Dr.

Nerve DYNAMIC DIAGNOSERS

 PREFACE
Greetings from Dr.Nerve……..!!!
This is Dynamic Diagnosers from Dr.Nerve.
We have launched this team to acknowledge you
about case presentation which includes history
taking and examination. The viewpoint of this
project is to make it useful for your clinical
studies as reference. The following are the
departments covered by us,
❖ ENT
❖ ORTHOPAEDICS
❖ PEDIATRICS
❖ COMMUNITY MEDICINE
❖ OBSTETRICS AND GYNAECOLOGY
❖ GENERAL MEDICINE
❖ GENERAL SURGERY
The case Performa for GENERAL SURGERY
has been uploaded here. Kindly make use of
it…….

Dr.Nerve DYNAMIC DIAGNOSERS

CASES COVERED IN THIS MODULE………

❖ BREAST CARCINOMA

❖ INGUINAL HERNIA

❖ SWELLING

❖ THYROID SWELLING

❖ ULCER

Dr.Nerve DYNAMIC DIAGNOSERS

 BREAST CARCINOMA
Name
Age
Sex
Occupation
Address
CHIEF COMPLAINTS
➢ Lump in the ___ breast since ____
➢ Pain in the ___ breast since _____
➢ Discharge from the _____ nipple since ____
HISTORY OF PRESENT ILLNESS
➢ She noticed a swelling/lump in _____ breast ______
days back
o Its rate of growth
o Any H/O trauma
➢ H/O pain
o Duration
o Severity – mild or severe
o Type – continuous/intermittent
o Aggravating factor and relieving factor
o Relation to menstruation
➢ H/O discharge from nipples
➢ H/O retraction of the nipple
o Recent retraction
o Long time since puberty
➢ History suggestive of metastasis

Dr.Nerve DYNAMIC DIAGNOSERS

 o H/O loss of weight
o H/O loss of appetite
o H/O bone pain
o H/O headache
o H/O cough / haemoptysis
o H/O swelling (axilla and neck)
o H/O pain in abdomen
o H/O ulcers
o H/O nodules
o History regarding ovarian metastasis in
premenopausal women
TREATMENT HISTORY
➢ Any biopsy/FNAC ?
➢ Any chemotherapy given ?
PAST HISTORY
➢ Any similar complaints in the past
➢ Any history of surgeries
➢ Any H/O DM/TB/HT/asthma/epilepsy
PERSONAL HISTORY
➢ Diet
➢ Any addiction
➢ Appetite, sleep cycle, bowel and bladder habits
MENSTRUAL HISTORY
➢ Age at menarche
➢ Any breast pain during menstruation
➢ Menstrual cycle

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ Any abnormal complaints from patient
MARITAL HISTORY
➢ Age at marriage, age at 1st conception
➢ Marital life
➢ No of children
LACTATION HISTORY
➢ Children breast fed or not
➢ Any abscess formation during first lactational period
FAMILY HISTORY
➢ Significant/not
➢ Patient’s mother grandmother/sister etc.,
GENERAL EXAMINATION
➢ Conscious/oriented to things, place and person
➢ Cooperative
➢ Built and nourishment
➢ Alopecia
➢ Anemia (pallor), icterus, cyanosis, clubbing, pedal
oedema, lymphadenopathy
➢ Oral cavity – loosening / loss of teeth, caries tooth,
palatine tonsil etc.,
➢ Chest – spider naevi
➢ Palmar erythema
➢ Wasting of muscles

Dr.Nerve DYNAMIC DIAGNOSERS

VITALS
➢ Pulse
➢ Respiratory rate
➢ Blood pressure
➢ Temperature
LOCAL EXAMINATION OF BREAST REGION
Inspection
Breasts
➢ Position – displaced in any direction
➢ Size, shape, larger/smaller than others
➢ Swelling – if any seen (its description)
o Site, size, shape, surface, extent, border, skin over
swelling etc.,
➢ Skin over breast
➢ Colour and texture
➢ Any scars
➢ Engorged veins
➢ Dimple retraction or puckering
➢ Peau’d orange appearance
➢ Any nodules
➢ Any ulceration and fungation
Nipples
➢ Both nipples affected/not, symmetry/not or one is
retarded/destroyed
➢ Levels of nipples
o Ca breast – down up towards lump
o Fibroadenoma – away from lump
Dr.Nerve DYNAMIC DIAGNOSERS
 ➢ Size and shape – prominent/flattened/retracted
➢ Number
➢ Surface – cracks/fissures/eczema
➢ Any discharge – from nipple or from its
neighbourhood – mammary gland
Areola
➢ Colour – hypo/hyperpigmented
➢ Size, surface and texture
➢ Patient is asked to fall forwards, ease of falling of
breasts is observed
Arm and thorax
➢ Multiple cancerous nodules and thickened infiltrated
skin like a coat of armour
➢ Edema of arm – extensive neoplastic infiltration of
axillary lymph nodes
Axilla and supraclavicular fossa
➢ Any swelling due to enlarged lymph nodes
PALPATION
➢ A swelling is palpable _______ quadrant of ______
breast
➢ Any local rise of temperature and tenderness
➢ A _______ shaped swelling in ______ quadrant of size
____
➢ Extent, surface, margins, consistency
➢ If cystic – fluctuation and transillumination test
➢ Fixity to the skin

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ If fixed
o dimpling of skin
o skin can’t be slide over tumour
o skin over tumour can’t be pinched up
➢ Fixity to the breast tissue
➢ Mass can be easily movable in breast substance/not
➢ Fixity to the underlying tissue and fascia
➢ Pectoralis major and serratus anterior
➢ Patient is asked to place her hand on her hip tightly –
lump is moved in the direction and perpendicular to the
direction of muscle fibres – fixed or not
➢ If tumour over outer and lower quadrant – may lie on
serratus anterior – patient is asked to push against a
wall or shoulder of the examiner and the outstretched
hand of affected side – mobility is tested
➢ Fixity to the chest wall
➢ If tumour is fixed, irrespective of contraction of any
muscle, it is fixed to chest wall
➢ Palpation of the nipple – any lump, if present – moved
causes increases retraction
Examination of the lymph node
➢ Palpation of axillary group of lymph nodes – pectoral,
central, apical, subscapular, branchial
➢ Palpation of the cervical lymph nodes
o Supraclavicular
o Infraclavicular
▪ Clavipectoral nodes
▪ Apical nodes

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ Number. Size, consistency, mobility
Examination of the opposite breast
Systemic examination
➢ RS
➢ Musculocutaneous system
➢ GIT
➢ CVS
➢ P/V
➢ P/R
➢ Oral cavity
PROVISIONAL DIAGNOSIS
➢ Anatomically swelling/lump arising in the _____ breast
➢ Pathologically _______
➢ Staging (TNM)

Dr.Nerve DYNAMIC DIAGNOSERS

 CASE SHEET OF BREAST CARCINOMA
Name – Mrs. Usha rani
Age - 55
Sex – female
Occupation – housewife
Address
CHIEF COMPLAINTS
➢ Lump in the right breast since 6 months
HISTORY OF PRESENT ILLNESS
➢ Patient was apparently normal before 6 months back
➢ She noticed a swelling/lump in right breast
➢ No H/O loss of weight
➢ No H/O loss of appetite
➢ No H/O bone pain
➢ No H/O headache
➢ No H/O cough / haemoptysis
➢ No H/O swelling (axilla and neck)
➢ No H/O pain in abdomen
➢ No H/O ulcers
➢ No H/O nodules
➢ No History regarding ovarian metastasis in
premenopausal women
PAST HISTORY
➢ No similar complaints in the past
➢ No history of surgeries

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ Patient is a known case of diabetes mellitus for 3 years
and on regular medications tab. Metformin 1 bd
➢ No history of HT/bronchial asthma and seizures
➢ No history of previous surgery
➢ No history of OCP intake
PERSONAL HISTORY
➢ Diet- mixed
➢ No addictive habits
➢ Normal Appetite, sleep cycle, bowel and bladder habits
MENSTRUAL HISTORY
➢ Age at menarche – 13 years
➢ Attained menopause 5 years ago
➢ No history of bleeding PV
FAMILY HISTORY
➢ No Significant family history
GENERAL EXAMINATION
➢ Conscious/oriented to things, place and person
➢ Cooperative
➢ Moderately Built and nourished
➢ No Anemia (pallor), icterus, cyanosis, clubbing, pedal
oedema, lymphadenopathy.
VITALS
➢ Pulse – 76/min
➢ Respiratory rate – 18/min
➢ Blood pressure – 130/70 mm Hg
➢ Temperature - afebrile
Dr.Nerve DYNAMIC DIAGNOSERS
LOCAL EXAMINATION OF BREAST REGION
Examination of right breast
After getting a consent from the patient and in the
presence of a female attender, the patient is stripped up to
waist
Examined in sitting posture with arms by the side, arms
raised, arms at the hip, leaning forward and supine posture
under bright light.

INSPECTION
Arms by the side
➢ Right breast is larger than the left breast
➢ Fullness is noted in the upper outer quadrant of the
breast
➢ Skin over the lump is normal
➢ No peau’d orange appearance
➢ No ulcers, sinuses, nodules, fungation and dilateed veins
➢ No dimple/puckering seen
Nipple
➢ Size 1*1 cm centrally located
➢ Same level as the contralateral side
➢ No retraction of nipple
➢ No discharge from the nipple
➢ No ulcers, cracks, fissures

Dr.Nerve DYNAMIC DIAGNOSERS

Areola
➢ Size 4*4 cm brown in colour
➢ Circular, no cracks, fissures, and ulceration
Arms And Thorax
➢ No oedema, no cracks, no visible nodes, and fullness
Axilla
➢ No visible nodes
Supraclavicular Fossa – no fullness
On Raising Hands Above Heads
➢ Both breasts move equally
➢ Under surface of the breast appear normal
➢ No prominence of lump
➢ No peau’d orange appearance
➢ No retraction of nipple
On Leaning Forwards
➢ Breast fall equally on both sides
On Contracting Pectoralis Major By Keeping Hands At Hip
➢ The lump does not become prominent
PALPATION
➢ Not warm and not tender
➢ Single lump of size 4*3 cm hard in consistency, ovoid in
shape, well defined margins, irregular surface, felts in
the upper outer quadrant.
➢ Skin over the lump is pinchable

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ The lump moves along the breast tissue on contracting
and relaxing the pectoralis major there is no restriction
of mobility along the line of muscle fibre
➢ No fixity to chest wall/serratus anterior
Nipple
➢ No palpable mass deep to the nipple
➢ No discharge from the nipple
➢ No retraction of the nipple
➢ Examination of right axilla – no lymph node palpable
Right supraclavicular fossa – no nodes palpable
Examination of contralateral breast – normal
Examination of contralateral axilla – normal
Examination of contralateral supraclavicular fossa – normal
PERCUSSION
➢ Resonant note felt over parasternal areas
➢ Per rectal examination – to be done
➢ Per vaginal examination – to be done
Examination of other systems
➢ Examination of abdomen -soft, not tender, no
organomegaly, no palpable mass, no free fluid, hernia
orifices- free, external genitalia – normal
➢ Examination of RS – normal vesicular breath sounds
heard. No added sounds
➢ Examination of CVS – S1 and S2 heard, no murmur
➢ Examination of CNS – no focal neurological defects
➢ Examination of thyroid gland – normal and no swelling
Dr.Nerve DYNAMIC DIAGNOSERS
DIAGNOSIS
➢ Carcinoma of right breast – T2N0M0 stage II A
MANAGEMENT
➢ Investigations
o CBC, x-ray chest, ECG
o Mammogram of right breast
o FNAC of right breast lump
o Core needle biopsy
o Sentinel node biopsy
o Staging investigations
▪ X-ray chest
▪ USG abdomen
▪ Liver function test
▪ Bone scan
▪ X-ray skull and pelvis
▪ Mammogram of contralateral breast
TREATMENT
Wide location excision
Breast conservative surgery and adjuvant radiotherapy
of right breast

Dr.Nerve DYNAMIC DIAGNOSERS

 INGUINAL HERNIA

Name:
Age/Sex:
Occupation:
Education:
Address

CHIEF COMPLAINTS
Swelling in the lower abdomen near genital region for
____ days

HISTORY OF PRESENTING ILLNESS

Swelling
➢ Onset
➢ Progressive or not
➢ Aggrevating factor
➢ Relieving factor
➢ H/o pain
➢ Frequency of micturition
➢ Nocturia
➢ H/o nausea, vomiting, constipation, bloating sensation,
abdominal distension, bloating sensation.
➢ H/o chronic cough.

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ H/o prolonged heavy work/ weight lifting work.

PAST HISTORY
➢ H/o similar complaints in the past
➢ H/o previous abdominal/groin surgery
➢ H/o tb, asthma, bronchitis
➢ H/o trauma
➢ H/o diabetes, hypertension

TREATMENT HISTORY
➢ Taken any treatment for current condition
➢ Taken any medication for other ailments
➢ H/o allergy to drugs

FAMILY HISTORY
➢ H/o similar complaints in the family
➢ H/o any inherited disorder in the family

PERSONAL HISTORY
➢ Patient has good appetite
➢ Mixed diet consumer
➢ Sleep-undisturbed
➢ Bowel & bladder habits - regular, not strained
➢ Smoking
➢ Alcohol consumption

Dr.Nerve DYNAMIC DIAGNOSERS

GENERAL EXAMINATION

➢ Consent was obtained from the patient

➢ Patient is conscious
➢ Moderately built
➢ Moderately nourished
➢ Oriented or time, place, person, comfortable at rest

➢ Pallor, icterus, cyanosis, clubbing, edema and

generalised lymphadenopathy

VITALS:
➢ Bp
➢ Respiratory rate
➢ Pulse-
➢ Temperature
➢ BMI

LOCAL EXAMINATION
INSPECTION
➢ Size: shape:
➢ Surface: margins:
➢ Expansile cough impulse
➢ Reducibility
Dr.Nerve DYNAMIC DIAGNOSERS
 ➢ Surrounding skin
➢ Visible pulsation
➢ Visible peristalsis
➢ Penis
➢
PALPATION
➢ Inspectors findings confirmed
➢ Local rise in temperature
➢ Tenderness
➢ Consistency
➢ ReducibilitY
➢ Expansile cough impulse .
➢ Pulsation over swelling
➢ Get above the swelling
➢ Deep ring occlusion test:
➢ Ziemen’s test:
➢ Ring invagination test

PERCUSSION:

AUSCULTATION:
➢ Examination of superficial inguinal lymph nodes
➢ Per rectal examination

SYSTEMIC EXAMINATION

Dr.Nerve DYNAMIC DIAGNOSERS

Abdominal examination
CNS:
CVS:
RS:

DIAGNOSIS

INVESTIGATION

TREATMENT

CASE SHEET OF INGUINAL HERNIA

Name: Mr.Kumar
Age/Sex: 65/Male
Occupation: Watchman
Education: No formal education
Address: Poonamallee, Chennai
Dr.Nerve DYNAMIC DIAGNOSERS
CHIEF COMPLAINTS
Swelling in the right groin since 5 months

HISTORY OF PRESENTING ILLNESS

➢ Patient was apparently normal 5 months back after which
he noticed swelling in the right groin while walking.
Swelling was insidious in onset, initially small and now
progressed to the present size.
➢ It aggravates on standing, walking, coughing and lifting
heavy objects and disappears on lying down
➢ No h/o pain
➢ No h/o of other swelling in the body
➢ No h/o increased frequency of micturition, nocturia
➢ No h/o straining during micturition or defecation

➢ No h/o nausea, vomiting, constipation, bloating

sensation, abdominal distension, bloating sensation.
➢ No h/o chronic cough.
➢ No h/o prolonged heavy work/ weight lifting work

PAST HISTORY
➢ No h/o similar complaints in the past
➢ No h/o previous abdominal/groin surgery
➢ No h/o TB, asthma, bronchitis

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ No h/o trauma
➢ Not a known case of diabetes, hypertension

TREATMENT HISTORY
➢ Not taken any treatment for current condition
➢ Not on any medication for other ailments
➢ No h/o allergy to drugs

FAMILY HISTORY
➢ No h/o similar complaints in the family
➢ No h/o any inherited disorder in the family

PERSONAL HISTORY
➢ Patient has good appetite
➢ Mixed diet consumer
➢ Sleep-undisturbed
➢ Bowel & bladder habits - regular, not strained
➢ H/o smoking since 25 years (1 pack/day)
➢ No h/o alcohol consumption

GENERAL EXAMINATION

➢ Consent was obtained from the patient

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ Patient is conscious, moderately built, moderately
nourished, well-oriented or time, place, person,
comfortable at rest
➢ No pallor, icterus, cyanosis, clubbing, edema and
generalised lymphadenopathy

VITALS:
➢ BP-120/80 mm Hg
➢ RR- 16 cycles/min
➢ Pulse- 76/min ;
➢ Temperature - Afebrile
➢ BMI: 21 kg/m2

LOCAL EXAMINATION
Inspection
INGUINAL REGION
Right Groin:
➢ Patient is exposed from umbilicus up to mid thigh
➢ A solitary swelling is seen in the right groin
➢ Site and extent: Extends from medial to midinguinal point
up to root of the scrotum
➢ Size: 4*3 cm Shape: Globular
➢ Surface: Smooth Margins: Well-defined
➢ Expansile cough impulse present
➢ Reducibility present

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ Surrounding skin appears normal
➢ No visible pulsation
➢ No visible peristalsis
➢ Penis present in midline, no deviation seen
➢ Testis visible separately from swelling
➢ Left groin is normal, no swelling seen

PALPATION
➢ Inspectory findings confirmed
➢ No local rise in temperature
➢ No tenderness
➢ A solitary swelling of 4*3*1 cm extending from 1cm
above midinguinal point up to root of scrotum medial and
above to public tubercle
➢ Consistency: soft and elastic Reducibility: Reducible,
initial part difficult, last part easy
➢ Expansile cough impulse present. No pulsation over
swelling

➢ Not possible to get above the swelling

➢ Deep ring occlusion test: Swelling appears medial to
occlusion
➢ Ziemen’s test: impulse felt on middle finger
➢ Ring Invagination test: Impulse felt at superficial ring with
the pulp of the finger and the swelling is directed
backwards

Dr.Nerve DYNAMIC DIAGNOSERS

PERCUSSION: resonant

AUSCULTATION: Peristalsis sounds occasionally heard

External genitalia normal by palpation
Examination of superficial inguinal lymph nodes normal
Per rectal examination not done
On examination of left groin, it was found to be normal

SYSTEMIC EXAMINATION

ABDOMINAL EXAMINATION: Tone of abdominal muscles

normal, no abdominal masses, no ascites, no scars over
abdomen

CNS: No focal neurological deficit

CVS: S1,S2 heard, no murmurs
RS: Normal vesicular breath sounds heard

DIAGNOSIS

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ 65 year old man diagnosed with Right, incomplete,
uncomplicated, reducible, direct inguinal hernia,
probably containing intestine

INVESTIGATIONS
➢ Routine investigations: Complete Blood count (CBC),
RFT, serum electrolytes, Blood sugar, chest X-ray, ECG
➢ USG Abdomen

TREATMENT
➢ Lichtenstein’s tension-free hernioplasty.

Dr.Nerve DYNAMIC DIAGNOSERS

 SWELLING
Name :-
Age :-
Sex :-
Occupation :-
Address :-
Socioeconomic status :-
CHIEF COMPLAINTS
Swelling in the ________ for ____days
HISTORY OF PRESENT ILLNESS
➢ The patient was apparently normal before _______ days
and then he develops
HISTORY OF SWELLING
➢ Onset
➢ Progression
➢ Associated symptoms (fever ,pain)
H/O fever
H/O trauma
H/O discharge from the swelling
H/O other swellings
H/O loss of weight and appetite
H/O restriction to movements
Dr.Nerve DYNAMIC DIAGNOSERS
PAST HISTORY
➢ H/O similar complaints
➢ H/O diabetes mellitus, hypertension, TB, asthma
➢ H/O allergy
➢ H/O previous surgery
➢ H/O any treatment
PERSONAL HISTORY
➢ Diet – veg/non veg
➢ H/O smoking
➢ H/O alcohol intake
➢ H/O sleep
➢ H/O bowel and bladder habits
FAMILY HISTORY
➢ H/O similar complaints in the family
GENERAL EXAMINATION
➢ Consciousness and orientation to time, place, person
➢ Built and nourishment
➢ Pallor
➢ Icterus
➢ Cyanosis
➢ Clubbing
➢ Lymphadenopathy
➢ Pedal oedema

Dr.Nerve DYNAMIC DIAGNOSERS

VITALS
➢ Pulse rate
➢ Temperature
➢ Blood pressure
➢ Respiratory rate
LOCAL EXAMINATION
SWELLING
➢ Location
➢ Shape
➢ Measurement
➢ Margins – well defined or not
➢ Surface – smooth or hard
➢ Skin over swelling
o Colour change
o Punctum present or not
o Any visible pulsation
INSPECTION
➢ Any scar, sinus, dilated veins
➢ Any secondary changes in skin
➢ Surrounding area appearance
PALPATION
➢ Tenderness
➢ Warmth
➢ Margins
➢ Consistency
➢ Skin over swelling

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ Plane of swelling
➢ Motility
➢ Fluctuation test
➢ Compression
➢ Pulsation
➢ Transillumination
➢ Regional lymph node

OTHER SYSTEM EXAMINATION

➢ RS – normal vesicular breath sounds
➢ CVS – s1 and s2 heard normally
➢ Abdomen – any organomegaly present or not
➢ CNS – neurological defects
PROVISIONAL DIAGNOSIS

Dr.Nerve DYNAMIC DIAGNOSERS

 CASE SHEET OF SWELLING CASE
Name :- Dhanabal
Age :- 30 yrs
Sex :- Male
Occupation :- Cashier
Address :- Karur
Socioeconomic status :- Low socioeconomic status
CHIEF COMPLAINTS
Swelling in the right arm for past one and half years
HISTORY OF PRESENT ILLNESS
➢ The patient was apparently normal before past one and
half years and then he develops swelling in right arm
HISTORY OF SWELLING
➢ Onset - insidious
➢ Progression - Gradual
➢ Not associated with pain or fever
No H/O fever
No H/O trauma
No H/O discharge from the swelling
No H/O other swellings
No H/O loss of weight and appetite
No H/O restriction to movements

Dr.Nerve DYNAMIC DIAGNOSERS

PAST HISTORY
➢ No H/O similar complaints
➢ No H/O diabetes mellitus, hypertension, TB, asthma
➢ No H/O allergy
➢ No H/O previous surgery
➢ No H/O any treatment
PERSONAL HISTORY
➢ Diet – Non veg
➢ No H/O smoking
➢ No H/O alcohol intake
➢ H/O sleep is normal
➢ Normal H/O bowel and bladder habits
FAMILY HISTORY
➢ No H/O similar complaints in the family
GENERAL EXAMINATION
➢ Consciousness and oriented to time, place, person
➢ Moderately Built and moderately nourishment
➢ No Pallor
➢ No Icterus
➢ No Cyanosis
➢ No Clubbing
➢ No Lymphadenopathy
➢ No Pedal oedema

Dr.Nerve DYNAMIC DIAGNOSERS

VITALS
➢ Pulse rate :- 83 beats/min
➢ Temperature :- 114/72 mm Hg
➢ Blood pressure :- 17 /min
➢ Respiratory rate :- afebrile
LOCAL EXAMINATION
SWELLING
Informed consent was obtained from the patient
➢ Located in the right arm
➢ Shape- ovoid
➢ Measurement
o Upper limit – 10 cm from coracoid process
o Lower limit – 11 cm from the lateral epicondyle
➢ Margins – well defined
➢ Surface – smooth
➢ Skin over swelling
o No Colour change
o No Punctum
o No visible pulsation

INSPECTION
➢ No scar, sinus or dilated veins
➢ No secondary changes over the skin
➢ Surrounding area is normal

Dr.Nerve DYNAMIC DIAGNOSERS

PALPATION
➢ Tenderness - No
➢ Warmth - No
➢ Margins are well defined
➢ Consistency - soft
➢ Skin over swelling is pinchable
➢ Plane of swelling is subcutaneous
➢ Motility – free in all direction
➢ Fluctuation test- negative
➢ No Compressible
➢ No Pulsation
➢ Transillumination - negative
➢ Regional lymph node are not palpable

OTHER SYSTEM EXAMINATION

➢ RS – normal vesicular breath sounds
➢ CVS – s1 and s2 heard normally
➢ Abdomen – no organomegaly
➢ CNS – no focal neurological defects
PROVISIONAL DIAGNOSIS
A case of soft tissue, most probably lipoma

INVESTIGATIONS
GENERAL
➢ HB % TC less than DC less than ESR
➢ Urine albumin and sugar
Dr.Nerve DYNAMIC DIAGNOSERS
 ➢ Bleeding time, clotting time
➢ Blood sugar and urea
SPECIFIC
➢ FNAC
TREATMENT
➢ Under local anaesthesia
➢ Invasion along skin crease
➢ Excision is done

Dr.Nerve DYNAMIC DIAGNOSERS

 THYROID SWELLING
Name
Age
Sex
Occupation
Address
CHIEF COMPLAINTS
Swelling in front of neck
HISTORY OF PRESENT ILLNESS
➢ Elaborate the complaints of the patient
o Swelling – Onset, Duration, Rate of growth
➢ Ask about important local points or pressure effects
o H/O pain (Hemorrhage – local pain only)
o H/O sleep disturbance
o H/O palpitation
o H/O breathlessness
o H/O difficulty in swallowing
o H/O neck discomfort
o H/O hoarseness of voice
➢ Hyperthyroid symptoms
o H/O loss of weight despite good appetite
o H/O intolerance to heat and preference to cold
o H/O excessive sweating
o H/O tremors of hand
o H/O weakness of muscle
o H/O protruding eyes
Dr.Nerve DYNAMIC DIAGNOSERS
 o H/O difficulty in closing eyelids
o H/O double vision
o H/O oedema and swelling of conjunctivitis
o H/O amenorrhoea
o H/O chest pain
o H/O swelling of ankles
➢ Hypothyroid symptoms
o H/O weight gain despite poor appetite
o H/O intolerance to cold and preference to heat
o H/O dry skin puffiness of face
o H/O loss of hair
o H/O muscle fatigue
o H/O lethargy
o H/O failing of memory
o H/O constipation
o H/O oligomenorrhoea
➢ Any systemic complaints (history suggestive of metastasis)
o H/O fever – duration, grade, type, chills, rigor
o H/O bone pain
o H/O headache – unilateral or bilateral
TREATMENT HISTORY
Investigations done and up to date
PAST HISTORY
Any similar complaints
Any childhood irradiation
H/O TB and bronchial asthma
FAMILY HISTORY
Dr.Nerve DYNAMIC DIAGNOSERS
 ➢ Diet
➢ DM / HTN
➢ Addictions
➢ Sleeping habits
➢ Appetite
➢ Any STD
➢ Menstrual history
GENERAL EXAMINATION
Patient comfortably sitting, cooperative and well
oriented
Eye signs – horness syndrome – enophthalmos meiosis,
pseudoptosis, anhidrosis
➢ Built and nourishment
➢ Pallor, icterus, clubbing, cyanosis, pedal oedema and
lymphadenopathy
➢ Skin over neck
VITALS :-
➢ Pulse rate
➢ Blood pressure
➢ Temperature
➢ Respiratory rate
LOCAL EXAMINATION OF THYROID
INSPECTION
Pizillos method – short neck and obese people
Swelling site – front of lower part of neck

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ Shape and size
➢ Extent – horizontal and vertical
➢ Surface – smooth or irregular
➢ Border – well defined or ill defined
Movement with deglutition
Movement with protrusion of tongue
Skin over swelling – any pulsation or engorged veins, scars
Tracheal position
Any other swellings in the neck
PALPATION
➢ Thumb over atlanto-occipital joint
➢ Forefingers along the lower border of mandible rested
over skin
➢ Local rise of temperature
➢ Swelling palpable in front of lower part of neck
➢ Inspection findings about site, shape, size, extent,
borders, surface of swelling is confirmed
➢ Consistency of the swelling
➢ Plane and mobility
➢ Any fixity
➢ Moving on deglutition
➢ Getting below thyroid
➢ Skin over swelling – pinchable or not
➢ Carotid pulsation – on both sides equal or not
➢ Trachea position
➢ Any thrill palpable over gland
➢ Palpation of regional lymph node
Dr.Nerve DYNAMIC DIAGNOSERS
PERCUSSION
➢ On sternum – resonant / dull retrosternal goitre
AUSCULATATION
➢ Bruit over superior poles of thyroid
SYSTEMIC EXAMINATION
➢ Respiratory system
➢ Cardiovascular system
➢ GIT
➢ CNS
➢ Genitourinary system
➢ Oral cavity swelling on posterior border
PROVISIONAL DIAGNOSIS
➢ Anatomically - Swelling arising from the thyroid gland
➢ Pathologically – benign or malignant
➢ Functionally – thyroid status – hyper or hypothyroid

Dr.Nerve DYNAMIC DIAGNOSERS

 CASE SHEET OF THYROID

Name - Mrs. Gowri

Age - 45 years
Sex - female
Occupation – Home maker
Address - karur
CHIEF COMPLAINTS
Swelling in front of neck for past 5 years
HISTORY OF PRESENT ILLNESS
➢ Onset – insidious
➢ Duration – 5 years
➢ Rate of growth - gradual
➢ Ask about important local points or pressure effects
o No H/O pain (Hemorrhage – local pain only)
➢ Presence of Hyperthyroid symptoms like,
o H/O loss of weight despite good appetite
o H/O intolerance to heat and preference to cold
o H/O excessive sweating
o H/O tremors of hand
o H/O weakness of muscle
o H/O protruding eyes
o H/O difficulty in closing eyelids
o H/O double vision
o H/O oedema and swelling of conjunctivitis
o H/O amenorrhoea
Dr.Nerve DYNAMIC DIAGNOSERS
 o H/O chest pain
o H/O swelling of ankles
➢ Absence of Hypothyroid symptoms like,
o H/O weight gain despite poor appetite
o H/O intolerance to cold and preference to heat
o H/O dry skin puffiness of face
o H/O loss of hair
o H/O muscle fatigue
o H/O lethargy
o H/O failing of memory
o H/O constipation
o H/O oligomenorrhoea
➢ No systemic complaints (history suggestive of metastasis)
o H/O fever – duration, grade, type, chills, rigor
o H/O bone pain
o H/O headache – unilateral or bilateral
TREATMENT HISTORY
No significant treatment history
PAST HISTORY
No similar complaints
No childhood irradiation
No H/O TB and bronchial asthma
No DM,HT, epilepsy
FAMILY HISTORY
• No significant family history
PERSONAL HISTORY
Dr.Nerve DYNAMIC DIAGNOSERS
 ➢ Diet - mixed
➢ Addictions - no
➢ Sleeping habits - normal
➢ Appetite - normal
Menstrual history
• Attained menarche at 13 years
• Normal flow and regular cycle
• Not associated with pain and clot
• Not attained menopause
GENERAL EXAMINATION
Patient comfortably sitting, cooperative and well
oriented
➢ Moderately Built and nourished
➢ No Pallor, icterus, clubbing, cyanosis, pedal oedema and
lymphadenopathy
➢ No signs of hyperthyroidism like moist palm
➢ No signs of hypothyroidism like dry skin
➢ Eyes are normal and no evidence of toxic eye signs like
lid lag, lid retraction, conjunctival congestion and
corneal ulcer.
VITALS :-
➢ Pulse rate – 90/min
➢ Blood pressure – 130/70 mmHg
➢ Temperature - afebrile
➢ Respiratory rate – 18/min

Dr.Nerve DYNAMIC DIAGNOSERS

LOCAL EXAMINATION OF THYROID
INSPECTION
➢ A swelling in front of the neck, right lobe of size 6*4 cm
and isthmus 3*2 cm in region of thyroid
➢ Extent – upper border 2 cm from transverse ridge of
thyroid cartilage.
➢ Lower border 2 cm from suprasternal notch
➢ Right and left borders upto anterior border of
sternocleidomastoid muscle
➢ Surface – smooth
➢ Border – well defined
Movement with deglutition - yes
Movement with protrusion of tongue - no
Skin over swelling – normal
Tracheal position – appears to be in midline
No other swellings, scars, sinuses, dilated veins and visible
pulsations.
PALPATION
➢ No Local rise of temperature
➢ Swelling palpable in front of lower part of neck
➢ Inspection findings about site, shape, size, extent,
borders, surface of swelling is confirmed
➢ Two nodules palpable on either lobe of thyroid gland

Dr.Nerve DYNAMIC DIAGNOSERS

Nodule of left side
➢ single nodule of size 1*1 cm hemispherical in shape
present in right lobe
➢ Extent
o Upper border 2 cm from the transverse ridge of
thyroid cartilage
o Lower border 4 cm from the suprasternal notch
o Right border 3 cm from the anterior border of
sternocleidomastoid muscle
o Left border 2 cm from the midline
Nodule of right side
➢ Another nodule of size 1*2 cm hemispherical in shape
present in the right lobe
➢ Extent
o Upper border 3 cm from the transverse ridge of
thyroid cartilage
o Lower border 3 cm from the suprasternal notch
o Right border 4 cm from the anterior border of the
sternocleidomastoid muscle
o Left border 0.5 cm from the midline
➢ Firm in consistency
➢ Skin is pinchable
➢ Plane of swelling – deep to deep cervical fascia
➢ Lower border is palpable
➢ Carotid pulsation is felt equally on both sides
➢ Trachea is in midline
➢ No palpable thrill

Dr.Nerve DYNAMIC DIAGNOSERS

PERCUSSION
➢ No retrosternal dullness
AUSCULATATION
➢ No Bruit over superior poles of thyroid
SYSTEMIC EXAMINATION
➢ Respiratory system - normal
➢ Cardiovascular system - normal
➢ GIT - normal
➢ CNS - normal
➢ Genitourinary system - normal
PROVISIONAL DIAGNOSIS
➢ With the above history and clinical findings probable
finding is MULTINODULAR GOITRE without any
complications and with patient in euthyroid state.

Dr.Nerve DYNAMIC DIAGNOSERS

 ULCER
Name
Age
Sex
Occupation
Address
Religion
CHIEF COMPLAINTS
➢ Wound over ______ since ______
➢ If pain is there, since
HISTORY OF PRESENT ILLNESS
➢ The patient was apparently normal before _______
HISTORY OF WOUND/ULCER
➢ Appearance - trauma/spontaneous
➢ Site
➢ Onset
➢ Duration
➢ Progression
➢ H/o healed burns before wound care at that site
History of pain
➢ Site
➢ Onset
➢ Duration
➢ Progression

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ Character
➢ Severity
➢ Duration
➢ Diurnal and postural variation
➢ Aggravating an relieving factors
H/O Discharge
➢ Smell
➢ Nature
History Suggestive Of Varicose Veins
➢ Any h/o thread like swelling over legs
➢ H/o pigmentation, itching over legs before development
History Suggestive Of Vascular Insufficiency
➢ H/o intermittent claudication
➢ H/o rest pain
➢ H/o discolouration of one or more toes
➢ H/o pain by limb deviation
PAST HISTORY
➢ Any similar complaints in the past
➢ H/o diabetes,tb, asthma, mi, leprosy
➢ History suggestive of tb
➢ Cough
➢ Hemoptysis
➢ Loss of weight
➢ Loss of appetite
➢ Evening rise of temperature
➢ 6 months of antitubercular treatment

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ Any previous surgery
Allergy history
Treatment history
Family history
Personal history
➢ Diet
➢ H/o smoking
➢ H/o alcohol
➢ H/o substance abuse
➢ H/o appetite
➢ Regular bladder and bowel movements
➢ H/o sleep
EXAMINATION
General Examination
➢ Conscious, well oriented to time place and person
➢ Built and nourishment
➢ Pallor
➢ Icterus
➢ Cyanosis
➢ Clubbing
➢ Pedal oedema
➢ Lymphadenopathy
VITALS
➢ Temperature
➢ Respiratory rate
➢ Blood pressure
Dr.Nerve DYNAMIC DIAGNOSERS
 ➢ Pulse rate
LOCAL EXAMINATION
Inspection
Ulcer
➢ Size and shape – oval/circular/semilunar/vertically
oval/irregular
➢ Number
➢ Position
➢ Edge of ulcer – undetermined/punched
out/slopping/raised and pearly white beaded/everted
edge
➢ Floor – red granulation tissue/pale and smooth granular
tissue/wash leather slough
➢ Extent
Discharge
➢ Amount
➢ Smell
➢ Colour – yellow/greenish/golden yellow
➢ Nature – serous/purulent/sero sanguineous/bloody
Surrounding area – red and oedematous/pigmented/
stretched/skinny
➢ Any loss of hair
➢ Any scars or sinuses
➢ Any dilated tortuous veins around ulcer
➢ Rest of lower limb at other site is normal or not

Dr.Nerve DYNAMIC DIAGNOSERS

PALPATION
➢ Local rise in temperature and tenderness
➢ Edge, margins, base of ulcer – any indications
➢ Depth of ulcer
➢ Whether bleeds on touch
➢ Mobility/fixity of ulcer
➢ Surrounding skin
o Temperature and tenderness
o Mobility and fixity
o Any loss of sensations/motor functions
o Any thickened/oedematous
➢ Peripheral nerves around any abnormal thickening/
tenderness
➢ Joint functions – restricted or not
EXAMINATION OF LYMPH NODES
➢ Enlarged tender and shows signs of acute lymphadenitis
➢ Enlarged and slightly tender – tb ulcer
➢ Stony hard and fixed – malignant ulcer
SYSTEMIC EXAMINATION
➢ Examination of chest
➢ Examination of neck
➢ Examination of abdomen
➢ All lymph nodes of body
➢ CVS and spine
➢ CNS

Differential diagnosis
Dr.Nerve DYNAMIC DIAGNOSERS
 ➢ Traumatic ulcer
➢ Ischemic/arterial ulcer
➢ Venous ulcer
➢ Trophic ulcer
➢ Diabetic ulcer
➢ Tuberculous ulcer
➢ Lupus vulgaris

Investigations
➢ Blood examination
➢ Urine examination
➢ Blood sugar
➢ Culture from discharge
➢ Skin test
➢ Chest x-ray
➢ Biopsy
➢ Contrast radiography

Provisional diagnosis

Dr.Nerve DYNAMIC DIAGNOSERS

 CASE SHEET OF DIABETIC ULCER

Name - XXX
Age - 60
Sex - male
Occupation – daily wage worker
Address - XXXX
Religion - X
CHIEF COMPLAINTS
➢ Wound over left foot since 1 month
HISTORY OF PRESENT ILLNESS
➢ The patient was apparently normal before 1 month
HISTORY OF WOUND/ULCER
➢ Appeared after trauma
➢ Site left foot
➢ Onset - sudden
➢ Duration – 1 month
➢ Progression - gradual
➢ No H/o healed burns before wound care at that site
H/O Discharge
➢ Smell - foul
➢ Nature - pus
➢ Duration – since 3 weeks

Dr.Nerve DYNAMIC DIAGNOSERS

PAST HISTORY
➢ He is a known case of diabetes past 10 years
➢ No H/O HTN, TB, asthma, leprosy, epilepsy
➢ No H/O fever
➢ No H/O previous surgery
No Allergy history
Treatment history
➢ Regular treatment for diabetes
Family history
➢ No significant family history
Personal history
➢ Diet
➢ No H/o smoking, alcohol and substance abuse
➢ H/o appetite is normal
➢ Regular bladder and bowel movements
➢ H/o sleep is normal
EXAMINATION
General Examination
➢ Conscious, well oriented to time place and person
➢ Well Built and nourished
➢ No Pallor
➢ No Icterus
➢ No Cyanosis
➢ No Clubbing
➢ No Pedal oedema

Dr.Nerve DYNAMIC DIAGNOSERS

 ➢ No Lymphadenopathy
VITALS
➢ Temperature - afebrile
➢ Respiratory rate – 14/min
➢ Blood pressure – 125/78 mm Hg
➢ Pulse rate – 76/min
LOCAL EXAMINATION
Inspection
Ulcer
➢ Size and shape – 3*4 cm and solitary, irregular
➢ Number - 1
➢ Position – lateral aspect of left foot occupying 5th toe
➢ Edge of ulcer – slopping, inflamed and oedematous
➢ Floor – red granulation tissue with slough
➢ Extent – plantar aspect of the toe
Discharge
➢ Amount - scanty
➢ Smell - foul
➢ Nature – purulent.
Surrounding area
Inflamed and pigmented
➢ No loss of hair
➢ No scars or sinuses
➢ No dilated tortuous veins around ulcer
➢ Rest of lower limb at other site is normal

Dr.Nerve DYNAMIC DIAGNOSERS

PALPATION
➢ No Local rise in temperature and tenderness
➢ Inpectory findings are confirmed
➢ Depth of ulcer – 0.5 cm
➢ No bleeding on touch
➢ Mobile ulcer
➢ Surrounding skin
o No rise in Temperature and tenderness
o Mobility - mobile
o No loss of sensations/motor functions
o No thickened/oedematous
➢ Peripheral nerves around any abnormal thickening/
tenderness
➢ Joint functions – normal

EXAMINATION OF LYMPH NODES

No enlarged lymph nodes

SYSTEMIC EXAMINATION
➢ Examination of chest - normal
➢ Examination of neck - normal
➢ Examination of abdomen - normal
➢ All lymph nodes of body - normal
➢ CVS and spine - normal
➢ CNS - normal

Dr.Nerve DYNAMIC DIAGNOSERS

Differential diagnosis
➢ Traumatic ulcer
➢ Venous ulcer
➢ Diabetic ulcer
Investigations
➢ Blood examination
➢ Urine examination
Provisional diagnosis
➢ Diabetic ulcer

Dr.Nerve DYNAMIC DIAGNOSERS

TEAM OF DYNAMIC DIAGNOSERS…..

AARTHIKA MYTHILI PRIYA

AKSHAYA NIRMAL
GEETHANJALI PRAVITHA
JAMEEN SNEHA
KRISHNA KUMAR SOWMIYA RAJ
MAMTA SURJITH
MOONITHA SUVEETHA

TEAM IMPULSE…..
MUKESH KANNA

Dr.Nerve DYNAMIC DIAGNOSERS

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Dr.Nerve DYNAMIC DIAGNOSERS

Dr.Nerve DYNAMIC DIAGNOSERS