacy.
1. Expose up to the waist. Use a cloth to cover the lower torso and a chaperon.
2. Ask the patient on which side the lump is and whether it is tender before you touch.
3. Look for breast asymmetry, skin changes (erythema, ulceration, peaud’orange appearance)
and nipple changes (deviation, retraction, destruction).
4. Ask to raise both upper limbs and look for skin tethering. Don’t forget to inspect the sub-
mammary area.
5. Ask the patient herself to squeeze her nipple if she complains of a nipple discharge and check
CASE 10
whether it is blood stained.
Then ask her to lie down and put her both arms behind her head.
1. First palpate the normal breast using the flat of the fingers. Then palpate “6 areas”; namely the
four quadrants, subarealoar area and axillary tail in order.
2. Then palpate the contralateral breast. Determine the site, size, shape, consistency, surface,
regularity and the margins of the lump (if the lump is not palpable, ask the patient herself to
locate it for you).
3. Check the skin attachment of the lump while in the supine position.
1. Look for deep structure attachment. Ask her to keep her ipsilateral hand on the hip and press
against waist when she is asked to. Check whether there is a reduction in mobility when the
Pectoralis Major muscle is contracted. Proper contraction of the muscle is confirmed by
palpating the anterior axillary fold by the other hand of the examiner simultaneously.
2. Assess both axillae. Ask the patient to rest her arm relaxed on top of yours as shown in the
picture (Fig-9.1). Palpate all the axillary lymph node groups - anterior, lateral, medial,
posterior, central and apical. Assess their consistency and mobility if palpable.
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PRESENTATION
At the end of the examination, come to a clinical staging depending on your findings.
On inspection there is no breast asymmetry, tethering, any skin or nipple changes. She is
having a lump in the upper outer quadrant of her right breast measuring about 3cm x 4cm x 4cm in
size. It is hard in consistency, irregular in shape and margins are ill defined. It is not attached to the
skin or the underlying muscles. There is a hard mobile solitary lymph node in right axilla in the
anterior group. Left breast and left axilla is clinically normal.
My clinical staging is T2N1Mx and I would like to complete the triple assessment and proceed.
CASE 10
Fig 10.1 - Examination of axilla Fig 10.2 - Peaudo’range appearance
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CASE 10
Yes. It must be done to exclude multifocality and to detect impalpable lesions in the
contralateral breast.
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CASE 10
3. Ipsilateral supraclavicular/ internal mammary nodes.
3. M staging
MX – Unknown Mets.
M0 – No Mets.
M1 – Metastatic Breast CA.
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EXAMINATION
Talk to the patient and ask how she is feeling now and get an idea of her general condition.
1. Examine (or offer to examine if covered), the scar for early wound related complications. Look
for the degree of healing, wound dehiscence, seroma formation, infection and flap necrosis.
2. If there is a drain, check whether it is functioning. Comment on the volume & colour and ask
when it was last emptied.
3. Examine the contralateral breast and both axillae and comment on any palpable lump or
lymphnodes.
4. Clinically exclude any intraoperative nerve injuries.
a. Intercostobrachial nerve - An area of sensory loss over the medial aspect of upper
arm.
b. Long Thoracic nerve - Check for winged scapula (Ask the patient to push against a wall/
CASE 11
against resistance and look for elevation of the medial border of the scapula).
c. Thoracodorsal nerve - Assess Latissimusdorsi (Instruct the patient to cough while
feeling the posterior axillary fold).
PRESENTATION
I examined this patient who has undergone a right sided simple mastectomy recently. The
wound is still covered with a plaster and I would like to remove it to examine for early wound
related complications. The drain has red/pink colour drainage of 50ml and it is functioning. There are
no palpable lumps in the contralateral breast or axilla. Intercostobrachial nerve, Longthoracic nerve
and Thoracodorsal nerve on the right side is clinically intact.
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CASE 11
An elliptical insicion is made around the nipple and areola, not extending beyond the midline or
midaxillary line.
They are usually left for few days or until the drainage is less than 20ml per day. Usually it will
take around 7-8 days for a mastectomy as the removed bulk is of vascular tissue.
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EXAMINATION
Examination of a patient who had undergone a mastectomy some time ago is quite different from a
patient who had a mastectomy in the same hospital admission. Although some of the steps are
common for both cases, there are slight differences.
1. Examine the scar for late wound related complications. Look for hypertrophic scar or keloid
formation.
2. Comment on radiotherapy (RT) marks.
3. Examine both breasts and axillae and comment on any palpable lumps or lymphnodes. (Local
recurrence?).
4. Ask the patient to straighten both upper limbs and look for lymphoedma of the ipsilateral one.
5. Clinically exclude any intraoperative nerve injuries.
a. Intercostobrachial nerve - An area of sensory loss over the medial aspect of upper arm.
b. Long Thoracic nerve - Check for winged scapula (Ask the patient push against a wall/
against resistance and look for elevation of the medial border of the scapula).
c. Thoracodorsal nerve - Assess Latissimus dorsi (Instruct the patient to cough while
feeling the posterior axillary fold).
6. Look for features of metastatic disease.
a. Palpable scalp lump?
b. Jaundice?
c. Enlarged Virchow’s node?
d. Spinal tenderness?
e. Pleural effusion?
f. Enlarged liver?
CASE 12
Chapter: POST MASTECTOMY
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PRESENTATION
I examined this lady who has undergone a right sided mastectomy 6 months ago. The scar is
completely healed and there is no hypertrophic scar or keloid formation. There are no visible
radiotherapy marks. There are no palpable lumps or lymphnodes in contralateral breast and axilla.
There is no lymphoedma of the ipsilateral upper limb and the right intercostobrachial nerve, long
thoracic nerve and thoracodorsal nerve are clinically intact. There are no clinical features suggestive
of the metastatic disease.
CASE 12
3. BM - Bone marrow suppression.
4. Renal - Cystitis.
5. GIT - Oral ulcerations, Diarrhoea.
6. Reproductive - Sterility, Mutations.
7. Oncogenicity - 20-fold increase of other malignancies!
1. General - Tiredness.
2. Skin - Desquamation.
3. Vessels - Endarteritis obliterans.
4. Renal - Cystitis.
5. GIT - Radiatio proctitis.
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CASE 12
Fig 12.3 - Keloid formation
Chapter: POST MASTECTOMY
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GYNAECOMASTIA CASE 13
EXAMINATION
Gynaecomastia is benign hypertrophy of male breast and the examination of such a patient should
aim to find a probable cause and to exclude breast carcinoma (rare). Hence the sequence of
examination should follow that of the female breast.
CASE 13
b. Examine testis - Orchidectomized? Atrophied? Tumours?
c. Klinefelter’s syndrome -Tall?
d. Examine signs of hypo/hyperthyroidism.
e. Offer to take a brief drug history - Cimetidine, Spiranolactone, Digoxin.
(mild case)
Chapter: GYNAECOMASTIA
PRESENTATION
This patient has painless bilateral enlargement of breasts. There are no nipple changes or
palpable lumps and the overlying skin is normal. There are no signs of alcoholic liver disease or
thyroid dysfunction. External genitalia are clinically normal with no evidence of testicular atrophy or
testicular tumours. I would like to take a brief drug history to find out a probable aetiology for
gynaecomastia.
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CASE 13
3. Hyperprolactineamia.
4. Acromegally.
Fig 13.3 - Bilateral gynaecomastia
It depends on the clinical scenario. Some patients require none. But serum Alfa Feto Proteins
(AFP), serum beta hCG level, thyroid function tests may be useful as well as serum FHS, LH and
testosterone levels.
But if a lump is palpable patient should undergo triple assessment including FNAC of the lump.
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EXAMINATION
You will be asked to examine the groin area of a patient who is lying supine, but always remember to
examine the patient in the erect position as well, at some point of your examination.
CASE 14
5. ONLY IF the hernia still cannot be seen, ask the patient where the lump is (It may be a scrotal
swelling!!) and ask him to stand up at this point & look for a bulge appearing on the groin area
on coughing (Very rare to give invisible ones in an exam setting).
6. Once the hernia is visible, demonstrate the palpable expansile cough impulse.
7. ONLY IF there is no past surgical scar indicating a previous repair, differentiate whether it is
direct or indirect hernia.
a. Ask the patient himself to reduce the hernia fully for you.
b. If the patient is unable to do so, ask the examiner whether you may try to reduce it
(DO NOT try to reduce without the consent of the examiner)
c. ONLY IF the hernia is reduced,
i. Locate the deep inguinal ring (2methods can be used).
1. 1 cm above the femoral pulse (Easy way).
2. 1 cm above the mid inguinal point (midpoint between the anterior
superior iliac sine and pubic tubercle).
ii. Ask to cough while you are applying firm pressure on deep inguinal ring with
your index finger.
iii. If the lump can be controlled by digital pressure over the deep ring, it is an
“Indirect inguinal hernia”, if not it is a“Direct inguinal hernia”.
8. Examine the external genitalia to exclude phimosis and coexisting scrotal lump which is very
common.
9. If the patient was supine throughout your examination, ask him to stand up before you finish
and look for,
Chapter: INGUINAL HERNIA
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PRESENTATION
This patient has got a globular shaped lump in the right groin region. It has visible and
expansile cough impulse. The hernia can be completely reduced and cannot be controlled by
applying firm pressure over the deep inguinal ring. He has got no phimosis and there are no
coexisting scrotal lumps. The contralateral groin is normal. So my probable diagnosis is
uncomplicated right sided direct inguinal hernia and I would like to offer him inguinal hernia repair
under spinal anaesthesia.
CASE 14
2. If you see a scar of a previous repair, do you still want to locate the deep inguinal ring?
No. Once a hernia is repaired, its anatomy is disturbed. So a recurrence of a hernia arises from
the weakest part of it. Hence it is neither direct nor indirect.
3. If you cannot control the hernia by applying firm pressure over the deep inguinal ring, can
it still be an indirect hernia? Why?
Yes it can be.
1. Not enough pressure applied.
2. Finger is not on the deep inguinal ring.
It occurs as a result of weakened posterior wall of the inguinal canal and arise medial to the
inferior epigastric artery. So a direct inguinal hernia is not within the spermatic code. It may
descend to the scrotum though.
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7. What is the landmark to differentiate direct from indirect inguinal hernia during the surgery?
Inferior epigastric artery.
CASE 14
11. What are the aetiological factors?
1. Chronic cough.
2. Constipation.
3. Cigarette smoking.
4. Bladder outflow obstruction (BOO).
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EXAMINATION
The probability of getting a femoral hernia is uncommon at exam setting than its counterpart;
inguinal hernia. It’s because they are rarer as well as they are operated shortly after the
presentation due to higher incidence of strangulation.
Sometimes it will be difficult to differentiate it from inguinal hernia for an inexperienced candidate.
CASE 15
5. Ask the patient himself to reduce the hernia fully for you - femoral herniae are more often
than not irreducible.
6. Locate the exact anatomical location of the hernia neck.
a. To do that, locate the pubic tubercle which is about 1 cm lateral to the pubic symphisis in
the midline.
b. The neck of a femoral hernia always lies below and lateral to the public tubercle (where
as that of an inguinal hernia lies above and medial to it).
7. Examine the contralateral groin for a coexsisting hernia.
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PRESENTATION
There is a hemispherical lump over the left inguinal region which is approximately 2 cm in
diameter. It has no expansile cough reflex and it is irreducible. It is neck is located below and lateral
to the pubic tubercle. So my probable diagnosis is obstructed femoral hernia.
CASE 15
5. Inguinal lymphadenopathy.
6. Undecended testis.
1. Femoral Nerve.
2. Femoral Artery.
3. Femoral Vein.
4. Hernial sac (through the saphenous opening).
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EXAMINATION
You may be directed to the case with the commanding line of “Do an abdominal examination
of this patient”. The patient is usually a middle aged overweight female.
1. Expose the abdomen fully from the xiphisternum to the pubic symphisis.
2. Notice any lump around the umbilicus which bulges out beside it. In a paraumbilical hernia,
the umbilicus is pushed to a side and stretched forming a crescent shaped crest, giving the
appearance of a “Smiling Umbilicus”.
3. Note the presence of any overlying scar (recurrent hernia?).
4. Inspect the crest carefully. It may go deep and there may be foul smelling discharge, even
an “Ompholith” (dried up sebaceous secretions).
CASE 16
5. Ask the patient to cough to visualize non-apparent hernia and to elicit expansile cough
impulse.
6. Ask the patient to reduce the lump herself for you (Do not try to do this by yourself
without the consent of the examiner).
7. ONLY IF the lump is fully reducible, try to determine the size of the neck of the hernial sac.
a. Once the lump is fully reduced, insert a finger through the defect.
b. EITHER ask the patient to lift the head against resistance & look at her abdomen
OR raise straightened both lower limbs together to contract Rectus Abdominis
muscle.
c. Feel the hardened edge of the defect (of fibrous linea alba) with the finger and
assess the approximate size of it.
8. Always exclude coexisting herniae (Eg: inguinal hernia) and divarication (diastasis) of recti.
9. If the initial command is to do an abdominal examination, continue with the rest of the
examination unless the examiner intervenes.
PRESENTATION
Chapter: PARAUMBILICAL HERNIA
I examined the abdomen of this middle aged overweight female who is having a lump at the
umbilicus. There is a globular shaped lump measuring 2 cm in diameter near the superior edge of
the umbilicus and the umbilicus is pushed aside forming a crescent shaped pit below it. There are no
overlying scars and the pit is deep but clean, with no foul smelling discharge. Patient cannot reduce
the lump and there is no expansile cough impulse. But it is not tender to touch. There are no
coexisting inguinal herniae or divarication of recti and the rest of the abdominal examination is
unremarkable.
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CASE 16
Fig 16.3 - Divarication (diastasis) of Fig 16.4 - Diagram showing diastasis
recti of recti Chapter: PARAUMBILICAL HERNIA
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CASE 16
It is a condition where the right and left sides of the Rectus Abdominis muscles spread apart in
the midline (Linear Alba). It is common in pregnancy and postpartum.
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EXAMINATION
1. Examine the lump as usual (Site, Size, Shape, Surface, Consistency, Margins).
2. Look for skin attachment.
3. Look for muscle attachment (Masseter) – Ask the patient to clench the teeth to contract
Masseter.
4. Instruct to open the mouth and look for,
a. Opening of the parotid duct (opposite the 2nd upper molar) - Inflammation or pus?
b. Bulging of the tonsil of the affected side (Deep lobe of the gland).
5. Assess the integrity of facial nerve (Ask to wrinkle the forehead, close the eyes tightly,
blowout the cheeks, and show the teeth).
6. Look for cervical Lymphadenopathy.
CASE 17
7. Offer to palpate the parotid duct for a stone wearing a pair of gloves.
PRESENTATION
There is a hemispherical lump in the right preauricular area which is 2.5 cm in diameter. It is of
firm consistency with regular surface and distinct margins. The lump is not attached to skin or
underlying Masseter. Facial Nerve is intact and there is no cervical lymphadenopathy. So my clinical
diagnosis is a benign parotid tumour most probably a pleomorphic adenoma.
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CASE 17
3) What are the types of malignant parotid tumours?
1. Mucoepidermoid carcinoma.
2. Adenocystic carcinoma.
3. Oncocytoma.
2. Salivary fistula.
3. Frey’s syndrome (Gustatory sweating).
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EXAMINATION
1. Examine the lump as usual (Site, Size, Shape, Surface, Consistency, Margins).
2. Look for skin attachment.
3. Look for muscle attachment (Myelohyoid) – Ask the patient to press the tongue against the
hard palate to contract Myelohyoid and look for reduction in mobility of the lump.
4. Instruct to open the mouth and look for the opening of the Submandibular duct (either side of
the frenulum lingulae) - Inflammation or pus?
5. Look for cervical Lymphadenopathy.
6. Wear gloves & palpate bimanually- If it is submandibular gland it is bimanually palpable.
7. Palpate along the submandibular duct for a stone.
CASE 18
PRESENTATION
There is an oval shaped lump in the right submandibular fossa which is 2 cm x 3 cm in size. It is
of firm consistency with regular surface and distinct margins. The lump is not attached to skin, but to
the underlying Myelohyoid. There is no cervical lymphadenopathy. The lump is bimanually palpable
and I could not feel any stone along the submandibular duct. So my clinical diagnosis is a
submandibular gland tumour.
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2. What are the common reasons for a palpable enlarged submandibular gland?
1. Submandibular sialedenitis and sialectasis.
2. Submandibular tumours.
CASE 18
4. What is sialectasis?
Irregular dialatation and stenosis of the intraductular duct system due to recurrent infection.
9. What are the nerves that can be damaged during submandibular sialadenectomy?
1. Marginal mandibular branch of the facial nerve.
2. Lingual nerve.
3. Hypoglossal nerve.
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EXAMINATION
Ask the patient to stand up and inspect the anterior and posterior surfaces of both lower limbs from
below upwards. (You may have to kneel down by the side). If the both lower limbs are affected, you
will be asked to examine one leg only. You will need a tourniquet (a urinary foleycatheter would do)
during the examination.
1. Identify the affected territory (If anteromedial – Long saphenous territory and If posterior -
Short saphenous territory).
2. Look for “Saphenavarix”.
3. Look for “Blow-outs”.
4. Carry out “Tap test”.
CASE 19
Ask the patient to lie down on the bed,
1. Inspect the lower limb for pigmentation, ezema, venous ulcerations, lipodermatosclerosis and
superficial thromboblephitis.
2. Lift the lower limb up and empty all the dialated veins.
3. Apply the tourniquet as high as possible just below the saphenofemoral junction (SFJ).
Offer to do the Perthe’s Test to check the integrity of the deep veins. (Apply a tourniquet just below
SFJ and ask the patient to walk/ tip toe for about 10-15 min. A Cramping leg pain is indicative of
affected deep veins.
PRESENTATION
He is having dilated torturous veins involving the antero-medial aspect of his right lower limb
and there is lump in the right femoral triangle with a cough impulse and fluid thrill most probably a
Chapter: VERICOSE VEINS
saphinavarix. I did not notice any blow-outs and the tap test is positive. There is pigmentation,
lipodermatosclerosis and a superficial ulcer on the Gaiter’s area. He has got both saphenofemoral
and perforator incompetence. I would like to do Perthe’s test to assess the intergrity of the deep
veins.
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Fig 19.1 - Vericose veins affecting Fig 19.2 - Vericose veins affecting
greater saphenous system lesser saphenous system
CASE 19
Fig 19.3 - Saphenavarix Fig 19.4 - Blow-outs (perforator
incompetence)
Gaiter’s area
QUESTION AND ANSWERS
1. What are varicose veins?
The presence of dilated, elongated, tortuous superficial veins.
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CASE 19
4. What are the treatment options?
1. Conservative management (Reassurance, Lifestyle modification, Stockings).
2. Sclerotherapy (For below knee varicosities with Sodium tetradecyl sulfate).
3. Surgery.
a. Saphenofemoral junction ligation and greater saphenous stripling.
b. Saphenopopliteal junction ligation and lesser saphenous stripling.
c. Stab avulsion of the perforators.
4. Endovascular ablation (Induce permanent endothelial damage by heat).
6. What are the measures that are taken to reduce the risk of postoperative DVT?
1. Ensure hydration.
2. Adequate mobilization.
3. Limb physiotherapy.
4. Tight fitting stockings for 4 weeks.
5. Low molecular weight heparin (LMWH) to high risk patients.
Chapter: VERICOSE VEINS
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EXAMINATION
Take consent. Expose well. Remember to examine the contralateral hemiscrotum and for a
coexsisting inguinal hernia which is not uncommon.
1. Palpate the Spermatic cord to differentiate a scrotal lump from an inguino-scrotal lump.
Scrotal lumps- Hydroceles, Epididymal cysts, Cysts of the cord.
Inguino-scrotal lumps - Inguinal hernia (usually indirect).
2. Check whether you can feel the testis separately from the lump.
a. If yes, check whether there is a distinct gap between the testis and lump (Cyst of the
cord) or not (Epididymal cyst).
b. If no, it’s a hydrocele (But in “Lax hydrocele” testis can be palpable due to small amount
of fluid).
CASE 20
3. Stabilize the lump (against the thigh using your fingers of both hands) and elicit cross
fluctuations.
4. Stretch the scrotal skin and keep a pen light away from the testis to look for transillumination
(Transillumination will not be elicited across the testis).
5. Examine the contralateral hemiscrotum as well.
6. Get the patient out of the bed and look for coexisting inguinal hernia and vericocele.
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PRESENTATION
Hydrocele - He is having a lump confined to the right hemiscrotum which is fluctuant and
transilluminant. The right testis cannot be separately palpable (The Left hemiscrotum and testis is
normal and he does not have coexsisting inguinal hernia or vericocle).
Epididymal Cyst - This patient is having a lump confined to right hemiscrotum which is fluctuant
and brilliantly transilluminant. The right testis is separately palpable and there is no distinct gap
between the lump and testis.
Cyst of the Cord - He is having a lump confined to the right hemiscrotum which is fluctuant and
brilliantly transilluminant. The right testis is separately palpable and there is a distinct gap
between the lump and testis.
CASE 20
QUESTION AND ANSWERS
1. What are the types of hydroceles?
1. Primary Hydrocele (Idiopathic Hydrocele).
2. Secondary Hydrocele (Lax Hydrocele) - Due to testicular tumours, torsion, infection, trauma
or following inguinal hernia repair.
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CASE 20
Fig 20.3 - Epididymal cyst being
operated
Chapter: SCROTAL LUMPS
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EXAMINATION
Usually the command is to examine the hands of the patient, but sometimes you might be given a
clue like “This lady presented with tingling sensation in her hands”. The disease is often bilateral.
CASE 21
7. Offer assessment of the patient’s quality of life (QOL).
a. Nocturnal and early morning worsening of symptoms.
b. Effects on occupation or activities of daily living (eg: Washing clothes).
Chapter: CARPAL TUNNEL SYNDROME
PRESENTATION
This patient who presented with tingling sensation of hands, has bilateral thenar muscle
wasting but there is no wasting of hypothenar eminence or dorsal guttering. There are no visible
surgical scars, suggestive of previous carpal tunnel decompression surgery. Her opposition of the
thumbs is weak and the pen touch test is positive, but there is no weakness in finger adduction or
extension. There is an area of sensory loss over the palmar aspect of the lateral three and half
fingers and no other areas of sensory loss. Tinel’s test and Phalen’s test are positive. So my tentative
diagnosis is bilateral Carpal Tunnel Syndrome (CTS) and I would like to assess her functional
disability and probable aetiology.
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Fig 21.1 - Wasting of thenar eminence Fig 21.1 - Severe wasting of bilateral
thenar muscles
CASE 21
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3. What are the structures that pass through the carpal tunnel?
1. Median nerve.
2. Four tendons of Flexor Digitorum Superficialis.
3. Four tendons of Flexor Digitorum Profundus.
4. Tendon of Flexor Pollicis Longus.
5. Tendon of Flexor Carpi Ulnaris (in a separate compartment).
4. What are the structures that pass over the carpal tunnel?
1. Palmar cutaneous branch of the Median nerve.
2. Ulnar nerve.
3. Ulnar artery.
4. Tendon of Palmaris Longus.
5. Why not the sensation over the radial aspect of the palm is affected?
Because the palmar cutaneous branch of the Median nerve is given away proximal to the flexor
retinaculum and which passes over it.
6. What are the muscles in hand which are innervated by the Median nerve?
1. All thenar muscles except Adductor Pollicis.
2. Radial two Lumbricals.
CASE 21
5. Rheumatoid Arthritis.
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EXAMINATION
1. Ask the patient to spread out the arms for you and look for a “Wrist drop” (flexion of wrist and
fingers of the affected hand).
2. Examine the functions of the muscles supplied by the Radial nerve.
a. Long extensors in forearm (wrist and MCPJ extensors) - Ask the patient to extend the
wrist & fingers against resistance.
b. Triceps - Ask the patient to extend the elbow against resistance.
c. Brachioradialis - Ask to flex the elbow in the semipronated position against resistance.
d. Supinator - Ask to supinate the forearm with extended elbow against resistance.
3. Examine the sensory distribution.
a. There is an area of sensory loss over the 1stinterdigital space on the dorsum of the hand.
CASE 22
Chapter: RADIAL NERVE PALSY
PRESENTATION
There is a wrist drop in the right side compared to the left side and he cannot extend
the wrist or fingers at metacarphalangeal joints against resistance. Extension of the elbow is
weak as well as the flexion of elbow in the semipronated position compared to the other side.
Supination is also impaired with extended elbow against resistance. There is an area of sensory
loss over the dorsal aspect of the 1st web space. Opposition of thumb, adduction and abduction
of the fingers are intact. So my probable diagnosis is right sided radial nerve palsy.
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CASE 22
physiotherapy.
Chapter: RADIAL NERVE PALSY
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EXAMINATION
Given below is a targeted examination for Ulnar nerve palsy. But remember to examine other
nerves (Median & Radial) to exclude multiple nerve involvement.
1. Ask the patient to spread out the hands for you and try to spot diagnose the “Ulnar claw hand”
(Clawing of the medial two fingers of the hand).
2. Inspect carefully both the palmar and dorsal aspect of the hands and look for,
a. Wasting of hypothenar eminence (compare with the other side).
b. Dorsal guttering (due to wasted Interossei muscles) - Palpate the 1st finger web where
the wasting is often obvious.
3. Examine the functions of the muscles supplied by the Ulnar nerve.
a. Palmar Interossei - Ask the patient hold a card between two fingers while you attempt
pull it away using the same two fingers.
b. Dosrsal Interossei - Ask the patient to keep the hand on a flat surface and spread out
the fingers against resistance.
c. Adductor Pollicis - Ask the patient hold a paper between the thumb and the radial
aspect of the index fingers while you attempting to pull it away. Flexion of the terminal
phalanx of the thumb to hold the paper indicates a positive Froment’s sign.
4. Examine the sensory distribution.
a. High lesions - There is an area of sensory loss over the both palmar & dorsal aspects of
the medial side of the hand and medial one and half fingers.
b. Low lesions - There is an area of sensory loss only over the palmar aspect of the medial
side of the hand and medial one and half fingers.
5. Try to identify a probable aetiology.
a. Look for depigemented anaesthetic patches and Ulnar nerve thickening at elbow
(Leprosy).
CASE 23
b. Look for scars on the forearm (trauma).
6. Offer to assess the patient’s quality of life.
PRESENTATION
Chapter: ULNAR NERVE PALSY
There is marked clawing of the ring and little fingers of the right hand and there is wasting of
hypothenar eminence with dorsal guttering, but the thenar eminence is not affected. The actions of
palmar and dorsal interossei are impaired and Froment’s sign is positive. Opposition of the thumb
and finger extension is intact. There is an area of sensory loss over the palmar aspect of the medial
side of the hand and medial one and half fingers. There is no hypopigmented patches or ulnar nerve
thickening and there is no visible scars on the forearm. So my tentative diagnosis is right sided Ulnar
nerve palsy, probably a lower lesion.
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Fig 23.1 - Ulnar claw hand Fig 23.2 - Ulnar claw hand
(Dorsal view) (Palmar view)
CASE 23
supplied by the median nerve are spared).
In higher lesions the innervation to medial half of Flexor Digitorum Profundus is also lost, causing
less intense flexion of the fingers.
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7. What are the muscles that are innervated by the Ulnar nerve?
1. Flexor Carpi Ulnaris.
2. Medial half of Flexor Digitorum Profundus.
3. All Palmar Interossei.
4. All dorsal Interossei.
5. 3rd & 4th Lumbricals.
6. Adductor Pollicis.
10. What are the surgical options for Ulnar nerve palsy you know of?
1. Ulnar nerve decompression.
2. Ulnar nerve anterior transposition.
3. Medial epicondylectomy.
CASE 23
Chapter: ULNAR NERVE PALSY
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EXAMINATION
1. Ask the patient to spread out the hands with palmar surface facing upwards as for any hand
examination. Note any degree of flexion in ring (and middle) fingers.
2. Then ask the patient to flex and extend the fingers.
3. After flexion of the fingers, extension will be painful and there will be an obvious rapid phase
(triggering) in finger extension.
4. Then palpate gently over the palmar surface, proximal to the finger affected and feel for a
small tender nodule along the tendon (commonly found over the metacarpal heads).
CASE 24
Fig 24.1 - Trigger finger
PRESENTATION
Chapter: TRIGGER FINGER
This patient is having difficulty in extending the ring finger of the right hand after flexion and
there is a sudden extension when attempting to do so. There is a small tender nodule over the 4 th
metacarpal head of the right hand. So my probable diagnosis is stenosing tenosinovitis in the right
ring finger.
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CASE 24
1. Heat fomentation.
2. A short course of analgesics.
Fig 24.2 - Tendon release surgery Fig 24.3 - Trigger finger (operated)
Chapter: TRIGGER FINGER
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EXAMINATION
The principle steps of an examination of a lump should be followed as outlined below.
Remember to examine both knees.
1. Site - Over the popliteal fossa, in the midline below the joint line of the knee.
2. Size - Medium to large.
3. Shape - Hemispherical / oval.
4. Skin - No punctum.
5. Surface - Smooth.
6. Tissue plane - Not attached to skin or underlying muscle.
7. Consistency - Soft.
8. Pulsatility - Not Pulsatile.
9. Compressibility - Can be emptied to the knee joint.
10. Fluctuance - Fluctuant.
11. Transillumination - Transilluminant.
12. Examine the knee for Osteoarthritis - Swollen knee/ Patellar tap/ Crepitus.
PRESENTATION
CASE 25
measuring 4 cm in diameter, over the left popliteal fossa in
the midline below the line of the knee joint. Surface is
smooth, edge is well defined and it is not attached to the skin
or the underlying muscle. It is soft in consistency, fluctuant
and trasilluminant. It can be emptied to the knee joint and it
is not pulsatile. There is no lump over the right side and both
of the knee joints show degenerative features like crepitus.
osteoarthritis.
Fig 25.1 - Baker’s cyst
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3. What is the critical condition that you should rule out first?
Deep vein thrombosis (DVT).
CASE 25
By an ultrasound scan.
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EXAMINATION
You may be given a patient with peripheral vascular disease (PVD) who is having an
amputated limb, with or without gangrenous toes. Remember to examine the both lower limbs,
especially assess the peripheral pulses of the non-amputated limb which could be vital, but easily
forgotten.
CASE 26
of the bed and look for
reactive hyperaemia).
f. Auscultate for a femoral
bruit.
05. Look for nicotin stains in the right
hand.
06. Examine/ Offer to examine
Chapter: AMPUTATED STUMP
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PRESENTATION
The left lower limb of the patient is amputated at below knee level and the skin wound is
completely healed. The skin over the amputation stump is freely movable and there is no fixed
flexion deformity.
There are no scars suggestive of previous vascular bypass surgeries. Both femoral pulses are
felt and good in volume, but distal pulses are weak in the contralateral limb. There are no partial
amupatations, gangrenous toes or ischemic ulcerations of the right lower limb. The peripheries are
warm and capillary refilling time is less than 2 seconds. Beurger’s test is negative. There are no
femoral or carotid bruits, no nicotin stains, pulsatile epigastric lumps and the apex beat in the
normal position and it is normal in character.
CASE 26
1. What are the Indications for amputation?
1. Dead - Dry gangrene.
2. Deadly - Wet gangrene, Spreading celluilitis, Osteomelitis, Trauma.
3. Dead loss - Paralyisis.
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4. What is “Gangrene”?
It is the tissue death due to persistent ischemia.
CASE 26
and tissue loss (gangrene & ischemic ulceration).
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14. What are the treatment options available for Peripheral Vascular Disease (PVD)?
1. Conservative management
i. Risk factor modification.
ii. Graded exercise.
iii. Foot care.
iv. Medications (Statins, Aspirin).
2. Percutaneous Transluminal Angioplasty (PTA)
3. Surgery
i. Vascular bypass.
ii. Endarterectomy.
iii. Profundaplasty.
iv. Sympathetectomy.
v. Limb Amputation.
CASE 26
Only when an intervention is planned (due to its own risks like anaphylaxis and acute renal
failure).
Chapter: AMPUTATED STUMP
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CELLULITIS CASE 27
EXAMINATION
Consider yourself lucky if you are given a patient with cellulites as one of your exam cases. But
always remember that the easier cases may get tricky. Often the diagnosis is evident, but still the
methodical examination and the presentation may carry the bulk of the marks.
1. Comment on the area affected and up to which level. Lower limbs are the most affected.
3. Look for regional lymphadenopathy - Check for enlarged tender inguinal lymphnodes.
CASE 27
b. Necrosis of skin
PRESENTATION
Chapter: CELLULITIS
This patient is having swelling and erythema of right leg with indistinct demarcation. The
affected limb is warmer, tender and there is pitting ankle oedema. There is tender right inguinal
lymphadenopathy. She is febrile to touch and having a pulse rate of 110bpm. So she is having right
leg cellulitis and there is no blister formation.
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Fig 27.1 - Upper limb cellulitis Fig 27.2 - Lower limb cellulitis
CASE 27
5. Loss of function
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Typically caused by a mixture of aerobic and anaerobic organisms that cause necrosis of
subcutaneous tissue usually including the deep fascia. Without timely treatment (broad spectrum
antibiotics, surgical debridement, amputation if nessasary) the area becomes gangrenous.
CASE 27
Chapter: CELLULITIS
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STOMAS CASE 28
EXAMINATION
1. Look at the site and morphology of the stoma and try to identify it.
2. Check whether it is functioning or not (presence of effluent or gas).
3. Comment on the effluent (consistency, colour and amount).
4. Look for possible complication of the stoma (offer the removal of colostomy bag with gloved
hands).
5. Try to figure out the possible surgery patient might have undergone (look at the abdominal
scar/ perineal scar).
CASE 28
Fig 28.1 - End ileostomy Fig 28.2 - Loop ileostomy
PRESENTATION
This patient is having an end colostomy at Right Illiac Fossa (RIF). The Mucosa appears pink
Chapter: STOMAS
and healthy. It is functioning and contains moderate amount of faeculent effluent with gas. There is
no evidences of bleeding or necrosis. There is a midline laparatomy scar evidencing pervious
Hartman’s procedure or Abdominoperineal Resection (APR). I would like to inspect for a perineal
scar to differentiate it.
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CASE 28
Fig 28.3 - Colostomy bag
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CASE 28
5. What are the factors to consider when selecting the stoma site?
1. Easily accessible.
2. At least 5 cm away from the umbilicus.
3. Should not overlie the skin creases and waist line of clothes.
4. Should not overlie past surgical scars.
5. In a place where the stoma bag does not come in contact
with anterior superior iliac spine.
Early
1. Bleeding.
2. Necrosis.
3. Suture detachment. Fig 28.5 - Fecal excoriation
Late
1. Stenosis.
2. Retraction.
3. Prolapse.
4. Parastormal Fig 28.4 - Stomal prolapse
herniation.
5. Fistula formation.
6. Skin excoriation.
Chapter: STOMAS
7. Stoma diarrhea.
Fig 28.6 - Mucocutaneous
seperation
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EXAMINATION
You may be shown a patient who is having a POP cast and asked to comment. Be prepared to
discuss the indications, advantages and complications of POP casts.
CASE 29
ii. The hand is held in “Glass holding
position”.
PRESENTATION
Chapter: POP CASTS - UPPER LIMB
Patient is having a below elbow complete POP cast down to midpalm without incorporating
the heads of metacarpals of the fingers or the ball of the thumb. The forearm is held in semiprone
position and the wrist is semiflexed and ulnar deviated. So this is a Colles’ POP.
He can move the fingers actively without any pain and there is no pain to passive extension of
fingers. Tips of the fingers are pink in colour and capillary refilling time is less than two seconds.
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Fig 29.2 - Above elbow POP cast Fig 29.3 - Colle’s POP cast
CASE 29
Fig 29.4 - Scaphoid POP cast Fig 29.5 - U slab for humeral
shaft fracture
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3. How do you reduce Colles’ fracture before applying the POP cast?
Displaced fracture segment is manipulated under anesthesia (GA or Hematoma block). Distal
fragment is disimpacted, palmarflexed and ulnar deviated. Then the forearm is kept
semipronated and a POP cast is applied from below elbow down to midpalm without
incorporating the ball of the thumb or the metacarpal heads of the fingers.
Early
1. Vascular damage (Volkman’s ischemic contracture).
2. Nerve damage (Median nerve).
CASE 29
Late
1. Malunion.
2. Carpal Tunnel Syndrome (CTS).
3. Rupture of Extensor Pollicis Longus tendon.
4. Joint stiffness.
5. Reflex sympathetic dystrophy (Sudeck’s atrophy).
radioulnar joint.
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CASE 29
4. More radiolucent.
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EXAMINATION
You may be shown a patient who is having a POP cast and asked to comment. Be prepared to
discuss the indications, advantages and complications of POP casts.
CASE 30
tibia.
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CASE 30
Fig 30.1 - POP casts of fractures of lower limb
PRESENTATION
` Patient is having an above ankle complete POP cast from groin down to the heads of
metatarsals of toes on left lower limb. Metatarso-phalangeal joints are not incorporated. Knee is
kept slightly flexed and ankle is held in 900 of flexion. There is a window over the anterior aspect of
the left tibia.
He can move the toes actively without any pain and there is no pain to passive extension of
toes. Tips of the toes are pink in colour and capillary refilling time is less than two seconds. So my
probable diagnosis is he has had an open fracture tibia.
Chapter: POP CASTS - LOWER LIMB
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CASE 30
1. Wound is kept covered with sterile dressing until the patient is transferred to the OT.
2. Skin wound is explored to see the full extent.
3. Wound is thoroughly washed with large amounts of Normal Saline.
4. Wound is cleaned with Povidone iodine.
5. All the devitalized tissue is excised (thorough debridement).
6. Apply an external fixator or an above knee POP cast with a window.
7. Do not suture the skin of wound and allow it to heal by secondary intention.
8. Later close the wound with skin grafts/ flaps.
5. What are the advantages of external fixator over above knee POP in the management of an
open tibial fracture?
1. Allow early mobilization.
Chapter: POP CASTS - LOWER LIMB
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CASE 30
4. Non rotator boot with sliding skeletal traction using a tibial pin.
10. What is the classification used to describe the types of ankle fractures?
Weber’s classification.
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EXAMINATION
You may be shown a patient who is having an external fixator in situ and asked to comment.
Be prepared to discuss the indications, advantages and complications of external fixators.
CASE 31
Fig 31.1 - Types of external fixator systems
PRESENTATION
Chapter: EXTERNAL FIXATORS
This patient is having a unilateral frame type external fixator on the left lower limb probably
due to underlying fracture shaft of the tibia. There is an area of bony loss in the middle of the shaft
of the left tibia but no apparent shortening of the left leg. There is a superficial ulcer with healthy
granulation tissue over the fracture site which is ready for skin grafting. No sign of pin site infection
and he can move the affected lower limb without any pain.
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Fig 31.2 - Open fracture tibia Fig 31.3 - External fixator for a
compound fracture tibia
Fig 31.4 - Skin grafted wound with EF Fig 31.5 - X-ray view of an external
fixator
CASE 31
QUESTION AND ANSWERS
1. What are the main two types of external fixators (EF)?
1. Unilateral frame.
Chapter: EXTERNAL FIXATORS
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4. What are the types of internal fixators (IF) you know of?
1. Plate & Screws.
2. Intramedullary nails (K nails).
3. Compression screw plates.
CASE 31
2. Less expensive.
3. Need less expertise.
4. Neurovascular damage.
5. Chronic pain.
6. Joint stiffness.
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EXAMINATION
You may be shown a patient who is having an IC tube inserted and asked to do relevant
examination & comment. In case of a left sided IC tube, inspect the drain and tube from the left
side and approach the patient from the right side (as usual) for the rest of the examination.
1. Inspect the IC tube & drain carefully and comment on its side, volume and colour of the
drainage.
2. Check whether it is functioning (look for the swinging movements of the fluid column. If
not swinging, ask the patient to cough).
3. Palpate around the site of insertion of the IC tube and look for surgical emphysema.
4. Auscultate the lungs and look for lung re-expansion.
CASE 32
Fig 32.1 - Intercostal (IC) tube Fig 32.2 - Underwater sealed chest drain
Chapter: INTERCOSTAL TUBE
PRESENTATION
This patient is having an IC tube inserted to left side of the chest and it is functioning. The drain
contains 150ml of blood stained fluid. There is subcutaneous emphysema. Breath sounds are
reduced over left lower zone.
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Fig 32.5 - IC tube connected to the drain Fig 32.6 - IC tube in situ in chest X-ray
CASE 32
QUESTION AND ANSWERS
1. What are the Indications to insert an IC tube?
1. Drainage of heamothorax,
2. Drainage of Empyema (Pyothorax).
3. Drainage of large pneumothorax.
Chapter: INTERCOSTAL TUBE
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6. What could be the reasons if the fluid level does not swing with respiration?
CASE 32
1. Malposition of the tube.
2. Obstructed tube – Blood clot.
3. Kinked tube – too long tube.
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QUICK-REVIEW FLASHCARDS
1. EXAMINATION OF A LUMP
2. LIPOMA
6. Well defined.
7. Not attached to the skin or the underlying muscle.
8. Soft to firm.
9. Pseudofluctuant.
10. May be transilluminant.
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3. SEBACEOUS CYST
1. Commonly over the scalp and hairy areas, NOT in palms and soles.
2. Medium to large.
3. Hemispherical.
4. Punctum.
5. Infected?
6. Smooth & well defined.
7. Always attached to skin & not to underlying structures.
8. Soft to firm.
9. Fluctuant.
10. Not transilluminant.
4. DERMOID CYST
1. Commonly over the midline, behind the ear, over the lateral eye brow.
2. Small to medium.
3. Hemispherical.
4. Overlying scar (Implanted dermoid).
5. Smooth & well defined.
6. Implanted dermoids are attached to skin but not inclusion dermoids.
Chapter: QUICK-REVIEW FLASHCARDS
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5. GANGLION
1. Commonly over the dorsum of the hand and foot (near joints).
2. Small.
3. Hemispherical.
4. Scar?
5. Smooth & well defined.
6. Not attached to skin. Horizontal mobility is reduced when the tendon is
contracted.
7. Soft to firm.
8. Fluctuant.
9. Brilliantly transilluminant.
6. ULCER EXAMINATION
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7. MALIGNANT MELANOMA
8. THYROID EXAMINATION
B2 - Cervical lymphadenopathy.
F1 - Tracheal deviation.
F2 - Retrosternal extension .
F3 - Displaced carotids.
F4 - Bruit.
E - Exopthalmous, Lid retraction, Lid lag and Opthalmoplegia.
H - Sweaty hands, tachycardia, fine tremors.
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9. THYROIDECTOMY POST-OP
1. Stridor?
2. Horseness of voice?
3. Drainage - When last emptied? Colour? Volume? Functioning?
4. Offer to inspect the scar.
5. Elicit Chvostek’s sign.
Seated,
Breast asymmetry, Skin changes and Nipple changes.
Skin tethering & sub mammary area.
Nipple discharge?
Seated again,
Pectoralis Major Attachment.
Assess both axillae & Supraclavicular lymphadenopathy.
Dress her up.
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13. GYNAECOMASTIA
1. Expose.
2. Unilateral or bilateral?
3. Changes of the overlying skin or nipple?
4. Any palpable lump? Axillary nodes?
5. Look for a probable cause (CLCD signs, testicular cause, drug history).
8. If the patient was supine throughout your examination, ask him to stand up
before you finish and look for, coexisting small hernia on the other groin&
coexisting varicocele.
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sac.
a. Insert a finger through the defect.
b. Ask the patient to lift the head against resistance & look at her abdomen
or raise straightened both lower limbs together.
c. Feel the hardened edge of the defect and assess the size of it.
8. Exclude coexisting herniae) and diverication of recti.
9. If the initial command is to do an abdominal examination, continue with the
rest of the examination.
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10
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Erect
1. Identify territory
2. Saphena varix?
3. Blowouts?
4. Tap test
Chapter: QUICK-REVIEW FLASHCARDS
Supine
1. Complications?
2. Lift and empty.
3. Apply Tourniquet.
Erect
1. SF +/- Perforator incompetence?
2. Perthe’s test (Offer)
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27. CELLULITIS
28. STOMAS
Chapter: QUICK-REVIEW FLASHCARDS
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1. Type of EF.
2. Bones involved.
3. Fracture site.
4. Shortening of the affected limb? Bony loss? Skin grafts?
5. Pin site infection?
6. Joint stiffness? Chapter: QUICK-REVIEW FLASHCARDS
10
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