Contents

BREAST .......................................................................................................................................................... 2

PROSTATE...................................................................................................................................................... 4

HERNIA .......................................................................................................................................................... 6

COLORECTAL CARCINOMA............................................................................................................................ 8

PEPTIC ULCER DISEASE ................................................................................................................................ 10

GASTRIC OUTLET OBSTRUCTION ................................................................................................................ 11

CHRONIC LEG ULCER ................................................................................................................................... 12

OESOPHAGEAL DISEASE .............................................................................................................................. 14

THYROID DISEASES ...................................................................................................................................... 15

HAEMORRHOIDS ......................................................................................................................................... 17

BLADDER OUTLET OBSTRUCTION ............................................................................................................... 19

OBSTRUCTIVE JAUNDICE ............................................................................................................................. 20

LONG BONE FRACTURES ............................................................................................................................. 21

CHRONIC OSTEOMYELITIS ........................................................................................................................... 22

PARAPLEGIA ................................................................................................................................................ 23

ANAL CONDITIONS ...................................................................................................................................... 24

BREAST
PC: lump in the breast

• How did you notice it

• What was the size when it was noticed

• Has it been increasing in size

• Any other mass on any part of the body

• If so gradually or rapidly

• Is there any associated trauma to the breast(R/O fat necrosis)

• Is it associated with pain, if so characterize it

• Is the pain in any way related to menstrual period (R/O mammary dysplasia wc is worse during menses)

• Any nipple discharge, if so is it bloody, serous, purulent and odour or a mixture

• Is there any nipple retraction

• Any itching of the nipple( r/o eczema)

• Any skin changes over the breast (ulceration, peau d’orange)

• Any hx of weight loss

• Any hx of fever (r/o mastitis or breast abscess)

• If there is fever, characterize it (high grade or low grade)

• Any hx of chronic cough or contact with persons with chronic cough ( r/o TB mastitis)

• Any hx of trauma to the breast (r/o traumatic fat necrosis, haematocyst or harmatoma)

• Any hx of breast ca in the family (r/o familial breast ca)

• Any hx of oral contraceptives or taking of some drug prior to the onset especially in males (r/o
gynecomastia)

• Any hx of cough or dyspnea after the onset (r/o metastasis to the lungs)

• Any hx of bone pain or jaundice (r/o metastasis to the bone and liver)

• Treatment hx, investigations and improvement or not and referral etc

GENERAL EXAMINATION

IMEN

Examination of the mass and report

Inspection (tell patient to sit up)

• - Any asymmetry (is it underdeveloped or overdeveloped)

• Any skin changes (dimpling, excoriation, tethering, peau d’orange)

• Any nipple discharge

• Any nipple changes (absent, inverted)

Palpation (tell patient to lie down)

• - Site

• Surface

• Shape

• Size

• Fluctuancy (consistency)

• Skin attachment

• Chest wall attachment

• Attachment to muscle

• Mobility

• Expressive discharge

• Lymph node palpation, if present, characterize it

• Liver palpation

• Percussion of the spine

• Do rectal exam or VE

Investigations

1. General : FBC, SEUCr, urinalysis, HIV 1 & II screening

2. Biopsy: FNAC first to establish diagnosis. There may be a false +ve/-ve. Open wide excision or trucut
biopsy for paraffin section histology core biopsy with sonographic guidance, mammography or
ultrasonograhic guidance as an alternative to excision biopsy. Excisional

biopsy for a lump <3mm, incisional biopsy for a lump that is too big.

3. Estrogen/progesterone receptor assay: done with tissue specimen but can now be done with tissue
aspiration cytology specimen.

4. Imaging studies: This includes mammography and skeletal scintigraphy.

PROSTATE
PC: difficulty in passing urine

• When did you notice it

• Is it gradual in onset or insidious

• Do you have increased freq of urination, if there is, how many times

• Is it nocturnal or not

• Any increase in eating (polyphagia), drinking (polydypsia) or are you a known diabetic (r/o DM)

• Any hx of drug ingestion (diuretics)

• Do you feel like passing urine before you get to the point you want to pass it (urgency)

• When you get to the point you want to pass urine, do you wait for some time before passing urine
(hesitancy)

• Do you strain to pass urine and if so does it improve your urination

• How is your stream of urine like (poor or good)

• At the end of micturition, does urine keep coming out in drops for some time(terminal dribbling)

• Do you wet your clothes with urine (over or low incontinence)

• Any passage of blood in urine, if so characterize it (initial, total, terminal, painful or painless)

• Do you feel incomplete voiding after passage of urine

• Any hx of STD in the past if so, where was it treated(r/o stricture)

• Any hx of trauma in the past(r/o stricture)

• Any hx of urological surgery or instrumentation in the past(r/o stricture)

• Any hx of dysuria

• Any hx of fever (r/o infective processes like prostatitis)

• Any hx of urethral discharge (r/o infection)

• Any weight loss, anorexia, low back pain (r/o CAP and metastasis to bone)

• Any hx of cough (r/o metastasis to the lungs)

• Any hx of straining to pass stool and blood in the stool (r/o metastasis to the rectum)

• Any hx of headache and confusion (r/o uraemia)

• Treatment received so far before coming and investigations done

 • Treatments received in the wards and investigations done so far.

Examination

General

Systemic

• Cardiovascular system

• Urogenital system (palpate suprapubic area for enlarged bladder and the entire length of the urethra

• Abdominal exam

• Digital rectal examination

Reporting of DRE

• Anal hygiene, warts, external haemorrhoids, obvious prolapsed, sentinel tags, fissures, fistula-in-ano

• Any prolapsed on bearing down

• How is the sphincter tone

• Size of the gland

• Surface of the gland

• Presence of median sulcus

• Consistency of the gland (firm, soft, or hard)

• Wall of the rectum (free or fixed to the prostate)

• Any protruding mass (tell px to bear down as you remove your finger)

• Check finger for staining with faeces or blood

Investigations

1. 1. General : FBC, urinalysis, SEUC, ESR, HIV screening, Urine MCS, group and cross match blood

2. Radiological : abdominopelvic US, IVU, urethrocystoscopy, urodynamic studies, CXR

3. Serum prostate specific antigen

4. Prostate biopsy

5. Others : bone scan, skeletal survey, ECG

Complications

1. BPH : urinary tract infections, chronic renal failure

2. Prostatectomy: hemorrhage, wound infections, incontinence, frequency, retrograde ejaculation,

impotence, damage to the urethra.
HERNIA
PC: protruding mass from the groin

• How did you notice the mass

• Is the development –gradual or sudden

• Is the mass always there

• Does it reduce on its own or you are the one that pushes it back

• Has it been the same since or has it progressively increased in size

• Is it associated with pain, if so characterize it as before (r/o abscess)

• Is it associated with fever, if so characterize it

• Any hx of trauma prior to onset

• Any hx of chronic cough

• Any hx of lifting heavy loads

• Any hx of chronic constipation

• Any abdominal mass

• Any hx of frequent dysuria, hesitancy, incontinence (r/o prostatism)

• Any hx of saphenous varices on the leg (r/o increased intra abdominal pressure)

• Any hx of vomiting

• Any surgical hx in the past, if so where was it done and what site

• How long did patient stay on admission (r/o possible wound infection)

• Did the wound breakdown

• Was patient carrying heavy load after the operation

• Any cough after the operation

• Any straining at urination or defecation after the operation or chronic constipation

• Treatment hx so far and investigations so far

Examination of the hernia

• - Site

• Protrusion on standing

• Expansile cough impulse

 • Palpable cough impulse

• Reduction on lying down on its own

• If it doesn’t reduce on its own but by the examiner, estimate the size

• Consistency of the mass

• Mobility of the mass

• Can you go above and below it

• Ask patient to cough to check for visible cough impulse on lying down

• Palpable cough impulses on lying down

• Is it direct or indirect (palpate ASIS and pubic tubercle; locate the midpoint of the inguinal ligament. Then
go a finger breadth above this point and occlude with the index finger and tell patient to cough, if the
mass comes out, it is a direct inguinal hernia but if not, it is an indirect inguinal hernia).

Investigations

1. General: FBC, urinalysis, MCS, SEUC, HIV 1 and 2, genotype, grp and cross match blood.

2. Others : CXR, abdominal x-ray, ECG

Complications

Injury to vas deferens, injury to ilioinguinal nerve, nerve entrapment, hemorrhages, scrotal hematoma,
hypertrophic scar, faecal fistula.
COLORECTAL CARCINOMA
PC: bleeding per rectum

• How did you notice it

• Does it follow stooling or comes out even without stooling

• If it follows stooling, does it mix completely with stool or comes out as a streak on the stool (r/o fissure-in-
ano)

• Is it frank blood or altered blood

• Any mucus in the stool (r/o amoebiasis, shigellosis)

• Any hx of constipation or diarrhea

• Any change in bowel habit e.g. constipation or diarrhea or alternating diarrhea with constipation.

• Any abdominal pain , if present characterize it

• Any tenesmus

• Any feeling of lump in the abdomen

• Does anything protrude from your anus

• Any anal pain (r/o fissure in ano)

• Any fever (r/o infective process e.g. appendicitis, abscess) if present characterize it.

• Any hx of weight loss (evidenced by loosening of clothes etc)

• Any associated faintness or breathlessness

• Any associated cough (r/o metastasis to the lungs)

• Any hx of low back pain(r/o metastasis to the spine or sacral plexus)

• Any hx of jaundice (r/o liver metastasis)

• Do you still pass stool or flatus (r/o total or partial obstruction)

• Treatment hx as before

Examination

• General examination

• Abdominal examination

• Digital rectal examination

• Proctoscopy where possible

Investigations

• General routine investigations

• Special investigations : colonoscopy, sigmoidoscopy, barium enema, rectal endoscopy, Ultrasound

Complications of colorectal CA

Pre op: intestinal obstruction, perforation, internal fistula, anaemia

Post op: leakage or dehiscence of anastomosis, faecal fistula, stenosis of anastomosis, urinary and sexual
dysfunction, injury to surrounding structures.

Complications of colostomy

• - Necrosis of the stoma

• Stenosis

• Colostomy prolapsed

• Strangulation of the small intestine

• Excoriation of the surrounding skin

• Faecal impaction

• Para colostomy herniation

• Diarrhea

• Mental depression

• Social isolation
PEPTIC ULCER DISEASE
PC: epigastric pain

• When was the pain first noticed

• Characterize the pain

• Does the pain relate to breathing (r/o pleuritic pain)

• Does the pain wake you up at night

• Does the pain worsen or get better with food

• If so what type of meals

• Does it get worse on bending forward (r/o hiatus hernia causing reflux oesophagitis)

• Any hx of dyspnea, orthopnea, or palpitations (r/o cardio respiratory disease)

• Any hx of haematemesis or passage of melena stool

• Any hx of heartburn

• Any hx of water brash

• Any hx of ingestion of aspirin or NSAIDS

• Any hx of stressful life events

• Any hx of head injuries or burns in the past

• Any hx of protracted fasting

• Any family hx of PUD

• What is your blood group (PUD is associated with blood grp O while CA stomach with blood group A)

• Any associated weight loss or weight gain

GASTRIC OUTLET OBSTRUCTION
PC: persistent vomiting

• Characterize the vomiting

• Is it projectile

• Is it bilious

• Does It contain recently ingested food/food of 3 days ago

• Is it blood stained

• How often do you vomit

• What is the volume

• What relieves it or makes it worse

• Is it associated with retching or is it effortless

• R/o PUD as above as it is the commonest cause of GOO from cicatrization of the ulcer

• Any hx of weight loss(r/o PUD and ca stomach)

• Any hx of weakness or fatigue (r/o anaemia as a complication)

• Any associated pain or abdominal mass, if present characterize it

• Any hx of fever, back pain and jaundice (r/o pancreatitis or ca head of pancreas)

EXAMINATION

• General examination

• Abdominal examination

• DRE

INVESTIGATIONS

General: FBC, urinalysis, SEUC, HIV 1 and 2 screening

Specific

• Endoscopy

• Barium meal

• Plain abdominal x-ray

• Gastric aspiration
CHRONIC LEG ULCER
PC: leg ulcer

• How did you notice it

• Was it of insidious onset or was there any trigger or hx of trauma

• Has it been increasing in size or same

• Is it associated with pain (if so characterize it as before)

• Is there associated discharge

• If so, what is the color, smell and volume

• Any associated itching around the site (r/o dracunculiasis)

• Any signs of intermittent claudication i.e. pain in the calf muscle (r/o arterial ulcers)

• Any tortuous or dilated veins on the legs (r/o varicose vein ulcers)

• Any hx of cough or contact with person with chronic cough (r/o TB ulcer)

• Any hx of night sweats (r/o TB)

• Any hx of fever(r/o pyoegnic ulcer)

• Any symptoms suggestive of DM (polyphagia, polydypsia, polyuria) or is patient a known diabetic

• Past hx of prolonged immobility from surgery (r/o DVT)

• Any hx of prolonged bed stay or bedridden (r/o pressure sores)

• Any hx of weight loss (r/o malignancy)

• Any hx of loss of sensation (r/o neuropathic ulcers)

• Is patient a known sickler

• Is there any difficulty in moving the joints

• Any hx of STD or ulcer in any other part of the body (syphilitic ulcers)

Examination

• - General examination

• Examine the ulcer and report

1. Site

2. Size

3. Shape
 4. Edge

5. Surrounding surface

6. Surface of the ulcer

7. Floor

8. Base

• Pulsation of regional arteries

• Lymph nodes in the region

• Check for varicose veins with patient standing

• Sensations in surrounding skin

• Systemic examination

Investigations

• General : FBC, ESR, urinalysis

• Others: wound swab, Mantoux test, VRDL, FBS & 2HPP, genotype, CXR, plain X-ray, lipid profile, HIV 1 & 2
screening, SEUCr.
OESOPHAGEAL DISEASE
PC: dysphagia

• - How did you notice it

• Was it of sudden onset or insidious onset

• Was it intermittent initially and later become constant (achalasia)

• Can you point out where the food sticks (r/o

• Is it dysphagia to solid or both solid and liquid. If both, which one started first

• Any associated pain

• Any hx of ingestion of corrosives in the past

• Any hx of swallowing of

• Any hx of fever, if so characterize it (r/o infective or inflammatory process)

• Any retrosternal pain which worsens on bending down or lying down (r/o GERD)

• Any hx of weight loss and possibly anaemia ( r/o ca oesophagus)

• Any hx generalized body weakness, dizziness, fast breathing (r/o anaemia)

• Any hx of haematemesis

• Any hx of regurgitation esp. while sleeping

• Any hx of vomiting

• Any hx of coughing (r/o aspiration pneumonitis)

• Treatment hx so far

Investigations

• General : FBC, ESR, urinalysis, SEUCr, HIV

• Specific: barium swallow, oesophagoscopy, oesophageal manometry, serum proteins.

THYROID DISEASES
PC: anterior neck swelling

• Who noticed the swelling

• How has the swelling been increasing in size

• Any hx of associated pain, if present, characterize it

• Any hx of trauma

• Any hx of fever (thyroiditis)

• Any hx of ingestion of drugs prior to onset (oral contraceptives, PAS, salicylic acid, phenylbutazone)

• Any hx of ingestion of large amounts of cassava and cabbage (dietary goitrogens)

• Any hx of polyphagia, polyuria, polydypsia (DM)

• Any hx of weight loss in the presence of normal or increased appetite, excessive sweating or heat
intolerance (thyrotoxicosis)

• Any hx of chronic cough, unexplained weight loss or night sweats (TB)

• Any hx of eye signs such as blurring of vision, bulging eyes

• Any hx of change in voice, dysphagia, lymph node swellings, bone pains, pathologic fractures (r/o
malignancy)

• Any hx of dyspnoea, dysphagia, hoarseness, snoring (obstructive neck symptoms)

• Any hx of joint pains and jaundice

• Any hx of neurological changes – nervousness, irritability, emotional liability, tremors

• Any associated CVS disturbances ( dyspnoea, angina, leg swelling, PND, orthopnea)

• Any associated skin changes (vitiligo, pruritus, palmar erythema)

• Any associated changes in the reproductive system (menses, infertility, libido, impotence)

• Any similar anterior neck swellings in the family

• Any hx of previous thyroid surgeries

Examination

• General examination

• Inspect the thyroid gland (swallowing, protrude tongue, temperature, consistency mobility, carotid
pulsation, kocker's sign, attachment to surrounding structures, lymph nodes)

• Examine the eyes ( proptosis, lid lag, joffroy’s sign, moebiu’s sign)
 • CVS and respiratory examination

• Check reflexes

• DRE

Investigations

• General : FBC, urinalysis, HIV 1 and 2, blood grouping and cross matching, genotype, SEUCr, LFT

• Specific : hormone assay (T3, T4 and TSH)

• X-ray of the chest neck and thoracic inlet

HAEMORRHOIDS
PC: bleeding per rectum

• Is the bleeding intermittent or constant

• When does he notice it, during defecation or any other activity

• If during defecation, does the blood mix very well with stool or is it merely a streak on the stool

• Is the bleeding profuse, mild or moderate

• Characterize the blood, is it frank blood or altered blood

• Any associated mucoid discharge

• Any pruritus at the anus

• Any hx of something protruding from the anus

• Any hx of straining at urination or defaecation

• Any lifting of heavy load

• Any hx of chronic cough

• Any feeling of mass in the abdomen

• Any hx of chronic constipation

• Any hx of yellowness of the eyes or associated hematemesis

• Any hx of tortuous cords on the legs (varicose veins to r/o portal hypertension)

• Any hx of abdominal pain, diarrhea and fever ( enterocolitis)

• Any hx of bleeding from any other site of the body (r/o blood dyscrasias)

• Any hx of drug intake (r/o anticoagulants)

• Any hx of tenesmus, weight loss, anorexia (ca rectum)

• Any change in bowel habit

• Any family hx of similar problem

• Any anal pain (r/o thrombosed hemorrhoids or fissure-in-ano)

• Any weakness, faintness, breathlessness or dizziness (r/o anaemia as a complication)

Examination

• General examination

• Look for tale tell signs of chronic liver disease

 • Examine the abdomen

• DRE

• Systemic examination

Investigations

• General routine examinations

• Specific: proctoscopy, sigmoidoscopy, abdominal ultrasound, liver function test.

BLADDER OUTLET OBSTRUCTION
PC: difficulty in micturition

Common causes: urethral stricture, BPH, ca prostate, bladder tumors, bladder calculi

• Any hx of frequency, urgency, urge incontinence and nocturia (irritative symptoms)

• Any hx of hesitancy, poor stream, straining, intermittency, terminal dribbling, feeling of residual urine
(obstructive symptoms)

• Any hx of difficulty in urination relieved by supine position ( bladder calculi)

• Any hx of recurrent fever, urethral discharge (sepsis)

• Any associated nausea, vomiting and pruritus (compromised renal function)

• Any hx of haematuria (initial, terminal or total)

• Any hx anorexia, weight loss, jaundice, bone pain and pathological fractures (malignancy)

• Any hx of trauma, pelvic fractures or urethral injury (stricture)

• Any hx of prostatic ca or bladder tumors in the family

• Any hx of occupational exposure to rubber, paints, aniline

• Any associated fever, night sweats, backpain or paraplegia (TB spine)

• Any hx of polyuria, polydypsia or polyphagia ( autonomic neuropathy)

• Any hx of anticholinergic drug use e.g. atropine

• Any hx of hypertension

Examination

• - General examination

• Abdominal examination

• DRE

• Other system examination

Investigations

• Routine : urinalysis, urine MCS, urine cytology, blood sugar, FBC, SEUCr

• Specific : abdominal ultrasound, cystourethrography, urethrocystoscopy, PSA, prostatic biopsy, IVU, plain
x-rays of the chest, spine, pelvis, proximal ends of long bones, skull
OBSTRUCTIVE JAUNDICE
PC: yellow discoloration of the sclera

• Determine if the jaundice is progressive or intermittent

• Any hx of generalized pruritus, pale stools and darkening of urine

• Any hx of bulky foul smelling stools with excessive bleeding ( pancreatic cancer)

• Any hx of fever, chills and rigors; progressive jaundice and right upper quadrant pain; “Charcot’s triad”
(cholangitis)

• Any hx of recurrent episodes of right upper quadrant pain worse on fatty meals (gallstones)

• Any hx of severe epigastric pain worse in the supine position (van zant sign – pancreatic ca)

• Any hx of severe episode of generalized pain ( acute pancreatitis)

• Any hx of prolonged alcohol abuse ( chronic pancreatitis)

• Any hx of previous upper abdominal surgeries (post op biliary strictures)

• Any hx of farming (ascariasis and clonorchis occlusion of bile ducts)

• Any hx of fever, cough and night sweats (TB)

• Any hx of ingestion of drugs such as anti TB, oral hypoglycaemics, sulphonamides, chlorpromazine, oral
contraceptives, steroids

• Any hx of multiple sexual partners and blood transfusions (chronic liver disease)

• Any hx of significant alcohol and cigarette intake (pancreatic ca)

• Detailed gynecological hx

Examination

• General examination

• Abdominal examination

• Digital rectal examination

Investigations

• Specific : Urinalysis, LFT, abdominal ultrasound, barium meal

• Others : CT scan, PTC, ERCP, MRCP

LONG BONE FRACTURES
PC: Any hx of pain, swelling, deformity, abnormal mobility and inability to use the limb

• Determine the mechanism of injury

• Determine if it is an open or a closed fracture

• Any associated injuries to the chest, abdomen, head, neck and pelvis

• Determine any medical care patient has received from time of injury

• Any hx of trauma

• Rule out other causes of fractures such as osteomalacia, osteoporosis, bone cysts, secondary bone
deposits, primary malignancies of the bone, Paget’s disease, chronic osteomyelitis

Examination

• General examination

• MSS examination

Investigations

• Radiograph
CHRONIC OSTEOMYELITIS
PC: discharge from a wound over the affected limb

• Any hx of serous and purulent discharge from a wound over the affected area

• Any hx of pain, fever and malaise

• Any hx of preceding trauma

• Any hx of previous open fracture and mgt

• Any hx of long standing ulcers or skin lesions

• Any hx of severe febrile systemic illness with pain (hematogenous osteomyelitis)

• Any hx of recent pain and inability to use the limb

• Any associated fracture of the limb (pathological fracture)

• Any associated multiple hand and foot swellings in childhood, recurrent yellowness of the eyes, recurrent
admissions and blood transfusions (sickle cell anaemia)

• Any hx of diabetes mellitus (neuropathic ulcers lead to chronic osteomyelitis)

• Any hx of multiple sexual partners (HIV chronic osteomyelitis)

Examination

• General examination

• Examine the affected part may show scars of previous sinuses with excoriated skin often having altered
pigmentation.

Investigations

• Swab taken from draining sinuses

• X-ray of the affected bone

• Others : MRI, radiographic scintigraphy, ultrasonography, CT scan

PARAPLEGIA
PC: inability to move both lower limbs

• Any hx of preceding trauma

• Determine care the patient has received since the injury

• Any hx of weight loss, low grade fever with drenching night sweats with severe back pain (potts
paraplegia)

• Any hx of unexplained weight loss, severe back pain (malignancy)

• Any hx of jaw or abdominal swellings, intermittent fever, anorexia, weight loss and recurrent infections
(burkits lymphoma, multiple myeloma)

• Any hx of breast diseases (females) and prostatic diseases (males)

• Any hx of occupational exposure to animals, bathing in streams and childhood haematuria (hydatid cysts,
schistosomiasis, histoplasmosis)

• Determine the progression of symptoms (traumatic or non-traumatic paraplegia)

ANAL CONDITIONS
Fistula-in-ano, haemorrhoids, rectal prolapsed, anal tumor, anorectal abscesses

• Any hx of pus like discharge through an external opening on the perianal skin

• Any hx of soiling underwear with faeces

• Any hx of perianal pruritus

• Any hx of a painful, perianal boil

• Any hx of associated fever and malaise at the time of the initial boil

• Any preceding hx of trauma from surgeries, impacted fish bone or other foreign bodies

• Any hx of chronic cough, hemoptysis, weight loss, drenching night sweats and contact with chronic cough
(TB)

• Any hx of recurrent bloody and mucoid stools (amoebiasis)

• Any hx of long standing hematuria and bathing in stream water (schistosomiasis)

• Any hx of skin lesions affecting the axilla and the groin (hydradenitis suppurativa)

• Any associated bleeding per rectum, tenesmus and sensation of incomplete defecation (anorectal
malignancies)

• Any hx of long standing diarrhea, weight loss (HIV induced fistula-in-ano)

• Any associated anal protrusion with bleeding (hemorrhoids)

• Any hx of mucus discharge, perianal discomfort and pruritus (hemorrhoids)

• Any associated straining at defecation, bleeding (colorectal tumors)