Carcinoma of Breast

 Name: DOA:
 Age: DOE:
 Sex:
 Occupation:
 Address:

Chief Complaints:
1. Swelling – in breast / axilla (lymph nodes)
2. Pain
3. Retraction of nipple
4. Discharge from nipple
5. Wound/ Trauma / Ulceration / Fungation
6. Metastasis symptoms
History of Presenting illness:
1. Lump in Breast:
 Duration
 Onset
 Rate of growth
2. Pain:
 Duration
 Type
 Radiation
 Aggravating/Relieving factors
 Associated symptoms (fever in mastitis)
 Relation to menstruation (cyclical mastalgia)
3. Asymmetry of Breast:
4. Discharge from nipple:
 Duration
 Quality-nature, colour, odour
 Quantity
5. Nipple changes:
 Retraction(depression)
 Deviation
 Destruction
 Displacement
 Discolouration
 Duplication
6. History of trauma (hematoma, traumatic fat necrosis)
7. History of swelling elsewhere (limb)
8. History of fever (mastitis)
 9. History of loss of weight/appetite
10. History of related to metastasis
 History of bone pain low back pain, altered sensation
like sense of position and vibration, lower limb
weakness, features of paraplegia,
 History of jaundice, Abdominal distention
 History of chest pain/breathlessness
 History of cough with hemoptysis
 History of convulsions, loss of consciousness, vomiting,
limb weakness, headache, visual disturbances,
behavioural changes (psychological changes)
 History of haematuria
11. History of Radiation exposure (15-20years ago)
12. History of Menstrual irregularities , Abdominal pain

Past History:
 History of contraception
 History of similar complaints in past (fibroadenosis, TB)
 History of colorectal or pancreatic carcinoma
 History of Radiation exposure
 History of surgery (radial incision)
 History of nipple Retraction ( in abscess)
 History of DM, HTN, TB, EPILEPSY, ASTHMA

Personal history:
 Menstrual History
 Age at menarche
 Cycles (regular/irregular)
 Duration
 Cyclical mastalgia
 Age at menopause
 Obstetric History:
 Marital status
 Number of pregnancies
 Still birth , Abortions, Spacing
 Age at first childbirth
 Breastfeeding,
 Last child birth
 Use of OCPs

 Appetite
 Diet
 Bowel and Bladder:
 Sleep
 Habits
Family History:
 History of similar complaints in 10 relatives ( common in sibling than mother)
 History of Ovarian Ca, Gastric Ca & Pancreatic Ca

Drug History: HRT

OCPs

Allergy History:

General Physical Examination:

Here is a ____ year old ____ patient, _______ built and nourished and ____ co-operative.

Pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy, Edema

Vitals:
 Pulse: (rate, rhythm, character, volume, condition of vessel wall
radio-radial/radio-femoral delay)
 BP: (position and limb in which BP is measured)
 RR:
 Temperature:

LOCAL EXAMINATION:
o Position of Patient:
 Sitting arms by side of patient
 Sitting arms over the head (Auchincloss method)
 Bending forward (Fixity to chest is observed)
o Exposure:
o Position of Examiner wrt. Patient:
o Light source:

Inspection: ( Inspect in all 3 Positions mentioned)

Comparitive inspection of both breasts.
 Size:
 Shape:
 Position / Extent on both sides: ( 2nd – 6th ICS)
 Symmetry
 Visible lump: Quadrant, size, shape
 Level of nipples

Inspection of affected Breast:

 Size and Shape of Breast
 Symmetry and Position (pulled towards/ pushed away from mass)
 Nipple
o Position (drawn up / pushed down)
o Symmetry (compare to normal side)
o Prominent / Flattened
 o Size & Shape
o Surface
o Displacement ( towards / away from lump)
o Retraction ( circumferential / slit like)
o Discharge
o Ulcer over nipple
 Areola
o Colour
o Size changes
o Cracks / fissures / Ulcer
o Eczema
o Discharge

 Skin over the Breast

o Scars
o Engorged veins
o Pigmentation
o Shininess
o Redness
o Skin changes
 Dimpling (Increases on bending)
 Puckering
 Peau d’orange
 Retraction ( Schirrous Ca Breast)
 Fungation / Ulceration
 Lump
o Position: (Quadrant)
o Number, Size & Shape
o Extent
o Surface & Edges
o Pulsations
o Skin over swelling
 Ulcer
o Position / Site
o Number, Size & Shape
o Extent
o Margins Edges & Floor
o Discharge & surrounding tissue
Edema of Arms:
Inspection of Axilla and Supraclavicular fossa for nodes:

Palpation: ( palpate by palmar surface of fingers quadrant wise including axillary tail of
spence and behind nipple)
Examination of Normal Breast: palpate all 4 quadrants (firm, lobulated, nodular)
Examination of affected Breast:
 Temperature & Tenderness
  Lump
o Number
o Position and extent (Quadrant)
o Size and Shape
o Surface, Margins
o Consistency
o Mobility
o Fixity to
 Skin
 Breast tissue
 Chest wall
 Pectoralis Major
 Serratus Anterior
o Fluctuation (if cystic in consistency)
o Trans-illumination test ( If Fluctuation +)

 Nipple
o Retraction
o Retro nipple mass
o Discharge Expression
 Ulcer:
Tenderness
Size, Depth
Edge, Margins, Base
Bleeding /Discharge
Relation to deeper structure
Mobility
Surrounding skin

Examination of Lymph nodes of both sides: (Axillary, Supra/Infraclavicular)

Examination of arm:

Systemic Examination:

CVS:
RS: altered breath sounds, features of consolidation or pleural effusion
PA: palpable nodular liver, Krukenberg tumours in ovaries in menstruating age group, and ascites
PR / PV examination:
CNS: neurological deficits

Differential Diagnosis:
 Carcinoma of Breast Differentials
1. Fibroadenosis. 6. Mastitis.
2. Traumatic fat necrosis 7. Antibioma.
3. Tuberculosis of breast. 8. Galactocoele
4. Bloodgood cyst 9. Mondor’s disease
5. Filariasis breast. 10.Cystosarcoma phylliodes
.
 Cystic swellings . Massive enlargement
• Bloodgood cyst • Benign hypertrophy usually
• Breast abscess bilateral
• Hydatid cyst • Giant fibroadenoma (> 5 cm)
• Galactocele • Serocystic disease of Brodie
• Serocystic disease of Brodie • Sarcoma
• Cystic necrosis in carcinoma breast • Carcinoma often when
• Lymph cyst extensively involved
• Haematoma in breast • Filariasis of breast.

Hard swellings
.
• Carcinoma breast
• Antibioma breast
• Traumatic fat necrosis
• Calcified haematoma
• Fibroadenoma—hard variety

DIAGNOSIS:
Complete diagnosis with side and staging should be given/written in case sheet.
TNM staging is used.
MANAGEMENT:
Diagnostic Work up: Age, History
Clinical
SIgns & Symptoms

<40 years - USG

Tripple assesment Imaging
>40 years -
MAMMOGRAM
FNAC
Tissue Diagnosis
Biopsy - CoreCut

STAGING WORK UP:

 Clinical Examination
 Mammogram on both sides
 USG abdomen
 Chest X-Ray
 Liver Function Tests
 Bone Scan
 Histo pathology
 ER & PR status
 HER2 status
 Lymph node status
Management of Early Breast Cancer
USG

BREAST CONSERVATIVE
SURGERY
interpretation

NO
YES Collagen vascular disease
Lump <4cm pt not willing for surgery
Clinically -ve node
+ve Axillary nodes
Mammogram lesions
Well differentiated with high s-phase
low s-phase
feasibility of axillary multicentricity
dissection
tumor beneath nipple

increased tumor breast ratio

BCS

yes no

SLNB MRM

Negative Positive Post op. RT

Breast & Chest/ Axilla

post op. RTto Axillary node

HT
breast & Chest dissection
wall
post op. RT to
Followup
breast & Chest
wall
 BCS

Adequate disese Positive margin

free margin non tumor free

Re-excision
>4 node <4 node
with 1cm
positive positive
margin

RT to breast &
Chemotherapy
chest wall

RT to
breast & Chemotherapy
chestwall

Followup RT
LFTs
USG abdomen
Bone scan

HT &
Follow up

MANAGEMENT OF LOCALLY ADVANCED CA. BREAST

FNAC of LN

Operable Inoperable

Simple / Total Multimodality

Mastectomy systemic therapy
with axillary
dissection

Neo adjuvent
CT
Post OP. RT to (CAF-
breast flap 3cycles)
and axilla

Complete/ No response
Partial progressive
Combination response disease
Chemotherapy (>25%)

BCS with RT
HT for Total mastectomy Operable Inoperable
receptor MRM
positive

Salvage RT
BCS surgery Chest , Breast
Follow up MRM Axilla

Follow up
(depending HT
on margins)

2nd line
chemo
therapy
 THYROID
Name:
Age:
<20 – 40 years >40 years
 SNT MNG
 Colloid Goitre Hashimotos
 Pappilary carcinoma thyroid Follicular Carcinoma
 Primary thyrotoxicosis Anaplastic

Address: Chikkamagalur and coorg IDG endemic

Sex: Thyroid disease 8 times & Ca 3 times more common in females
Occupation:

Chief Complaints:
Swelling
Pain (Haemorrhage, Infiltration of nerves, Thyroiditis, Anaplastic Ca.)
Alteration in voice
Bulging of eyes
Tremors / Involuntary movements
Palpitation
Increased appetite with weight loss
Diarrhoea ( Medullary Ca.)
Generalised weakness
Easy fatiguability
Genaralised increase in sweating

History of Presenting Illness

Pain: ( SOCRATES) ( Whether Pain appeared first or swelling)
Dull aching from start of swelling : Thyroiditis
Sudden onset pricking type of pain that appeared later: Haemorrhage
Dull aching, long standing , appeared later: Malignancy

Whether Swelling or Thyroid symptoms appeared first?

Symptoms precedes swelling : Graves disease
Swelling precedes Symptoms: Plummers Disease

Pressure Symptoms: ( due to Infiltration )

Difficulty in breathing and swallowing ( on trachea & oesophagus)
Altered voice (on RLN)
h/s/o Horners syndrome (on cervical sympathetic chain)
Stridor, Haemoptysis (Laryngotracheal complex)
Berry’s sign (on carotid sheath)
Syncope (on Carotid body)
Cranial nerve and Brachial plexus symptoms
Thyrotoxicosis
Increased appetite (10&20) Weight loss (10&20)
Heat loss Heat intolerance (10&20)
Amenorrhea Exertional Breathlessness
0
Nervousness (1 ) Irritability & Behavioural change (10)
Insomnia (10) Tremors (10)
muscle weakness (10) muscle wasting
Cold tolerance Increased sweating (10&20)
Diarrhoea (10&20) Difficulty in closing eyes
0
Eyes: (1 )
 Bulging – duration, progression
 Redness
 Watering
 Double vision
 Loss of vision
h/o anti-Thyroid drugs
h/o secondary thyrotoxicosis
Palpitation Ectopic beats
Arrythmias Exertional dyspnoea
Chest pain Ankle edema
CCF

Hypothyroidism
Weakness poor appetite > Weight gain
Obesity (back & shoulder) Fatigue & lethargy
Swelling- face n whole body Cold intolerance
Loss of scalp hair constipation
Hoarseness of voice Dry inelastic skin
Macroglossia Patchy pigmentation of skin
Mask like face(dull expression) Failing memory
Menorrhagia followed by amenorrhea ( due to anemia)

Symptoms of Retro sternal Extension

Noctournal dyspnoea Dysphagia
Postural cough on lying down Haemoptysis
Dilated veins over chest and neck

History of Metastasis
Symptoms suggestive of Hornors syndrome
Bony pain / swelling
Chest- cough dyspnoea haemoptysis
Brain- seizures vomiting
Significant weight loss & loss of appetite
  Past History:
 Exposure to radiation ( papillary carcinoma)
 Ionising ( Rx of Tinea capitis, Adenoids, Hodgkins, Hemangioma
etc. )
 Radio Iodine
 H/o previous thyroid swelling (Thyroglossal Cyst)
 H/o Malignancy
 H/o Thyroid surgeries in past ( thyroglossal fistula in TGC Sx)
 h/o DM, HTN, IHD, Asthma,

Personal History:
 Appetite: ( increased in thyrotoxicosis & vice versa)
 Diet:
o Consuming Brassica family vegetables
o Water rich in fluorine
o Type of salt
o Sea fish deficient of iodine
 Bowel & Bladder: Constipation in Hypo & Diarrhoea in Hyper )
 Sleep: insomnia in Hyperthyroidism
 Habits

Menstrual History
 Age at menarche
 Cycles Oligomenorrhea in Hyperthyroidism
 Duration Menorrhagea in Hypothyroidism
 Flow
 Clots

Family History
 H/o any Thyroid disease in family
 Dysharmonogenesis, Medullary Ca. Thyroid, Primary thyrotoxicosis
 H/o infertility in family ( altered thyroid function)

Drug History:
 Eroxin
 Antithyroid drugs
 Beta blockers
 Sulfonyl ureas
 Methyl DOPA
 T3 T4 TSH Followup

Allergy History:
 GENERAL PHYSICAL EXAMINATION
Built & Nourishment
Hyperthyroidism: lean & anxious
Hypothyroidism: Obese, sluggish & Over weight
Malignancy : Cachexia Anemia

Head to Toe Examination:

Hair
Madarosis
Eye signs
Pretibial edema
Warm , Moist hands
Sweatiness
Shaky hands
Facies :
Hypothyroidism: Moon facies, Expression less , mask like , puffy
Hyperthyroidism: staring, excited, irritable, nervous , tense face
IQ (low)
Oral cavity (tremors , lingual thyroid)
Gait
Hyperthyroidism: slow lethargic
Hyperthyroidism; Rapid gait
Assessment of voice:
Pitch :
Ability to alter rapidity of speech
Breathing support during speech
Indirect Laryngoscopy
Position of vocal cord
Increased thickness
Sluggish movement
(say ‘E’ to demonstrate vocal cor movement)
One side medialisation – Hoarseness
Both sides medialisation – Stridor

Pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy, Edema

Vitals:
 Pulse:
Rate – Tachycardia in Toxicosis
Rhythm – regular/regularly/irregularly irregular ( ectopics)
Character Pulsus paradoxus or corrigans pulse
Volume – High volume in Toxicosis
Condition of vessel wall
Radio-radial/radio-femoral delay
  BP: (position and limb in which BP is measured) (HTN in Toxicosis)
 RR:
Crile’s grading of sleeping pulse
 Sleeping Pulse rate: Mild - 90-100 bpm
Consent taken Moderate - 100-110 bpm
3 consecutive night readings Severe - >110 bpm
Done in late nights towards early mornings
 Temperature:

LOCAL EXAMINATION
 Position of Patient: Patient was examined in sitting position with neck
flexed slightly and patient examined from front
 Exposure:
 Position of Examiner wrt. Patient:
 Light source

Inspection:
 Movement with deglutition
 Swelling:
 Number
 Situation: sides or centre in neck
 Size
 Shape
 Butterfly – diffuse goitre
 Hemispherical/globular in Solitary Nodular Goitre
 Extent ( in diffuse swelling, describe 4 direction extent of each lobe
and upper and lower border of isthmus
 Surface
 Nodular – MNG
 Irregular – Anaplastic Ca.
 Smooth – SNT
 Borders ( generally well defined)
 Skin over swelling:
 Scars ( previous surgeries)
 Pigmentation
 Venous prominence over gland and neck
 Pulsatile – thyrotoxicosis
 Movement with protrusion of tongue
 Trail’s sign- prominence of SCM on side of deviation of trachea
 Pemberton sign ( if lower border not visible)
o Raise both arm over head, until they touch the ears
o Maintain the position for a while
o Congestion of face and distress occurs due to obstruction of great veins of
thorax
Palpation:
Patient sitting comfortably. palpate with neck partially flexed , examiner being behind the
patient. Examine with thumb placed on cervical spine and palpate with remaining fingers
anteriorly to feel the gland both lateral lobes and isthmus for all features.. Additional
information about lobe is obtained by relaxing SCM of that side by flexing and rotating
face to same side.

Other methods
Crile’s method of palpation of gland: It is the palpation of the nodule/swelling in front
using the pulp of the thumb.
Lahey’s method
To palpate right lobe push the right lobe with right hand to right side and palpate with left
hand
Pizzilo’s method
In case of obese and short necked individuals
Ask the patient to keep the hands behind the head and ask to push head backwards against
clasped hand on occiput

 Palpate for Isthmus in midline against Trachea ( normally not palpable)

 Temperature over swelling: ( warm in toxic, malignancy, thyroiditis)
 Tenderness ( tumour necrosis, Haemorrhage, Thyroiditis)

Swelling:
 Extent, position & shape
 Palpate the lower border:
 Size vertical and horizontal measurement
 Surface :
 Smooth - Colloid goitre, Grave’s disease
 Bosselated - Multinodular goitre
 Consistency :
 Soft - Colloid goitre, Graves disease
 Firm - SNG, MNG
 Hard - Carcinoma, Riedel’s thyroiditis
 Margins
 Fixity to skin
 Mobility : Restricted in malignancy and chronic thyroiditis
 Plane of swelling
*Stretching of neck: deep fascia stretches and swelling becomes less
prominent
*Chin Compression against resistance: both SCM become prominent
*SCM contraction- turn neck to one side against resistance
*Strap muscles : ask patient to hold tongue against palate and deglute
  Palpate for thrill
 Measurement of circumference of the neck at regular intervals is important if
patient is not undergoing surgery to assess the increase in size of the thyroid.

 Position of trachea and larynx

 Pressure effects:
 Trachea - Kocher’s test
Patient is asked to see straight. With fingers and thumb both lateral lobes of
the thyroid gland are gently compressed directing posteromedially. If patient
develops stridor-Kocher’s test is positive. If patient develops no stridor, it
means test is negative

In long standing cases Trachea is kept patent because of forward traction by goitre
itself. But after thyroidectomy lack of support to trachea cause tracheomalacia—
weakening of the tracheal rings. Such patients need tracheostomy after thyroidectomy.
It is usually temporary tracheostomy for 2-3 weeks, by then tracheal rings regain their
strength to maintain the patency of the trachea. ’Scabbard trachea’ is narrowing of
trachea
 Carotid artery - Carotid sheath is pushed back by benign swelling where
carotid pulsations felt.\

Normally carotid pulse is felt at the level of the upper border of thyroid cartilage over
medial aspect of the sternomastoid muscle on the Chaissagne tubercle (carotid tubercle)
on the transverse process of C6 vertebra. It may be deviated posteriorly/laterally in a
large goitre. It may be absent in advanced carcinoma thyroid due to infiltration of the
carotid sheath by the tumour (Berry’s sign).

 Sympathetic trunk - Horners syndrome

 Enophthalmos
 Miosis
 Anhidrosis
 Ptosis

PERCUSSION:
Over manubrium to Rule out Retrosternal extension.
Moses sign: pain on direct percussion over sternum in leukaemia

AUSCULTATION:
Any audible bruits near upper pole
Examination of Cervical Lymph Nodes: (level III, IV, V & VI)
It is common in papillary carcinoma of thyroid. It is usually in level III & IV nodes. It
could be firm, hard or cystic. It is usually brownish black in colour often with papillary
projections. Lymph nodes often can get enlarged in follicular carcinoma thyroid and
lymphoma.

Examination for Primary Thyrotoxicosis:

 Pulse
 Tachycardia
 Tremors
 Warm Moist skin
 Thyroid bruit
 Eye Signs
a. Lid retraction: Overactivity of sympathetic part of levator palpebrae
superioris (Muller’s muscle)
b. Exophthalmos.
i. Naffziger’s test: Go behind the patient, extend the neck, see through
the supraciliary ridge, you can diagnose exophthalmos.
ii. Gifford’s test: Test to differentiate exophthalmos from proptosis
(where pathology is behind the eyeball)
iii. Evert the upper eyelid. Impossible to do it in exophthalmos due to
Muller’s
iv. muscle hyperactivity. This test is possible in proptosis.
v. Stellwag’s sign - Starring look with infrequent blinking and wide
palpebral fissures.
vi. von Graefe’s sign - Lid lag sign. Tested by asking the patient to look
up and down many times fixing the head, you can see the upper lid lags
behind.
vii. Joffroy’s sign - Absence of wrinkling of forehead. The patient looks
the roof of the room without forehead wrinkling.
viii. Dalrymple’s - Visible upper sclera due to lid retraction.
ix. MÖbius sign - Inability to converge the eyeball.
x. Jellinek’s sign - Increased pigmentation of eyelids.
c. Ophthalmoplegia (malignant exophthalmos)
– Weakness of ocular muscles due to edema and cellular infiltration of these
muscles.
– Paralysis of superior rectus, inferior oblique and lateral rectus.
– On paralysis of these muscles, patient is unable to look upwards and outwards.
d. Chemosis: conjunctiva edematous, thickened ,
Examination for secondary Thyrotoxicosis:
Complication of multinodular goiter and adenoma.
Signs of cardiac failure:
•• Edema of ankles
•• Orthopnoea
•• Dyspnoea
•• Eye signs
Only lid lag and lid retraction can be seen
•• No tremor
•• No exophthalmos

SIGNS OF HYPOTHYROIDISM
•• Obese
•• Dry inelastic skin
•• Macroglossia
•• Mask like facies
•• Loss of hair in lateral eyebrow
•• Hoarseness of voice
•• Pseudomyotonic reflex (delayed ankle jerk); also called ‘hung up’ reflex.

Involvement of sympathetic chain: Horners syndrome

Systemic Examination:

Cardiovascular system - Secondary thyrotoxicosis

RS - To find secondary deposits
Abdomen - In lymphoma of thyroid, other lymphoid organs in abdomen may be involved.
CNS: Myopathy Neuropathy
Musculoskeletal System: Spinal tenderness, Pulsatile metastasis to skull & ribs
Oral cavity - Look for lingual thyroid, macroglossia, tremor of tongue.

Diagnosis:
Anatomical diagnosis : MNG/SNG/Diffuse
Functional diagnosis : Toxic/Euthyroid/Hypothyroid
Pathological diagnosis : Benign/Malignant
 PERIPHERAL VASCULAR DISEASE

Name:
Age: TAO - <50 years
Atherosclerosis - Old age
Raynold’s - Young age
Diabetic arteriopathy - Middle age
Sex:
TAO – Common in Males
Raynold’s - Common in women
Occupation:
Address:

CHIEF COMPLAINTS
 Pain
 Blackish Discolouration of toes / feet
 Ulcer

HISTORY OF PRESENTING ILLNESS:

1. Pain:
i. Site : initially in calf later in foot( gangrene changes)
ii. Character : Cramp like in calf and burning type (gangrene changes) in
foot
iii. Intermittent Claudication: distance of walking at which pain onsets (
previous and present distance is noted)
iv. Claudication distance: Distance at which pain compels him to take
rest from walking
v. Radiation:
vi. Aggravating factors:
vii. Relieving factors: (arterial disease pain do not relieve on medication)
viii. Presence of rest pain—its location/severity/whether the pain gets
relieved a little bit by holding the limb/foot/leg/toes (pain slightly
lessens probably by transmission of temperature from holding hand
into the part) or hanging the leg down or by applying the Warmth
ix. Progress of claudication:
x. Effect of heat and cold on pain
1. TAO - warmth increase symptoms
2. Raynold’s - symptoms increases on exposure to cold

2. BLACKISH DISCOLOURATION:
i. History of trauma
ii. Site
iii. Onset
1. Atherosclerosis/Buerger’s disease - spontaneous and gradual
progression.
 2. Embolism - sudden in onset, rapidly progressive with radiating
severe pain along the artery.
3. Diabetic - from trauma
iv. Progression ( initially tip of toes & progressed to whole toe/foot)
v. Extent of discolouration
vi. Associated with pain??

3. Ulceration
i. Whether precipitated by trauma/spontaneously.
ii. Pain in the ulcer/type/duration/aggravating or relieving factors.
iii. Discharge-type—serous-purulent-bloody.
iv. Progression.

4. History of colour changes in limb

5. Limitation of walking—as the result of muscle pain is an important complaint.
6. History of suggestive of superficial thrombophlebitis (30% TAO is associated)
i. Pain, swelling along course of superficial veins of lower limb
ii. Discolouration along course of superficial veins of lower limb
7. History suggestive of TIA
i. Syncope, Blackouts
ii. Transient loss of consciousness, fainting
iii. Blurred vision
8. History suggestive of Mesenttric ischaemia
i. Abdominal pain ( after having food)
ii. Bloody diarrhoea
9. History suggestive of Angina
i. Exertional chest pain, Palpitations
10.History of tingling/numbness/weakness in the limbs/pins and needles sensation in
the skin of foot and leg paraesthesia due to shunting of cutaneous blood to deeper
muscles
11.History of Impotence: Its duration has to be asked [due to bilateral internal iliac
artery (aortoiliac) block (Leriche syndrome)—present with pain in buttock].
12.History of distal Neurological deficit
13.History of haemoptysis, breathlessness ( Pulmonary Embolism)
14.History of Haematuria ( Renal Infarct)
15.History of repeated episodes or cyclic episodes of pain, paleness, bluish
discoloration, dusk red colouration, associated with tingling, numbness, burning
sensation on exposure to cold ( Raynolds phenomenon)
16.History of edema pigmentation or ulceration around ankle (venous diseases)

PAST HISTORY:
1. Similar history earlier.
2. History of drug intake earlier for similar conditions like vasodilators/drugs to increase
the perfusion.
3. History of earlier surgery like sympathectomy/ omentoplasty/their results or effects.
 4. History of exposure to cold
5. History of earlier cardiac illness( AF > embolism)
6. History of DM, HTN, Hypercholestrolemia, Collagen diseases

PERSONAL HISTORY:

 Appetite
 Diet
 Bowel and Bladder:
 Sleep
 Habits

Family History:
 History of Atherosclerosis
 History of Impotence

Treatment/Drug History:
 Drug treatment to relieve pain
 Previous surgical treatment already done ( amputation)

Allergy History:

General Physical Examination:

Here is a ____ year old ____ patient, _______ built and nourished and ____ co-operative.

Pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy, Edema

Vitals:
 Pulse: (rate, rhythm, character, volume, condition of vessel wall
radio-radial/radio-femoral delay)
 BP: (position and limb in which BP is measured)( in all 4 limbs)
 RR:
 Temperature:
Head to toe Examination:
o Signs of CCF
 JVP
 Pedal edema
 Hepatomegaly
 Ascitis
o Visual defects- loss of temporal field vision due to atherosclerosis of vessels

LOCAL EXAMINATION:
o Position of Patient:
Patient examined in lying position with outstretched legs
o Exposure:
o Position of Examiner wrt. Patient:
o Light source:
INSPECTION: ( keep both limbs side by side)

1. Attitude of limb
2. Any bony deformity
3. Any muscle wasting in thigh, calf or foot
4. Condition of veins:
i. Whether normally filled veins in both limbs
ii. Any discolouration along veins
iii. Guttering of veins
5. Signs of peripheral ischemia
i. Thinning of skin
ii. Diminished hair
iii. Lose of subcutaneous fat
iv. shininess
v. Trophic changes in nail: Brittle nails transverse ridges develop
vi. Minor ulcerations in pressure areas
( heel, malleoli, tip of toes, ball of foot 5th metatarsal head)
vii. Gangrenous changes
6. Colour of limb:
i. Minor changes in colour is noticed by comparing both legs
ii. Major or marked pallor in sudden arterial obstruction like embolism or
sudden spasm as in raynold’s disease
iii. Congestion & bluish cyanosed in ischaemia with pregangrenous
features, develops pallor on limb elevation
7. Gangrene
i. Site
ii. Extent
iii. Type of gangrene – dry(mummified) or wet(putrifying, oedematous)
iv. Line of demarcation
1. level &depth ( between gangrene tissue and viable tissue)
2. well defined in dry gangrene
3. ill defined and unclear in wet gangrene.
v. Colour of gangrenous area –
1. Black/purple/greenish black
2. Reddish black [in gas gangrene (H2S)]
vi. Discharge from area
vii. Odour of discharge from gangrenous area .
8. Observe limb above gangrenous area
i. Pale, congested, edematous
ii. Black patches – skip lesions
iii. Pre-gangrenous area ( ROHIT)
1. Rest pain
2. Oedema
3. Hyperesthesia
4. Ischaemic ulcer
5. Temperature and colour changes
 PALPATION:
 Skin temperature: over affected limb ( warm / cold)
 Level of equalization of temperature:
 Palpate with dorsum of hand from dorsum of foot upwards and find the
level at which the temperature becomes normal comparing with normal
area temperature of patients opposite limb.
 Tenderness
 Site extend and severity should be noted
 Palpation of gangrene and adjacent area:
Gangrene Pregangrenous area Adjacent limb
1. Site and Extent
2. Sensation
3. Tenderness
4. Local crepitations
5. Edema (pitting/non pitting)

Special Tests for Assessment of Circulatory Insufficiency

1. BUERGER’S test:
Test carried out in daylight, Patient lies supine, Raise the legs one after other with knees
extended
Normal limb: Remain pink even when raised to 90°
Look for: * Onset of pallor
* Guttering of veins
 Angle at which pallor appears is Buerger’s angle of circulatory insufficiency
 Less than 30° implies severe ischemia
 If foot does not become pale or when doubtful, repeated ankle flexion and extension is
done to point of fatigue.
 In occlusive arterial disease sole of foot becomes pale (cadaveric pallor)
with empty-guttered veins on the dorsum of foot
 Cyanotic congestion appears after lowering the foot in 3 minutes.

2. CAPILLARY REFILLING:
Inspection:
Elevate limb for a while.
Ask the patient to sit and hang his legs down the bed
Normal limb: pink in elevated as well as in dependent position
Ischaemic limb: becomes pale on elevation & gradually becomes purple-red and then
pink in more than 20 seconds. Purple-red colour is due to deoxygenated blood.
Prolonged capillary filling time signifies severe ischemia.

Palpation:
Tip of the nail or pulp of the finger or toe is pressed to blanch it and pressure is released
(in 2 seconds) to make it pink again. Time taken for blanched area to turn pink is capillary
refilling time.
It is prolonged in ischaemic limb
3. VENOUS REFILLING
Inspection:
After keeping the limb elevated for a while if it is laid flat on the bed, there will
be normal refilling of veins within 5 seconds; but in ischemic limbs it will be
delayed.
Palpation: Harvey’s venous refilling test:
 Two index fingers are placed over the vein and pressure is applied over it.
Proximal finger is moved for about 5 cm proximally without releasing the
pressure.
 Vein between the fingers gets emptied completely and becomes flat.
 Distal fingeris now released to see the flow of the blood and its refilling is
observed,
 whether good or poor.
 It is poor in ischaemic limb.

4. Crossed leg test (Fuchsig’s test):

 Indirect test for assessment of presence of popliteal pulse.
 Patient is asked to sit with the legs crossed one above the other so that the
popliteal fossa of one leg will lie against the knee of other leg.
 Oscillatory movements of foot can be observed synchronous with the
popliteal artery pulsation.
 If the popliteal artery is blocked oscillatory movements will be absent

5. COLD AND WARM WATER TEST

To provoke angiospasm in Raynold’s phenomenon
Patient is asked to dip his hand into
Ice cold water - hand becomes white
Warm water - blue due to cyanotic congestion

6. MOVEMENTS OF JOINTS & LIMB ADJACENT TO GANGRENOUS AREA

Movements of a. interphalyngeal joints
b. mid tarsal joint
c. ankle joint
d. knee joint
e. hip joint

7. EXAMINATION OF NERVE LESIONS IN LOWER LIMB:

Sensory Motor
• Crude touch/fine touch • Tone
• Pain sensation • Power of muscles
• Temperature sensation • Ankle flexion/extension
• Reflexes • Knee flexion/extension
• Plantar response

“On the borderline of gangrene, skin is hyperesthetic”

8. Examination of Regional lymph nodes ( Inguinal)

9. PALPATION OF PERIPHERAL PULSUS:
(++ normal , + palpable but feeble, - not palpable)
Pulse Right Left
1. Dorsalis pedis
2. Posterior tibial
3. Anterior tibial
4. Popliteal
5. Femoral
6. Radial
7. Ulnar
8. Brachial
9. Axillary
10. Subclavian
11. Carotid
12.Superficial temporal
 Condition of arterial wall ( Atherosclerosis )
 Tenderness
 Auscultation along major arteries for Bruit over major arteries.
 Carotid: along anterior border of SCM at level of thyroid cartilage
 Abdominal Aorta: Midline , 4 cm above transpyloric line extends to a point
2cm below and left to umbilicus ( upto L4)
 Ileac: L4 to a point midway between ASIS and pubic symphysis
 Coeliac: 4cm above transpyloric plane
 Superior mesenteric: 2cm above transpyloric plane

Palpation of various pulse:

1. Dorsalis pedis artery is felt just lateral to the extensor hallucis longus tendon at the proximal end
of first web space, felt against the navicular and middle cuneiform bones. It is absent in 10%
cases.
2. Posterior tibial artery is felt against the calcaneus just behind the medial malleolus midway
between it and tendo-Achilles.
3. Anterior tibial artery is felt in the midway anteriorly between the two malleoli against the lower
end of tibia just above the ankle joint lateral to extensor hallucis longus tendon.
4. Popliteal artery
 Supine: Flexing knee 40°, heel over bed; with thumbs over tibial tuberosity; other
fingers are moved sideways to palpate popliteal artery over the posterior aspect of tibial
condyles.
 Prone (knee flexed): Popliteal pulse felt over the posterior surface of lower end of
femur.
 Fuschig’s test: Crossed legs on sitting, inspect the oscillatory movements sitting on
chair

5. Femoral artery in the groin is felt just below the inguinal ligament midway between anterior
superior iliac spine and pubic symphysis (midinguinal point). Often hip has to be flexed for about
10-15° to feel it properly.
6. Radial artery is felt at the wrist on the lateral aspect against lower end of the front of radius.
7. Ulnar artery is felt at the wrist on the medial end against lower end of the front of ulna.
8. Brachial artery is felt in front of the elbow just medial to biceps brachii tendon.
9. Axillary artery is felt in lateral aspect of the axilla against upper end of the shaft of the humerus
with raised and elevated arm.
10. Subclavian artery is felt against first rib just above the middle of the clavicle in supraclavicular
fossa while patient is lifting the shoulder to relax deep fascia.
 11. Common carotid artery is felt medial to sternomastoid muscle at the level of thyroid cartilage
against carotid tubercle (Chaissagne tubercle) of transverse process of 6th cervical vertebra (in
carotid triangle).
12. Facial artery is felt against body of mandible at the insertion of masseter.
13. Superficial temporal artery is felt just in front of the tragus of the ear against zygomatic bone.

Diagnosis:

Peripheral Arterial Occlusive Disease affecting Right / Left limb with/without complication of gangrene
in the _____( site) or ischaemic ulcer over ____(site) due to obstruction at ______ level/segment
probably due to
 Buerger’s Disease
 Atherosclerotic Vascular Disease

Management:
Investigations:

Blood Investigations
•• Blood sugar and urine sugar
•• Lipid profile (LDL, HDL, TG, total cholesterol)
•• Anemia and conditions causing high blood viscosity (polycythemia and thrombocythemia)
•• ESR
•• Plasma fibrinogen
•• Serum creatinine (hypertension)—to give contrast agents
•• Coagulation profile: Prothombin time, bleeding and clotting time.
cardiovascular system assessment
X-ray Chest
ECG
Echocardiogram
Ankle-brachial pressure index (ABPI)
𝐻𝑖𝑔ℎ𝑒𝑟 𝑟𝑖𝑔ℎ𝑡 𝐴𝑛𝑘𝑙𝑒 𝑝𝑟𝑒𝑠𝑠𝑢𝑟𝑒 (𝐷𝑃/𝑃𝑇)
𝑹𝒊𝒈𝒉𝒕 𝑨𝑩𝑷𝑰 =
𝐻𝑖𝑔ℎ𝑒𝑠𝑡 𝑏𝑟𝑎𝑐ℎ𝑖𝑎𝑙 𝑎𝑟𝑡𝑒𝑟𝑦 𝑝𝑟𝑒𝑠𝑠𝑢𝑟𝑒 (𝑅/𝐿)

Normal : 0.9–1.2

Exercise Tests (Increases Ankle Pressure)

•• ‘To evaluate asymptomatic lesions’
•• ‘During exercise increased blood flow to muscle leads to fall in ankle pressure in the presence
of arterial disease’
•• Exercise protocol: Walk on treadmill 3.5 km/hr for 5 minutes ABPI is measured again, fall
in ABPI is indicative of degree of ischemia.

Angiography (Gold standard for lower limb assessment)

DSA ( Digital Subtraction Angiography)

Noninvasive Vascular Assessments

 Hand held Doppler
 Duplex scanCT angiogram
 MRA ( Magnetic Resonant Angiogram)
 Contra
indications for
MRI

Electrical Metallic Metallic

implanted devices at fragments in General state:
device risk in field eyes Cardiac failure
1st & 2nd
trimester
pregnancy
cardiac pacemaker claustrophobia
Aneurysm clips Foreign body
electrical stimulator Heart valves fragment
cochlear implant

 U/S Abdomen
 Plain X-Ray of the part
Transcutaneous oximetry

Treatment Options for Peripheral Vascular Disease

Conservative
Medical
Surgical—minimally invasive and open.

Modify the Risk Factors

•• Smoking: To be stopped
•• Diabetes control: Maintain normal blood sugar
•• Hypertension and heart disease corrected
•• Correct hyperlipidemia: LDL < 100 mg/dL: By giving statins
•• Obesity—weight reduction
•• Hyperhomocysteinemia > 5 mmol/L must be considered for treatment Vitamin B12 and folic acid
•• Exercise programs: 1 hour/day; 1 to 3 times weekly for 6 months.

Medical:
Established drugs with proven but small benefit in improving claudication:
•• Pentoxifylline : Improves red cell deformability, lowers serum fibrinogen, reduces platelet aggregation
No definite evidence to show it is better than placebo.
•• Naftidrofuryl : 5-hydroxytryptamine antagonist
Reduces platelet aggregation
•• Cilostazol : Phosphodiesterase III inhibitor
Antiplatelet and vasodilator activity

Established drugs with minimal or no benefit in improving claudication:

•• Aspirin : Low dose aspirin still remains the mainstay of therapy Inhibits the cyclo-oxygenase
Thereby decreases ADP release and platelet aggregation
•• Dipyridamole : Along with aspirin
Reduces stroke rate in atherosclerotic disease
•• Clopidogrel : GP2b3a inhibitor
Prevents platelet aggregation

Surgery : ANGIOPLASTY
 VARICOSE VEINS
Name:
Age:
Sex: more common in females 10:1
Address:
Occupation: More common in jobs having prolonged standing,
e.g.policeman, petrol bunk workers, tram drivers, etc.

Chief Complaints: Varicosity is seen in:

 Asymptomatic in 50% cases •• Lower limb
 Pain •• Esophageal varices
 Postural discomfort •• Hemorrhoids
•• Varicocele testis
 Swellings (Appearance of varicosity) in leg •• Vulval varices
 Ulcers •• Ovarian varices
 Pigmentation •• Gastric varices

History of Presenting Illness

Pain:
 Site : along the line of the vein is typical
 Onset :
 Duration:
 Character:
 dragging type in calf. Feeling of heaviness is common
 Bursting type of pain while walking (Deep vein thrombosis)
 Aggravating or Relieving factors: usually aggravates in the evening and gets
relieved by lying down.
 Pain in calf of short duration, may be due to coexisting deep vein thrombosis
Swelling: ( multiple swellings or varicosities}
 Site : along the line of the vein is typical
 Medial side of Lower limb: Large Saphenous System
 Lateral side of Lower limb: Small Saphenous System
 Onset :
 Duration:
 Aggravating or Relieving factors:
 History of swelling around ankle: (edema )(all routine history about swelling)
 duration;
 Diurnal variation:
 Postural variation: relation to work/standing/ lying down should be noted.
History suggestive of difficulty/altered gait due to pain/swelling/deformity
Pigmentation
• It is due to stasis and release of chemicals and usually occurs around ankle region.
• It is associated with itching and often ulceration.
Ulcer
 Onset
 Duration
 Site
 on the medial aspect of the ankle is due to long saphenous vein varicosity;
  on the lateral aspect is due to short saphenous vein varicosity.
 Discharge from ulcer—its type, smell, quantity signifies the severity of the infection.
 Itching and bleeding in the ulcer bed
 History of Trauma
 History of bleeding from the vein/ulcer
 History of urinary/bowel symptoms.
 Constipation
 Blood tinged stools
 Burning micturition
 Frequent micturition/ urgency
 History of abdominal distention, ascites
 History of lump or pain in abdomen
(Abdominal mass/pregnancy may compress IVC/iliac veins and cause bilateral varicose
veins)
 History of similar complaints on the other leg—Varicose veins are often bilateral.

Past history:
 History of prolonged immobilization ( Hospitalization)
 History of similar complaints
 History suggestive of earlier deep vein thrombosis like pain, calf swelling and fever
should be noted.
 History of any previous surgery
 H/o DM, HTN, IHD, Asthma,

Personal History:
 Appetite:
 Diet:
 Bowel & Bladder:
 Sleep:
 Habits
Pregnancy history in females is important
 delivery
 postdelivery period
 oral contraceptive intake

Family History
• Similar history in the family. Inheritance with FOXC2 gene.

Drug history:
 OCPs
 Allergic History
GENERAL PHYSICAL EXAMINATION:

Here is a ____ year old ____ patient, _______ built and nourished and ____ co-operative.

Pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy, Edema

Vitals:
• Pulse: (rate, rhythm, character, volume, condition of vessel wall
radio-radial/radio-femoral delay)
• BP: (position and limb in which BP is measured)
• RR:
• Temperature:

LOCAL EXAMINATION
o Position of Patient: standing position, for some tests patient
asked to lie down
o Exposure: below thigh
o Position of Examiner wrt. Patient:
o Light source: daylight is best
INSPECTION:
 Dilated, elongated, tortous veins on
 Medial side : long saphenous vein
 Posterior /lateral side : short saphenous vein.

 Swelling of the leg:

 Localized ( calf / foot/ thigh) : superficial system is involved
 Generalized : may be DVT

 Skin Changes:
 Pigmentation
 Edema
 Ankle flare
 Ulcer
1. Site :
i. Medial malleolus : LSV involved
ii. Lateral malleolus : SSV involved
2. Size & shape: Vertically oval varicose ulcer
3. Extent:
4. Floor
5. Margin & edges
6. Discharges
7. surrounding area
 Impending gangrene changes
1. Scars
2. Loss of hair
3. Brittleness of nail
 Scratch marks ( itching due to haemosiderin)
 Deformity : Talipes equinovarus
  Morrissey’s Cough Impulse test:
The varicose veins are emptied by elevating the leg in lying down position. Then the
patient is asked to cough. If there is saphenofemoral incompe tence, expansile impulse is
seen at saphenous opening - saphena varix.

PALPATION:
Examine the lower limb for:
 Temperature & Tenderness
 Thickening of skin
 Pitting edema
 Redness
 Lipodermatosclerosis
 Varicose venous ulcer: (describe ulcer)

Special tests: Saphenous opening:

•• Just 4 cm below and lateral to the public
Morrissey’s cough impulse: ( lying position) tubercle
•• Closed by cribriform fascia and forms the
• Limb is elevated to empty the veins and the lower boundary of femoral canal
limb is then put to bed and the patient is •• Saphenofemoral junction is seen just above
asked to cough forcible the saphenous opening
• An expansile impulse is felt at the
saphenofemoral junction in cases of saphenofemoral incompetence.

Brodie Trendelenburg tests:

Test 1. For saphenofemoral incompetence
Test 2. For perforator incompetence
Procedure:
Step 1 : Patient in recumbent position legs raised to empty the vein, may be hastened
by milking the veins.
Step 2 : Tourniquet is applied below saphenofemoral (SF) junction (Thumb may be
used to occlude the SF junction).
Test 1 : Pressure released at the SF junction.
• Varices fill very quickly from above
• Test 1 is positive, i.e. saphenofemoral incompetence is present.
Test 2 : Do not release the pressure for one minute
• Gradual filling of veins occur in the lower limb.
• Test 2 is positive, i.e. perforator incompetence is present.

Oschner’s Mahoner’s Test ( Multiple Tourniquet Test)

Step 1 : Patient in recumbent position, empty all the veins
Step 2 : Three tourniquets are applied:
1. Just below saphenofemoral junction
2. Just below mid-thigh
3. Just below knee
4. below-knee and above ankle level
Tourniquets are applied below each perforator. Ask the patient to stand.
Inference:
 Appearance of veins between tourniquet 1 and 2 is seen in adductor canal
perforator incompetence
 Appearance of veins between tourniquet 2 and 3 is seen in below knee
perforator incompetence
 Appearance of veins between tourniquet 3 and 4 is seen in lower leg
perforators incompetent.
 Appearance of veins below 4th tourniquet implies lower leg perforator
incompetence.

Short Saphenous Venous Incompetence

 Method 1
o Apply a tourniquet at the upper thigh, thus blocking the GSV blood to flow
into femoral vein and diverting most of the blood into the popliteal vein
o The blood from the popliteal vein backflows into SSV if there is
saphenopopliteal incompetence and the SSV becomes more prominent.
 Method 2
o Identify the saphenopopliteal junction (usually in the popliteal fossa) and
occlude it
o Ask the patient to stand
o Release the pressure at saphenopopliteal junction
o Veins fill rapidly on the lateral side if there is saphenopopliteal incompetence.

Schwartz test:
 Ask the patient to stand and keep thumb of one hand at the saphenous opening
 Tap with other hand along the course of long saphenous vein in the lower part of
leg.
Inference: Impulse is felt in the thumb at saphenous opening. This test implies the valves
along the GSV are incompletent

Pratt’s test:
To mark the position of weak perforators (blow outs).
Steps:
• Apply Esmarch elastic bandage from toes to groin to empty the superficial veins.
• Apply tourniquet at groin (below SF junction).
• With tourniquet in position remove bandage gradually from above below and
simultaneously apply another elastic bandage from groin to toes in reverse direction.
Inference: At the position of weak perforators blow outs can be seen. Mark
these blow outs with skin pencil.

Fegan’s test:
 Line of varicose vein is marked. On standing, the site where the perforators enter the
deep fascia bulges and these points are also marked. ( also by Pratt’s test)
 In lying down, button like depressions (crescentric gaps) in the deep fascia are felt
at the marked out points which confirms the perforator site.
Ian-Aird test:
On standing, proximal segment of long saphenous vein is emptied with two index fingers.
Pressure from proximal finger is released to see the rapid filling from above which
confirms saphenofemoral incompetence.

Tests for DVT

Modified Perthes test:

• To find deep vein thrombosis
• Important preliminary to do this test is that there should not be any
perforator incompetence to do this test.

Steps:
• Tourniquet is applied below the saphenofemoral junction (no need to empty the
veins before applying tourniquet).
• Ask the patient to walk with tourniquet.
Observation:
• Shrinking of varicose veins: Indicates that there is normal deep veins and
perforators.
(Note: If there is perforator incompetence there will not be shrinking of veins, hence
cannot be done in cases of perforator incompetence)
• More prominence of varicose veins associated with severe cramp like pain: Indicates
there is deep vein thrombosis.

Homan’s sign:
Forcible dorsiflexion of foot with knee extension causes pain in the calf.

Moses sign:
Squeezing the calf muscles from side-to-side results in severe pain at the calf.

Note: These tests are not to be done nowadays for the risk of dislodgement of thrombus
resulting in pulmonary embolism.

PERCUSSION: ‘Schwartz test’

AUSCULTATION: ‘Morrisey’s cough impulse test’.

Examine:
Regional nodes Vertical inguinal nodes and external iliac nodes (above and medial
aspect of the inguinal ligament) are palpated
Other limb
Ankle Joint movements (plantar and dorsiflexion) are checked for any restriction.
Measure both limbs circumference above or below a fixed bony point and mention
any swelling of affected limb.
Arterial pulsations ( associated arterial disease)
SYSTEMIC EXAMINATION:
Cardiovascular system: murmurs ( tricuspid incompetence)
RS:
Abdomen:
 Palpable mass
 Pregnancy
 Fibroid
 Ovarian cyst
 Carcinoma cervix or rectum.
CNS: for focal neurological deficit

Diagnosis:
 Primary (or) secondary varicose vein
 Involving great saphenous (or) short saphenous (or) both venous system
 With or without saphenofemoral incompetence (or) saphenopopliteal incompetence
 With or without perforator incompetence
 With clinical class ( CEAP grade 0-6)
 With or without complications
1. Due to dilated veins:
 Hemorrhage
 Phlebitis (Thrombosis)
 Calcification of veins.
2. Due to ulcer:
Ulcer complicates varicose vein in about 5 percent of the people.
 Marjolin’s ulcer : Malignant change in long-standing venous ulcer.
 Periostitis tibia : Occurs in long-standing ulcer on medial surface of
tibia.
 Equinus deformity : Walking on toe relieves pain, so he continues
walking resulting in shortening of tendo-Achilles.
3. Skin changes:
 Eczema
 Pigmentation (due to hemosiderin deposition) Due to high venous
pressure red blood cell (RBC) is forced into the capillaries resulting
in hemoglobin break down to form hemosiderin.
 Lipodermatosclerosis.

MANAGEMENT:
Investigations:
 Duplex scan
 Standing
 Lying
 Valsalva maneuver
 Hand Held Doppler
 Plethysmograthy
 Venography
o Ascending (DVT)
o Descending ( Valve incompetence)
 AVP: Ambulatory venous Pressure
 RAJU’s test ( for venous obstruction) Arm – Foot venous pressure study

Treatment:

Conservative therapy
Indications:
• Pregnancy
• Pelvic tumour
• Perthe’s positive patient
• AV fistula
 Elastic compression crepe bandage ( 30-40 mm Hg)
 Elevation of limb (3-4 times a day for 30 min)
 Unna boots
 Exercises
 Pneumatic compression ( not used commonly)

Sclerotherapy: ( contraindicated in DVT)

o Catheter Sclerotherapy
o Liquid Sclerotherapy
 Micro sclerotherapy
 Macro sclerotherapy
 Trans illumination sclerotherapy
o Foam Sclerotherapy ( sclerosant + CO2 + O2)
o Echo Sclerotherapy

Sclerosants used:
Osmotic Detergent
Chromated glycerine 10ml of 3% STDS
Hypotonic saline Polidocanal
Sodium marrhavate
Ethonolamine oleate

Complications of sclerotherapy
• Allergy
• Pigmentation ( STDS)
• DVT
• Thrombophlebitis
• Skin necrosis
Surgery:
 Trendelenburg operation and stripping
 Cockett and Dodd subfascial ligation
 Linton’s surgery ( don’t mention)
 Hook Phlebectomy ( don’t mention)

Minimally Invasive Procedures

 SEPS – Subfascial Endoscopic Perforator ligation Surgery
 RFA Radio Frequency Ablation
 EVLA Endo Venous Laser Ablation
 TRIvex
 CHIEVA ( don’t mention)
 HERNIA
Name:
Age: *Indirect Inguinal Hernia is common in Young
*Direct Inguinal Hernia is common in elderly
*Direct Inguinal Hernia never occurs in children and infants because superficial and deep
rings are opposed to each other and no posterior wall exists
Sex:

Most common hernia in females – Indirect Inguinal Hernia ( other than incisional)

Most common henia in males – Indirect Hernia

Femoral hernia is most common among females

Direct Hernia never occurs in Females
Occupation : most common in strenuous workers
Address:
DOA & DOE:

Chief Complaints:
o Swelling in the groin & Scrotum
o Pain over swelling
o Symptoms of Intestinal obstruction:
 Colicky pain
 Abdominal distention
 Obstipation
 Vomiting

History of Presenting Illness:

I. About the hernia
a. Swelling:
i. Duration
ii. Onset: Suddenly/gradually
iii. Site of start:
a. From groin to scrotum (hernia)
b. From scrotum to groin (hydrocele and varicocele)
iv. Progression: Size and extent of hernia at onset and at current stage
v. Aggravating factors:
a. On straining
b. On standing
c. On coughing
d. If it appears Spontaneously – Direct Hernia
1. Gradually - Indirect Hernia
vi. Relieving factors:
a. By lying down
b. Manually by himself
c. If it disappears
1. Immediately – Direct Hernia
2. Gradually – Indirect Hernia
3. Patient assisted – Indirect Hernia
vii. Any period of irreducibility ( strangulated henia , obstructed hernia)
viii. Any swelling on opposite side
 b. Pain:
i. Site :
ii. Onset:
iii. Character :
a. Dull aching
b. Dragging
c. Vague discomfort
d. Colicky pain – obstruction
iv. Radiation
v. Duration and severity
vi. Aggravating factors ( on straining)
vii. Relieving factors (on lying down)

II. Precipitating factors ( history of straining)

a) History of chronic cough and breathlessness
b) h/o Bowel obstruction
i. constipation
ii. straining at stools
c) h/o bladder disturbances
i. dysuria
ii. hesitancy: person feels bladders is full & wants to pass urine but has to
wait long to urine stream starts to flow
iii. urgency
iv. precipitancy: need to get to toilet in a hurry to prevent leakage
v. Frequency of micturition
vi. anuresis

III. Due to hernia (Complications)

History suggestive of Strangulation:
(Obstruction + irreducibility + Arrest of blood supply)
Colicky abdominal pain if continues and becomes gangrenous pain
disappears
Sudden increase in size of hernia; becomes tense and tender.
History suggestive of Intestinal Obstruction
Colicky pain
Abdominal distention
Obstipation
Vomiting

PAST HISTORY:
History of similar complaints in past on same side / opposite side
History of previous surgeries
(injury to ilioinguinal nerve > Direct Hernia)
Appendicectomy
Palomo’s operation for varicocele
Placing drain after surgery
History of DM, HTN, Asthma, TB, IHD
PERSONAL HISTORY

 Occupation
 Appetite
 Diet
 Bowel and Bladder:
 Sleep
 Habits
Smoking – chronic bronchitis
- collagen deficiency

Family History:
History of connective tissue disorders in family.

Drug/Treatment History:
History of use of TRUSS

Allergy History:

General Physical Examination:

Here is a ____ year old ____ patient, _______ built and nourished and ____ co-operative.

Pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy, Edema

Vitals:
 Pulse: (rate, rhythm, character, volume, condition of vessel wall
radio-radial/radio-femoral delay)
 BP: (position and limb in which BP is measured)( in all 4 limbs)
 RR:
 Temperature:

LOCAL EXAMINATION:
o Position of Patient:
Patient examined in standing position and in lying down
position for some tests
o Exposure: umbilicus to mid thigh
o Position of Examiner wrt. Patient:
o Light source:

Rules of hernia examination

• Never forget to check expansile impulse on coughing
and reducibility.
• Never forget to examine opposite side.
• Never forget to do per-rectal examination.
• Never forget to examine bulbar urethra.
• Never forget to check abdominal muscle tone.
Inspection
1. Side
2. Site
3. Position
a. Femoral – below & lateral to pubic tubercle
b. Inguinal – above & medial to pubic tubercle
4. Size ( horizontal and vertical dimensions)
5. Extent:
a. Swelling in inguinal/inguino scrotal region
b. Swelling extend upto inguinal canal, below upto __ cm above root of
scrotum/upto bottom of scrotum. Medially __ cm from midline to laterally __
cm from ASIS.
6. Shape:
a. Pyriform – Indirect
b. Globular – Direct
c. Retort – Femoral
7. Surface
8. Margins
9. Skin over swelling
a. Scar
b. Engorged veins
c. Redness
d. Pigmentation
10. Reducibility of the content on lying down
11.Expansile cough impulse
 No need to reduce the content
 Just ask the patient to stand and turn face away and cough
 Obser carefully at superficial inguinal ring
Inference
 Swelling increases in size if already exists
 swelling reappears, synchronous with cough
12.Any visible peristalisis over swelling
13.Opposite scrotum inspection
14. whether testis is seen separately from the swelling or covered by the swelling all over
15. Position of Penis
16.Urethral meatus
17.Opposite scrotum

Palpation:
1. Temperature
2. Tenderness Consistency:
3. Site Soft elastic—intestine
4. Size Doughy granular—omentum
5. Shape
6. Extent
7. Surface
8. Skin over
9. Consistency
10. Reducibility
11. Get above the swelling (Get above the swelling is a classical feature of hydrocele)
12. Cough impulse Propulsive and Expansile Impulse on Coughing'
Can be performed by:
–– Making the child cry
–– Valsalva maneuver
–– Head raising and abdomen contraction
13. Ring Invagination test Only test in hernia; done in lying position.
Prerequisite: –– Swelling should be reducible
–– Lax of skin should be there for invaginating (so this test could not be done in females)

Interpretation of Invagination test

•• Strength of superficial ring: Normal ring admits only the tip
•• Direction of canal:
Direct hernia—directly backwards
Indirect—goes upwards, backwards and laterally
•• Site of impulse:
Pulp—direct
Tip—indirect
•• Strength of posterior wall
•• To find early cases of hernia, impulse felt at tip

14. Ring occlusion test

After reducing the contents, patient in standing position, occlude the deep ring with thumb. Ask the patient to
cough.
If swelling appears – Direct
Does not appear - Indirect

15. Zieman's technique :

For right side inguinal hernia, place the right hand
–– Index finger over deep ring
–– Middle finger over superficial ring
–– Ring finger over saphenous opening
See where the impulse is felt
–– Direct hernia—superficial ring
–– Indirect hernia—deep ring
–– Femoral hernia—saphenous opening

16. Palpation of testis, epididymis and spermatic cord should be done without fail.
Relation of swelling to testis also should be noted.

17. Bulbar urethra is palpated by lifting the scrotum and feeling in the midline. (To look for
thickening and button like depression , a feature of stricture urethra).

18. Opposite inguinal region, opposite testis, epididymis and spermatic cord should be
examined. Presence or absence of impulse on coughing on opposite side should be
mentioned.
 How will you demonstrate hernia in children?
Gornall's Test
–– Child held from back by both hands of clinician on its abdomen
–– Abdomen is pressed and child is lifted up
–– Hernia appears due to increase in the abdominal pressure exerted.

Percussion
Without reducing contents of the swelling, percussion is done over the surface. If it is
resonant, it is enterocele. If it is dull on percussion, then it is omentocele.
TAXIS (Do not mention unless asked by the examiner)
Method of reducing the inguinal hernia
Procedure: Flex the knee, Adduct and internally rotate the hip
↓
Relaxes the abdominal muscles
*With the thumb and fingers hold the sac; guide with other hand at superficial ring*
Complications of Taxis
 Bowel injury
 Reduction en masse: Reducing the sac with the constriction being present at the neck; thereby making
the hernia with obstruction to go into the abdomen
 Sac may rupture at its neck and the contents may be reduced extra peritoneally.

Auscultation
Peristaltic sounds occasionally heard.

Others
1. Testis: ‘Traction Test’ to find whether the inguinal swelling is an Encysted Hydrocele of
Cord.
2. Epididymis.
3. Penis:
–– Phimosis
–– Penile strictures
–– Pinhole meatus
4. Regional nodes.
5. Opposite groin.

Per-rectal Examination
To Rule out:
1. Benign Prostate hypertrophy—micturition difficulty
2. Malignant obstruction
3. Chronic fissure—constipation

Respiratory system Examination:

Diagnosis
•• Side—right/left
•• Type—indirect/direct
•• Inguinal—femoral
•• Complete/Incomplete
•• Complicated/Uncomplicated
•• Content—enterocele/omentocele
Investegations
I. Routine
•• Hemoglobin
•• Bleeding time/Clotting time
•• Total count, differential count, ESR
•• Urine—albumin, sugar deposits
•• Blood—urea, sugar
•• Blood grouping/typing—for irreducible hernia/huge hernia
II. Anesthetic Purpose
•• X-ray chest (Chronic TB, Asthma—precipitate hernia)
•• ECG all leads
III. USG Abdomen and Pelvis
•• In old age group—to find benign prostate hyperplasia calculate post
voidal residual urine. If >100 ml it is significant
•• To find any mass

Expansile impulse on coughing Contents of spermatic cord

• Hernia  Arteries : Testicular Artery
• Meningocele  Artery of Vas
 Artery to Cremaster
• Laryngocele
 Veins : Pampiniform plexus of veins
• Empyema necessitans
 Veins corresponding to Arteries
• Intracranially extended
 Lymphatics of testis
dermoid
 Testicular plexus of sympathetic nerves
 Genital branch of genitofemoral N
 Vas deferens

Mechanisms that prevent hernia when abdominal pressure rises.

1. Shutter mechanism—arched fibers of internal oblique
2. Flap valve mechanism—oblique canal; approximation of anterior and posterior wall.
3. Ball valve mechanism—cremaster contracts, thereby superficial ring plugged by
spermatic cord.
4. Slit valve mechanism—crura of the superficial ring.