Case History and Management Protocol

EXAMINATION OF A FAMILY HISTORY

History of breast lump or surgeries /
BREAST LUMP gynaecological surgeries in 1st and 2nd
degree relatives

Name Age Pre/Post Menopausal TREATMENT HISTORY

Occupation Socioeconomic status OCP or HRT

COMPLAINTS: GENERAL EXAMINATION

Painless Lump in right or left breast Conscious, Coherent, comfortable
Nipple retraction/discharge in the recent Built and nourishment, PICCLE
past Vitals

PRESENTING ILLNESS: LOCAL EXAMINATION OF BREAST

Lump in Breast Site, Duration, Mode of
onset, Progression, any sudden increase in
size, associated symptoms like pain, fever
If present, describe about pain nature,
character, site, any radiation, duration
History of nipple retraction since birth /
recent retraction
History of nipple discharge Unilateral or
bilateral, nature(bloody/serous/milky),
quantity, surrounding skin erosion
History of lump elsewhere in this side or
contralateral breast
History of fever
History of Bone pain (Back ache)
History of abdominal pain, jaundice,
Breathlessness
History of loss of weight or loss of appetite
History of trauma
PAST ILLNESS
Comorbidities / Previous breast lump or
surgery done
Previous gynaecological surgeries
PERSONAL HISTORY
Smoking, Alcohol, Diet rich in fat
MENSTRUAL HISTORY
Age at Menarche
Cycles
LMP
MARITAL HISTORY
Marital status / sterilised or not
OBSTETRIC HISTORY
Age at 1st child birth
How many children, mode of delivery,
Adequately breast fed or not
(DISEASED SIDE FIRST)
INSPECTION:
After getting consent from patient, patient is
stripped from neck to waist. Inspecting the
patient in sitting with arms by side, arms
raised above, arms pressing and relaxing
over the hips, supine position, patient in
leaning forward position
Look for any asymmetry comparing both
Look for Contour, Nipple and areolar
complex Site, Position, Nipple retraction /
deviation
Any Lump or fullness, if seen describe its
size, shape, site, borders
Skin over the lump for ulceration, edema,
nodules, dilated veins
Inframammary fold
Look for lump falling forward along with
breast tissue
Axilla, Supraclavicular fossa for fullness
PALPATION:
Local rise of temperature, Tenderness
Lump Site, size, shape, extent, surface,
borders, consistency, intrinsic mobility
Any puckering or tethering on moving the
lump
Any nipple retraction or discharge while
palpating lump
Skin over the lump moves freely or not
Lump mobility on putting pectoralis major,
serratus anterior muscle into contraction to
look for chest wall and pectoral muscle
invasion
AXILLA: Single / multiple, discrete or
matted, hard , nodes involving anterior /
central group with largest measuring size
and mobile or fixed.
Supraclavicular region palpate for nodes

Dr Pradeep Dhanasekaran | Madras Medical College 1

 Case History and Management Protocol

PERCUSSION: for internal mammary nodes STAGE III Locally advanced Breast cancer

EXAMINATION OF CONTRALATERAL Bilateral Xray &Sonomammogram of both

BREAST, AXILLA AND
SUPRACLAVICULAR REGION
SYSTEMIC EXAMINATION
CVS, RS
ABDOMEN Liver, Ascites, Krukenberg
tumor
SPINE Paraspinal tenderness
LOCAL BONE REGION (if bone pain any)
DIAGNOSIS:
Aged pre/post menopausal women with
painless hard lump in right or left breast
with nipple retraction and chest wall or skin
infiltration with axillary nodes -------
Carcinoma right or left breast with TNM
________ belonging to stage _______
breast & axilla
Core needle biopsy and IHC
FNAC of the node
Staging Workup:
CT chest, CT abdomen and pelvis, Bone scan
CBC, RFT, LFT, Blood grouping, Viral
markers
ECG and ECHO(must as we start on NAC
which are cardiotoxic)
Neoadjuvant Chemotherapy 2 to 4 cycles
Then Modified Radical Mastectomy
Adjuvant Chemotherapy, Radiotherapy
and Hormonal therapy.

HOW WILL YOU PROCEED?

Stage I, II -
Bilateral Xray & Sono mammogram of
both breast and axilla
FNAC (expected by our examiners) or
Core needle biopsy of the lump with
IHC. FNAC of the axillary node(if
present).
If it confirms malignancy, as a part of
staging workup, Chest Xray PA view,
USG abdomen & Pelvis.

Then investigations for anaesthesia

including routine blood investigations, viral
markers, ECG and ECHO.

Surgery with Axillary dissection

and Radiotherapy, Adjuvant
Chemotherapy and Hormonal
therapy.

Dr Pradeep Dhanasekaran | Madras Medical College 2

 Case History and Management Protocol
EXAMINATION OF
ARTERIAL DISEASE
HISTORY
Name . Age/Sex Addiction to
Smoking. Occupation . Place .
COMPLAINTS
Pain in the R/L or Both Lower limb x
duration
With Non healing Ulcer involving the Region
x duration
Followed by Blackish discolouration over the
Ulcer x duration
ELABORATING PRESENTING ILLNESS
Pain Duration, Site, Mode of Onset,
Progression, Radiation of pain, aggravated
by walking/exercising/application of
warmth/cold / even at rest / increased by
keeping leg at higher level or not , Relieving
factors -- to find whether its claudicant or
rest pain.
If its claudicant limited to which region,
Whats the distance. And Grade
If its rest pain How he manage to tolerate
pain
Ulcer Duration, Site, Mode of onset,
Progression, Healing or Non healing,
Bleeding or Discharge and how it
transformed into gangrene (if any)
Associated any paraesthesia Duration, Site
& Extent, Nature & Character (Continuous
or intermittent, Pins & needle or pricking or
radiating
OTHER HISTORY:
Trauma to rule out it as a cause/ inciting
event
H/o Other Vascular symptoms due to other
vessel involvement:
H/o Syncopal attacks/ black outs / Visual
disturbances / Chest pain / Abdominal Pain
/ Upper limb paraesthesia or weakness /
Impotence
PAST HISTORY:
Comorbid Illness SHT/ DM / BA / COPD /
IHD / Seizures / Vascular illness
Previous Vascular Surgery / Any surgery
Previous treatment History
Dr Pradeep Dhanasekaran | Madras Medical College
PERSONAL HISTORY
Smoking with PYI, Alcoholic history, Food
Fatty / Cholesterol foods (NV)
FAMILY HISTORY
DRUG HISTORY
SUMMARY - aged Male who is addicted
to smoking, with Claudicant / Rest pain
involving the R/L lower limb with
associated Non healing Ulcer with Gangrene
with comorbidities probably we are
dealing with Peripheral vascular disease
GENERAL EXAMINATION
Consciousness, Built & nourishment,
Febrile, Hydration status
Pallor /Icterus / Cyanosis / CLUBBING /
PEDAL EDEMA / Lymphadenopathy
Nicotine Staining in the fingers / any
missing toe/leg
LOCAL EXAMINATION
INSPECTION Lower limb
1. Attitude of the limb
2. Colour of the limb with respect to
local region from normal region or
normal side
3. Look for Ischemic features Skin
thinning, Loss of hair / shininess,
Loss of subcutaneous fat, muscle
wasting, nails, guttering of veins all
compared to other side
4. Tell about the Ulcer Number,
Shape, Size, Site, Extent, margins,
edges, floor, any
slough/bleeding/exposing any bone
and surrounding skin
5. If any gangrenous changes Extent
& colour, Dry or wet and line of
demarcation and any skip lesions or
patch in normal surrounding area.
6. Range of movements of associated
joints
PALPATION
1. Local temperature and tenderness
associated with ulcer
2. Any muscle wasting / Guttering of
veins on elevation of limb
3
 Case History and Management Protocol

3. Capillary filling time General Blood Specific Investigations

4. Ulcer Number, shape, size, site, Investigations
extent, Margins, edges, floor, base, CBC anemia, Serum lipid profile &
mobility, surrounding skin leucocytosis, hsCRP
5. Gangrene hard & shrivelled or platelets Echocardiography
edematous & crepitus Blood and Urine Ankle Brachial
6. Surrounding area crepitus or edema sugar Pressure Index
7. Any thrombophlebitic changes in RFT Urea & Doppler Ultrasound of
veins / Tenderness along arteries creatinine, the lower limb
8. Palpation of Peripheral pulses Electrolytes arteries
Pulse volume and tension, Condition LFT Bilirubin, CT Angiogram
of the arterial wall or associated Albumin
thrombosis. Blood grouping,
9. Sensory examination to touch, ECG & Chest X ray
pain, temperature PA view
10. Motor examination range of
movements, power
11. Lymph Node examination
ATHEROSCLEROTIC DISEASE:
AUSCULTATION
Stop smoking
Local arterial bruit Control other risk factors
Start on Statins
SYSTEMIC EXAMINATION Aspirin

CARDIO VASCULAR Heart sounds, Claudicant alone Supervised exercise

murmur, thrill
RESPIRATORY respiratory sounds and
added sounds
ABDOMEN soft , organomegaly, fluid ,
tenderness
CNS any paralysis or paresis.
PROVISIONAL DIAGNOSIS :
aged male, who is a smoker & (comorbid
illness), relevant past history, claudicant or
rest pain duration, Nonhealing Ulcer with
features of chronic ischemia and dry
gangrene of the region with impalpable
.. pulse possibly Chronic Peripheral
arterial occlusive disease involving the ____
region of the lower limb due to
Atherosclerosis / TAO
MANAGEMENT
program and drugs.
Toe gangrene CT angio and locate the
disease, the plan on surgery
Only Infrainguinal disease Reversed
saphenous vein graft
Suprainguinal disease Endovascular
dilatation and stenting or Bypass graft using
PTFE or Dacron depending on TASC
guidelines.
TAO:
Stop smoking
It will prevent progression
Claudicant Supervised exercise program,
Buergers exercise

1. Pain relief Analgesics / Epidural Lumbar symphatectomy CI in claudication

2. Antibiotics
3. Cessation of smoking habits
4. Control of Sugar, Correction of
electrolyte abnormalities
5. Dressing or debridement of the
ulcer if needed
Read about the steps of procedure
Revascularisation to be done if distal run off
is good. (but in most cases run off wont be
good. So tell at last)

Dr Pradeep Dhanasekaran | Madras Medical College 4

 Case History and Management Protocol
EXAMINATION OF NECK
SWELLING
Name Age/Sex Occupation Place
COMPLAINTS:
Painful / Painless Swelling in the
midline/lateral neck
ELABORATING PRESENTING ILLNESS:
SWELLING Duration, Mode of Onset,
Progression, aggravating or relieving
factors, any discharge or colour change
associated with the swelling, associated
with fever or pain
PAIN Duration, Nature, Character,
Radiation, Aggravating or relieving factors
FEVER Duration, Nature, chills & rigor
DEPENDING ON LOCATION:
MIDLINE SWELLING Pain, Change in
voice, Breathlessness, Dysphagia, Fever,
Pain during swallowing
LATERAL SWELLING Increase in size
during meals, Increased salivation, Any
painful ulcers in oral cavity, Difficulty in
speaking, Change in voice, Referred pain to
ear, Odynophagia, Loss of hearing, Bleeding
through nose, Change in intonation of
speech, Dysphagia, Regurgitation,
Hemetemesis, Signs of horners syndrome
COMMON HISTORY:
Evening rise of temperature with night
sweats
Fever
Loss of weight, Loss of appetite
Cough with hemoptysis
Swelling elsewhere
Trauma
PAST ILLNESS:
Comorbidities
Previous Head & Neck surgery
Previous Irradiation to head & neck
HIV AIDS, Prolonged hospitalization
PERSONAL : Tobacco chewing, Smoking
and Alcoholic History
FAMILY / DRUG HISTORY
Dr Pradeep Dhanasekaran | Madras Medical College
GENERAL EXAMINATION:
PICCLE
Generalized lymph node examination
LOCAL EXAMINATION:
INSPECTION OF NECK:
Patient in sitting posture, inspected from
front
SWELLING Number, size, shape, site,
extent, surface, borders, Pulsations, cough
impulse
Skin over swelling colour, surface, dilated
veins, Sinus, fistula, Ulcer, Scars
If any of the above present, describe its
location, size, extent, discharge nature,
quantity, smell etc.
Any other swellings special mention about
Thyroid
Trachea & Carotids
Any obvious Muscle wasting
Anything obvious in Face and Chest
PALPATION:
Palpating from behind the patient with neck
flexed
Any local rise of temperature & tenderness
SWELLING Above findings + Surface,
Consistency, Borders, Reducible or
compressible (if soft) and Transillumination
and Fluctuation (if cystic)
Mobility & Pulsations (transmitted or
Expansile) & cough Impulse
Skin over the swelling able to glide over
the swelling
Trachea & Carotids
PERCUSSION : only in suspected
Laryngocele
AUSCULTATION : Bruit only in SCA / CA
aneurysm
EXAMINATION OF CRANIAL NERVES
Test the muscles SCM and Trapezius (SAN)
Test the muscles of Tongue for Hypoglossal
Deviation of uvula for Vagus
EXAMINATION OF DRAINAGE AREAS (IN
CASE OF NODAL SWELLINGS)
1. Scalp, Ear and Nose
2. Oral cavity
3. Thyroid
4. Lung, Breast
5. Abdomen and External Genitalia
5
 Case History and Management Protocol

EXAMINATION OF OTHER GROUP OF NONHODGKINS

NODES
CHEMOTHERAPY
SYSTEMIC EXAMINATION CHOP regimen Cyclophosphamide,
CVS, RS, Abdomen, CNS Hydroxydaunorubicin (Adriamycin) ,
Oncovin (vincristine) and Prednisolone
DIFFERENTIAL DIAGNOSIS: Rituximab added Anti- CD20 antibody for
B cell lymphomas.
NODAL SWELLING - SECONDARIES ,
TUBERCULOUS, LYMPHOMA CLINICALLY AND HISTORY IN FAVOUR OF
SECONDARIES NECK WITH KNOWN
RARELY STRAIGHTFORWARD SWELLINGS PRIMARY:
Thyroglossal Cyst, Branchial Cyst, Carotid
Body tumors Blood Investigations Plus Confirmation of
Neck Node by doing FNAC.
Malignant Deposits from Primary
PROTOCOL FOR FURTHER EVALUATION STAGING WORK UP OF PRIMARY

CLINICALLY AND HISTORY MORE IN Plan on Surgery.

FAVOUR OF TUBERCULOSIS
SECONDARIES NECK WITH UNKNOWN
CBC ESR Node biopsy under PRIMARY
RFT LFT LA/GA
Blood group Send for TB culture Blood Investigations
ECG and HPE and also IHC ECG Chest X ray PA view
Chest X ray PA if you have
Sputum for AFB lymphoma in mind Confirm its a metastatic node by FNAC
If proven, do Evaluation for Unknown
Confirmed as TB : Start on CATEGORY I Primary
ATT.
CECT or MRI of the Head and Neck
PRIMARY LYMPHOMA
Lesion Detected Biopsy from the Lesion
CBC ESR RFT LFT STAGING WORKUP
BG, Viral markers CT NECK Not detected Pan Endoscopy
ECG Chest xray PA CT CHEST (Nasopharyngoscopy, Esophagoscopy,
Node biopsy HPE CT ABDOMEN & Bronchoscopy, Video laryngoscopy)
and IHC PELVIS
Still Not detected Surveillance Biopsy
TREATMENT: from Tonsils, Fossa of rosenmuller,
Vallecula, Pyriform fossa and base of
HODGKINS : tongue)
STAGE I & II Radiotherapy If everything fails PET CT
STAGE III & IV Systemic chemotherapy
and Radiotherapy Lesion Detected BIOPSY PROVE
Chemotherapy regimen preferred Malignancy.
ABVD Adriamycin, Bleomycin, Vinblastine
and Dacarbazine Then STAGING WORK UP
Read about the drugs, mechanism of action CT CHEST & USG Abdomen
Radiotherapy fields and dosage
Plan for Primary RT Tumors of
Nasopharynx, Larynx and Oropharynx

Dr Pradeep Dhanasekaran | Madras Medical College 6

 Case History and Management Protocol

Primary Surgery
Oral cavity tumors ( Depends on Staging)

Might need Adjuvant or Palliative

Concurrent Chemoradiation depends on
Staging.

Neck dissection read in Oral cavity

malignancies management.

If it comes as adenocarcinoma, due to head

and neck origin like
Salivary gland tumors
Thyroid malignancies - Neck dissection
mandatory.

If its due to GI origin, prostate, testes, ovary,

breast
Its advanced.
So Paclitaxel and Dacarbazine as palliative
systemic chemotherapy initiated.

THYROGLOSSAL CYST:

Sistrunk Procedure (removal of cyst along

with the body of hyoid bone in midline )

BRANCHIAL CYST:

Evaluate with MRI Neck

Locate the cyst
Complete Excision of the cyst is needed to
prevent recurrence.

CAROTID BODY TUMORS:

CT Angiogram of the head and neck must

Look for the tumor relation with the ECA
and ICA and its encasement.
If tumor <5 cm, Go ahead with resection
Resection should be in the periadventitial
plane of the vessel.
Chances of Vagus nerve, hypoglossal nerve
and Marginal mandibular nerve to be
injured.
Should be explained to the patient.
Read about Shamblin classification.

Dr Pradeep Dhanasekaran | Madras Medical College 7

 Case History and Management Protocol

EXAMINATION OF ORAL Dentition Tobacco staining / caries /

missing tooth
CAVITY CANCERS - Hygiene
Lesion (ULCER) Site, size, shape, extent,
TONGUE / GB SULCUS margins, surface, floor, bleeding or not,
BUCCAL MUCOSA movements of the tongue

Rest of Oral cavity

Name Age/Sex Tobacco Chewer LIP ( Evert and see)
Occupation PALATE (Hard palate, soft palate and uvula)
Gingiva (on either sides of alveolus)
COMPLAINTS: Buccal Mucosa and Retromolar trigone
Painless Ulcer in the Tongue / Buccal Floor of Mouth
mucosa Look for openings of Stenson and Wharton
Swelling in the Lateral aspect of Neck duct
Faucial pillars, Tonsils, Posterior
ELABORATING PRESENTING ILLNESS: pharyngeal wall, Posterior third of tongue
ULCER Duration, Site, mode of onset, Look for any external swelling in the face.
progression, bleeding or pus from ulcer, any
pre-existing lesions PALPATION:
PAIN Duration, nature, character, any
radiation of pain to ear, aggravating or Tenderness, Bleeds on Touch
relieving factors All findings of Ulcer + Consistency, Base,
NECK SWELLING Mode of onset, Mobility & Surrounding induration
Progression, duration, any discharge or Palpate Base of Tongue, Floor of Mouth and
sinus or ulceration Mandible
Bidigital palpation of Buccal mucosa
Excessive salivation / Halitosis For tongue (Palpation to be done with
Difficulty in Speech / Opening mouth / tongue inside mouth, ie, relaxed tongue)
Pain during swallowing / Difficulty in
swallowing MOVEMENTS OF TONGUE Test the
Change in Voice Extrinsic muscles (Protruding, retracting,
Difficulty in protruding tongue out elevating and depressing tongue) and
Hemetemesis / hearing loss Intrinsic muscles (Rolling tongue
Fever horizontally upwards and downwards and
Trauma due to dentures / reverse smoking Rolling tongue longitudinally)
PAST ILLNESS: MOVEMENT OF TMJ : Protraction,
Comorbidities, Past Surgery or Retraction, Elevation, Depression and
hospitalization Lateral excursion.
PERSONAL : EXAMINATION OF NECK:
Smoking, Alcohol, Tobacco History Nodes Number, Mobility, Tenderness,
Consistency, Size, Groups of Nodes
FAMILY / DRUG HISTORY Carotids & Trachea
Muscle weakness
GENERAL EXAMINATION: Any facial
swelling, Cervical nodes EXAMINATION OF CRANIAL NERVES
LOCAL EXAMINATION EXAMINATION OF EAR AND NOSE
INSPECTION OF ORAL CAVITY:
SYSTEMIC EXAMINATION
Mouth Opening Adequate, Interincisior
distance CVS / RS / ABDOMEN / CNS

Dr Pradeep Dhanasekaran | Madras Medical College 8

 Case History and Management Protocol

DIAGNOSIS: T1 Wide local excision and primary

CARCINOMA TONGUE WITH CERVICAL closure
NODES WITH STAGE T2 Hemiglossectomy
CARCINOMA BUCCAL MUCOSA WITH T3 Hemiglossectomy
CERVICAL NODES WITH STAGE T4 Near total or total glossectomy

TREATMENT PROTOCOL NECK DISSECTION:

If anemic, do CBC Clinically Node negative In case of Tongue,

BT/CT/PT INR before Biopsy Floor of mouth, Buccal mucosa tumors, if its T2
or more, go ahead with Prophylactic SOHND.
1st Confirm the diagnosis
Edge Biopsy of the Lesion/Ulcer under
LA/GA

Biopsy Proven:

STAGING INVESTIGATIONS:

USG Neck for Nodes

CECT Head and Neck for T and N staging

USG Abdomen, Chest X ray PA view or CT

Chest for M staging

Depending on Stage, Management options

are
I Primary surgery/RT alone Tell about the Reconstructive options
II Primary surgery + RT (if close
margins, LV/perineural For T2 and T3 lesions after
invasion) hemiglossectomy, reconstruction option in
III Primary Surgery + Adjuvant the form of Radial forearm free flap cover
Concurrent Chemoradiation done.
IVA, Chemoradiation then surgery (if Postoperative speech rehabilitation needed
IVB resectable) & MRND
IV C Palliative Chemoradiation Then Radiotherapy:
1. More than 2 nodes involved
Surgery Options: 2. Extracapsular spread
1. 1-2 cm wide local excision in all 3. More than 1 level of nodes involved
sides necessary
2. Neck dissection for nodal disease 50Gy in 25# for 5 days a week for 5 weeks.
Cisplatin based chemotherapy
TONGUE:
BUCCAL MUCOSA:
Partial Glossectomy (less than one third of Same management
tongue) Wide local resection including buccinator
Hemiglossectomy (one third to half of muscle
tongue) Neck dissection
Near-total glossectomy (half to three N0 No neck dissection
quarters of tongue) N1 - MRND
Total glossectomy (greater than three
quarters of tongue)

Dr Pradeep Dhanasekaran | Madras Medical College 9

 Case History and Management Protocol

EXAMINATION OF PALPATION:

ULCER ULCER Same as above + Tenderness,

Edges, Margins, Depth, Base, Mobility,
Bleeding on touch
Name Age/Sex Occupation Place Surrounding skin Texture, Consistency
Regional Arteries, Veins, Nerves
COMPLAINTS:
Non healing / Healing Ulcer (Painful Neurologic examination Sensory and
/Painless) Region Motor
Range of Movements of Joints
ELABORATING PRESENTING ILLNESS
REGIONAL LYMPH NODE EXAMINATION
ULCER Duration, Mode of onset
(Traumatic / Spontaneous), Progression, SYSTEMIC EXAMINATION
Discharge, Pain
DIAGNOSIS
PAIN Duration, Nature, Character, Chronic Non healing / Traumatic Healing /
aggravating or relieving factors Diabetic / Malignant Ulcer
Discharge Nature, quantity, smell
EVALUATION:
Fever
Any swelling elsewhere Blood Investigations
Any chronic leg pain / Claudicant pain CBC Anemia, Leukocytosis
Any weakness / Loss of sensation in the Blood Sugar
Ulcer area Urea and Creatinine
Loss of Weight/Appetite (Malnutrition) Albumin and Proteins
LFT and Enzymes
PAST ILLNESS: Blood grouping
DM / SHT / TB / SYPHILIS / HIV AIDS Viral Markers
Previous surgery Lipid profile
Previous CVA / Spinal disorders ECG, Chest X ray PA view
Previous History of irradiation / Burns /
Chronic exposure to sunlight Local Part X ray Osteomyelitis
Biopsy of the Ulcer (Chronic)
PERSONAL : Tobacco, Alcohol, Smoking Wound Swab C/S
FAMILY / DRUG HISTORY Debridement (if Unhealthy)

GENERAL EXAMINATION: Appropriate antibiotics

Any Obvious disease stigmata of Leprosy /
Syphilis / DM / Vascular or Venous disease
PICCLE
LOCAL EXAMINATION:
Regular Cleaning and Dressing
Arterial and Venous Doppler (if vascular
disease in doubt)
Control of Diabetes

INSPECTION: Granulation tissue well developed

Swab Negative
ULCER Shape, size, Site, extent, edge,
Margins, floor, discharge Plan for Split Skin Grafting / Flap cover.
Surrounding skin Colour, edema, Dilated
veins
Examine for signs of Neuropathy / Chronic
Ischemia / Chronic venous insufficiency

Dr Pradeep Dhanasekaran | Madras Medical College 10

 Case History and Management Protocol

EXAMINATION OF PALPATION:

PAROTID Local rise of temperature, Tenderness

Swelling Above findings + consistency,
Surface
Mobility over masseter muscle
Name Age/Sex Occupation Place Skin infiltration by the tumor
Deep Lobe Palpation Bimanual Palpation
COMPLAINTS:
Superficial Temporal artery palpation
Painless swelling below the ear lobule
ORAL CAVITY EXAMINATION :
Deviation of angle of mouth
Trismus
ELABORATING PRESENTING ILLNESS:
Openings of stenson and Wharton duct
Bidigital palpation of stenson duct
Swelling Exact site, duration, mode of
Position of Tonsils
onset, progression, increase in size during Any minor salivary gland enlargement
meals, any discharge from the swelling,
Jaw movements
associated colour change in the swelling,
associated with fever and pain?
EXAMINATION OF NECK:
Pain Duration, Nature, character,
Trachea
aggravating or relieving factors
Carotids
Cervical Lymph nodes
Fever nature, associated with chills and
Any other swellings
rigor, duration
Halitosis / Dysphagia / Odynophagia
EXAMINATION OF CRANIAL NERVES
Swelling elsewhere in the body
Trauma
Facial Nerve Wrinkling of forehead, Bells
phenomenon, Puff out cheeks, Deviation of
PAST ILLNESS:
angle of mouth
Spinal accessory Nerve Muscle weakness,
Comorbidities
and Testing the SCM and Trapezius.
Viral fever
Previous Major surgery or Prolonged
EXAMINATION OF OTHER SALIVARY
hospitalization GLANDS
PERSONAL / FAMILY / DRUG HISTORY:
DIAGNOSIS:
GENERAL EXAMINATION:
Malignant Tumor involving the Right or Left
Parotid gland with or without Facial nerve
Look for other swellings / cervical nodes
weakness / palsy and cervical nodal
enlargement.
LOCAL EXAMINATION:

INSPECTION:

Swelling Shape, Size (lifting the ear lobule

or not, obliteration of the hollow), Site,
Extent, Borders, Surface
Skin over the swelling Colour, Brawny
induration / sinus / edema / ulceration.
Signs of Facial Nerve Weakness If obvious

Dr Pradeep Dhanasekaran | Madras Medical College 11

 Case History and Management Protocol

EXAMINATION OF DIAGNOSIS :

SUBMANDIBULAR Submandibular Sialdenitis / Malignancy

Right or Left side with Hypoglossal or
SWELLING Lingual or Marginal Mandibular Nerve palsy

COMPLAINTS: TREATMENT PROTOCOL FOR PAROTID

Swelling below the mandible
Pain
ELABORATING PRESENTING ILLNESS:
Swelling Exact site, duration, mode of
onset, progression, increase in size during
meals, any discharge from the swelling,
associated colour change in swelling,
associated with fever and pain?
Pain Duration, Nature, Character,
aggravating or relieving factors
Fever nature, associated with chills &
rigor, duration
Halitosis / Dysphagia / Odynophagia
Decreased or increased Salivation
Referred pain to the ear
Swelling elsewhere in the body
Trauma
INSPECTION:
Swelling Shape, Size, Site, Extent, Borders,
Surface, Skin over the swelling
Inspection of the duct orifice in oral cavity
PALPATION:
Swelling above findings + Surface,
consistency, mobility
Bimanual palpation of the gland
Palpation of duct
ORAL CAVITY
Trismus, Movements of Jaw
Thorough examination for any primary
Examination of Inferior ramus of mandible
EXAMINATION OF NECK
Trachea, Carotids, Cervical Nodes
NERVE EXAMINATION: Marginal
Mandibular Nerve, Hypoglossal, Lingual and
Inferior alveolar Nerve
OTHER SALIVARY GLANDS:
TUMOR
Blood: CBC, RFT, LFT, Viral Markers, Blood
Group
HF USG of the Parotid Region
FNAC of the Swelling (USG Guided)
Benign
Get Patient consent and Anaesthetic fitness
and plan for
Superficial Conservative Parotidectomy
Malignant Lesion
STAGING WORK UP:
CECT of the NECK
MRI Base of Skull (to rule out Neural
invasion see widening of the neural
foramina)
Chest X ray PA view
Patient Consent. Anaesthetic fitness
Use terms Adequate parotidectomy or Total
conservative parotidectomy or Total
parotidectomy if facial nerve paralysis is
present.
Stage I & II Adequate Parotidectomy
with facial nerve sparing (if No facial
paralysis)
Stage III Adequate Parotidectomy +
MRND + Post op RT
Stage IV A Preop RT + Surgery
Stage IV B & IV C Palliative
Radiotherapy
In cases of facial nerve involvement,
Resection of the facial nerve branch and
cable grafting with greater auricular nerve
or sural nerve is done or nerve suturing or
Transposition or redirection from
hypoglossal nerve is done.

Dr Pradeep Dhanasekaran | Madras Medical College 12

 Case History and Management Protocol

TREATMENT PROTOCOL FOR

SUBMANDIBULAR GLAND SWELLING:

BLOOD: CBC, RFT, LFT, Blood Grouping,

Viral Markers

Xray Neck AP and Lateral View

HF USG of the submandibular region
FNAC of the Swelling

Node Inflammatory Medical

Management
Node Metastatic from History, localize
the primary

Chronic Sialadenitis Submandibular

Sialadenectomy

Malignant Tumor
STAGING WORKUP
CECT NECK / MRI
Chest Xray PA view

Stage I & II Submandibular

Sialadenectomy with removal of
fibrofatty and nodal tissue around the
tumor

Stage III Submandibular

Sialadenectomy with removal of
fibrofatty and nodal tissue around the
tumor + MRND + Post operative RT

Stage IV Palliative RT

Dr Pradeep Dhanasekaran | Madras Medical College 13

 Case History and Management Protocol

TESTICULAR SWELLING PALPATION:

Local rise of temperature, Tenderness

COMPLAINTS: Swelling Above + Surface, Consistency,
Able to get above swelling, Fluctuation,
Painless swelling in R/L Hemiscrotum Transillumination
Reducible/ Compressible / Cough impulse
PRESENTING ILLNESS: Whether Testes palpable Presence,
position, size, shape, surface, consistency,
Swelling R/L Hemiscrotum Duration, weight, mobility, Testicular sensation.
Mode of onset, Progression, any Increase or Palpation of Epididymis, Spermatic cord
decrease in size, rapid increase in size, Palpation of Urethra
associated with Pain or Fever
If present, Elaborate Pain and Fever PER RECTAL EXAMINATION: Prostate,
Seminal vesicles
H/o abdominal pain/ distension
H/o trauma EXAMINATION OF PARA AORTIC,
H/o Swelling elsewhere INGUINAL, ILIAC AND
H/o Nausea, vomiting SUPRACLAVICULAR NODES
H/o Chest pain, breathlessness, Bone pain
H/o loss of weight SYSTEMIC EXAMINATION
H/o Edema of lower limb CVS/ RS / ABDOMEN (Kidney, Liver, Mass)
H/o Headache, seizures
DIAGNOSIS:
PAST HISTORY:
Testicular Malignancy (any firm to hard
Previous H/o STD / Regional surgeries swelling in testes >3cm, should be
Similar illness in the past considered as testicular tumor until proved
otherwise)
PERSONAL HISTORY:
Sexual contact history MANAGEMENT PROTOCOL:
Marital status
CBC, RFT, LFT, BG,
TREATMENT HISTORY: ECG, CHEST XRAY PA
Drugs for STD VIRAL MARKERS
TUMOR MARKERS LDH, AFP, BETA HCG
GENERAL EXAMINATION: (Always prior to Orchidectomy)
RADICAL ORCHIECTOMY(INGUINAL)
Conscious coherent comfortable HPE & IHC PROVEN
PICCLE (Pallor, Edema)
STAGING WORKUP CT CHEST /
Stigmata for syphilis
ABDOMEN & PELVIS
BONE SCAN & IMAGING OF BRAIN (If
LOCAL EXAMINATION
symptoms suggests)
INSPECTION
SEMINOMA:
Swelling in the R/L hemiscrotum Site,
Stage I Surveillance or Dog leg RT
Size, shape, extent, borders, surface
25-35Gy if follow up is
Skin over swelling rugosities/scar/sinus/
unlikely
ulcer/ discolouration/edema/dilated veins
IIA, IIB non Dog Leg RT 35 35 Gy and
Cough impulse/visible peristalsis
bulky <3cm BEP 3 cycles
Hernial orifices
Penis IIB Bulky Induction Chemotherapy
IS, IIC, III BEP 4 cycles

Dr Pradeep Dhanasekaran | Madras Medical College 14

 Case History and Management Protocol

Management of Residual Mass after

Chemotherapy in Seminoma

Mass < 3cm ---- Observe

Mass > 3cm ---- Do PETScan
If scan positive --- Do Post Chemotherapy
Surgery (RPLND)
Negative ---- Observe

NON SEMINOMATOUS TUMORS

Stage I RPLND alone

IIA, IIB Non bulky RPLND + BEP 3
cycles
IIA, IIB Bulky and Induction
Increased tumor chemotherapy then
markers RPLND
IS, IIC, III BEP 4 cycles

In Stage I disease, BEP 2 cycles to be given if

there is Lymphovascular invasion of tumor,
>40% embryonal histology and Increased
tumor markers.

FOLLOW UP:

For NSGCT - 5 years and

Seminoma 10 years follow up mandatory.

History, physical examinations

Serum markers
Chest Xray
Abdominal CT every 4 months for first 2
years
Then
Every 6 months for another 3 years.
Annually thereafter.

Dr Pradeep Dhanasekaran | Madras Medical College 15

 Case History and Management Protocol

RENAL SWELLING LOCAL EXAMINATION

INSPECTION

COMPLAINTS Abdomen routine inspection

Emphasis on Renal angle for fullness /
Dull aching pain in the R/L Loin edema
Mass in R/L Loin Dilated veins over the abdomen (Tumor
Hematuria thrombus extending into IVC)
External genitalia (Varicocele)
PRESENTING ILLNESS
PALPATION
Pain in R/L Lumbar region Severity,
Onset, Progression, Nature, Character, Warmth, Tenderness
Duration, Radiation/Referred, Relation to Mass in the Loin (palpate the other side too)
micturition, agg/relieving factors 1. Bimanual Palpation to look for size,
Swelling Site, Onset, Progress, Duration, shape, surface, borders, consistency,
increase or decrease in size with regard to Movement with respiration
micturition, Unilateral/bilateral 2. Ballotable or not
Hematuria Quantity, Relation to 3. Finger insinuation between mass
micturition, Associated with pain / fever and costal margins
Enquire about Urinary frequency 4. Renal angle Mass / Tenderness
H/o Retention of Urine Look for dilated veins
H/o Difficulty in urination (dysuria) Abdomen Liver, spleen, other mass
H/o discharge from urethra nature,
quantity PERCUSSION
H/o Incontinence Over the Swelling Resonant
H/o Fever, Malaise, Nausea, Vomiting, Renal angle Dullness
Drowsiness, Hiccough, Intense thirst
(Chronic Kidney disease) AUSCULTATION
H/o Weight loss, Malaise, Bone pain, Cough Look for bruit
with dyspnea, Cervical node (RCC
Paraneoplastic syndromes) EXAMINE BLADDER, URETHRA
Ask about GI symptoms like Vomiting,
Diarrhea, Hemetemesis, Melena, EXTERNAL GENITALIA
Hematochezia - to r/o DD colonic mass Testes, Varicocele

PAST HISTORY PER RECTAL EXAMINATION

For Prostate Size, surface, Median groove,
Comorbidities, H/o any urinary trouble in consistency, Movement of rectal mucosa
past over prostate
STD/TB
SUPRACLAVICULAR REGION
PERSONAL HISTORY
SYSTEMIC EXAMINATION
Smoking , Alcohol, Caffeine CVS / RS (very important)
Occupation exposure (any industrial) Parathyroid / Spine

GENERAL EXAMINATION PROVISIONAL DIAGNOSIS

Built Nourishnment Hydration SOLID CYSTIC

PICCLE (Anemia, Edema) Neoplasm HUN
Facial Puffiness, Tongue Advanced TB Solitary cyst
VITALS , Pulse BP (very important) Compensatory Polycystic kidney
hypertrophy Pyonephrosis

Dr Pradeep Dhanasekaran | Madras Medical College 16

 Case History and Management Protocol

MANAGEMENT PROTOCOL FOLLOW UP:

CBC for Anemia, PCV, ESR T1 Annual

Urea, Creatinine, Blood sugar Chest Xray PA
LFT Bilirubin, Liver enzymes, Proteins LFT RFT
Urinalysis Albumin, Sugar, Cells T2, T3 6 Monthly
Blood grouping Viral markers Chest Xray PA
Electrolytes Sodium, potassium, calcium LFT RFT
Coagulation profile PT/INR CT abdomen & Pelvis
ECG
Chest Xray PA view CT Abdomen in T1 - (To see local
DIAGNOSIS recurrence those who underwent partial
USG ABDOMEN & PELVIS nephrectomy or else not necessary)
CT ABDOMEN & PELVIS
STAGING WORK UP
CT CHEST
CT ABDOMEN & PELVIS
BONE SCAN & BRAIN IMAGING (Not
routine, but if symptoms present)

TREATMENT - SURGERY

T1a Lap/Robotic/ Open Partial

(<4cm) Nephrectomy with wedge
resection of normal parenchyma
T2 Lap / Robotic /Open Radical
Nephrectomy
T3a, Open Radical Nephrectomy with
T3b removal of thrombus
T4 / In patients who have good
M1 performance status and desire
systemic therapy
Cytoreductive Nephrectomy
done
Solitary Combined removal along with
Mets Nephrectomy

For T1, T2 Laparoscopic or Robotic

Partial/ Radical Nephrectomy is the
standard of care.

Only for T3 & T4 Open Radical

Nephrectomy

ROLE OF RADIOTHERAPY
In Brain, Bone, Lung Metastasis

TARGETED THERAPY FOR METASTATIC

RCC
1. Bevacizumab
2. Sunitinib
3. Temsirolimus
4. Recombinant IL-2 and IFN alpha

Dr Pradeep Dhanasekaran | Madras Medical College 17

 Case History and Management Protocol

PENILE CANCER PALPATION

Above + Palpate for mobility/fixed, base,

COMPLAINTS extent, Bleeds on touch
Involvement of corpora or urethra
Inability to retract the prepuce Hernial orifices
Ulcerative/Ulceroproliferative Lesion or Scrotum, Testes palpation
growth in Penis
REGIONAL NODES
PRESENTING ILLNESS Inguinal and Iliac nodes

Inability to retract prepuce - duration PER RECTAL EXAMINATION

Ulcer Duration, Site, Mode of onset, Pelvic nodes, Deposits, Prostate invasion
Progression, associated with pain or
discharge DIAGNOSIS
Pain Duration, nature, character,
radiation, relation to micturition MANAGEMENT PROTOCOL
Discharge quantity, quality, smell
H/o Urethral discharge Routine Blood investigations
H/o Fever Viral Markers
H/o Swellings in groin / thigh BT/CT/ PT INR
H/o Recent sexual contact ECG Chest X ray PA
H/o Edema of Lower limb or pain Edge wedge Biopsy from the Lesion
H/o LOW/LOA, Cough with breathlessness HPE Histologic type, grade important
H/o Low back ache HF USG ILIOINGUINAL REGION
FNAC OF THE NODES
PAST HISTORY STAGING WORKUP
Comorbidities CT CHEST
Any STD/TB/HIV CT ABDOMEN & PELVIS

PERSONAL HISTORY SURGERY:

Sexual contact history
Smoking Alcohol T1 lesions Circumcision with negative
in Prepuce margins
FAMILY HISTORY T1 lesions Glansectomy
TREATMENT HISTORY in Glans
T2, T3 in Partial Penectomy
GENERAL EXAMINATION Glans/Shaft
Built Nourishment
T4 Total Penectomy
PICCLE (Pallor, Lymphadenopathy, Pedal
edema)
PRIMARY RT to T1 lesions if No LV
invasion, patient refusing surgery, or
LOCAL EXAMINATION
inoperable cancer. Advantage of preserving
INSPECTION
organ and sexual function.
Describe Ulcer/ Lesion first Size, Shape,
ADJUVANT INDUCTION
Site, Extent, Margins, Edges, Floor, Bleeding
THERAPY CHEMOTHERAPY
or slough or active discharge
1. >2 positive 1. Fixed nodal
Prepuce able to retract and see upto
nodes mass
corona
2. Bilateral 2. >4cm mass
Glans
metastases 3. Pelvic nodes
Body / Shaft
External urethral meatus site of opening, 3. Pelvic
metastases
adequacy and discharge

Dr Pradeep Dhanasekaran | Madras Medical College 18

 Case History and Management Protocol
MANAGEMENT OF NODES

T1 lesions (G1-G2), No vascular invasion, Superficial growth

No Clinically palpable nodes Clinically palpable nodes

FNAC

OBSERVE Positive Negative

Antibiotic course 4 -6w

Still persists

Excision Biopsy

Positive Negative

OBSERVE

IPSILATERAL SUPERFICIAL AND DEEP INGUINAL + ILIAC NODE DISSECTION WITH

CONTRALATERAL SUPERFICIAL BLOCK DISSECTION

T2- T4/ ANY T with vascular invasion or nodular growth pattern/any T with G3

Bilateral Negative Unilateral positive Bilateral Positive

Bilateral SUP IBD & Ipsilateral IlioIng BD +

Contralateral Sup Ing BD FNAC
do Frozen section

If positive, Bilateral
If Positive, Ipsilateral IlioIng BD +
IlioIng BD If positive, Contralateral
Adjuvant therapy
ILIOING BD

If Negative, follow
Bil Negative Rx

FOLLOW UP:

Physical examination, RFT, LFT, Chest X ray PA every 3 months for first 2 years and 6 months
thereafter upto 5 years.

Dr Pradeep Dhanasekaran |Madras Medical College 19

 Case History and Management Protocol

RIGHT HYPOCHONDRIAC GENERAL EXAMINATION

Built, Nourishnment
MASS Hydration status
Temperature
COMPLAINTS: Pallor, Icterus
Pedal edema
Dull aching pain in Right hypochondrium Any lymphadenopathy
Vomiting Signs of Liver cell Failure
Malaise Vitals
Loss of appetite and Loss of weight
Jaundice LOCAL EXAMINATION OF ABDOMEN:
INSPECTION:
PRESENTING ILLNESS:
Shape of abdomen Scaphoid / fullness
Pain Site, Nature, Duration, Character, Umbilicus Normal in position, midline and
Aggravating or relieving factors, associated inverted
symptoms All quadrant inspection and its movement
Vomiting Episodes, When it occurs? with respiration
Quantity, Colour, Bilious or not Mass Number, Shape, Size, Site, Extent,
Loss of appetite and weight (whether Borders, Surface, Movement with
considerable) respiration, Pulsatile
Jaundice Sites, Duration, Progression, Skin over the swelling, Skin over abdomen
Continuous or intermittent, associated with for scars, dilated veins
fever and pain Visible peristalsis
Fever Plane of the swelling Carnetts test, Rising
Hemetemesis / Melena / Hematochezhia test
Diarrhoea / Constipation Hernial orifices & External genitalia
Abdominal distension Renal angle and Supraclavicular region for
Pruritus / Early satiety / Malaise fullness
Hematuria / Micturition difficulties
Back ache / Trauma PALPATION:

PAST ILLNESS: Local rise of temperature, Tenderness

Mass Number, Shape, Size, Site, Extent,
Comorbidities Surface, Borders, Consistency, Movement
Previous history of jaundice, blood with respiration, Mobility of the swelling,
transfusion Pulsatile or not
Any abdominal surgeries or skin tumor Finger insinuation between swelling and
excision or eye surgeries Costal margins
Previous similar illness Plane of the swelling Carnetts test and
rising test
PERSONAL HISTORY: Ballotable or not
Other organs palpable
Alcohol , Smoking, Tobacco External genitalia and hernia orifices
Diet Renal angle and supraclavicular fossa for
History of rearing pets at home any mass

FAMILY HISTORY / DRUG HISTORY PERCUSSION:

Mark Liver dullness
OCCUPATIONAL HISTORY: Exposure to Percussion over the swelling to find
Arsenic / vinyl chloride / paint industries whether its continuous with the liver
dullness
To detect Ascites

Dr Pradeep Dhanasekaran |Madras Medical College 20

 Case History and Management Protocol
AUSCULTATION: STAGING:
Bowel sounds CT chest, Bone scan in cases of HCC
Bruit or Venous hum over the swelling CEA, CA 19-9, AFP
Cross sectional Abdominal CT imaging and
PER RECTAL AND PERVAGINAL Liver reserve by CT Volumetry (planning on
EXAMINATION: resection)
Diagnostic Laparoscopy
DIAGNOSIS:
Positive symptoms + Hepatomegaly with TREATMENT:
nodularity / Mass arising from liver
HCC :
D/D : Secondaries Liver After staging, Localized and Resectable
Primary HCC If Functional liver reserve >30 -40%
Benign tumors of Liver Child score
Cystic Lesions from Liver Congenital / Cirrhotic/not
secondary
RESECTION (giving ORTHOTOPIC LIVER
DIFFERENTIAL DIAGNOSIS 2 cm clearance) TRANSPLANTATION
Small unifocal MILANS CRITERIA
LIVER Malignant Secondaries / tumors < 5cm
Primary HCC Childs class A 1 tumor < 5cm or 3
Benign Hemangioma, FNH, Non cirrhotic tumors each < 3cm
Hepatoma FLR >40% (after Childs Class A/B/C
Cysts Congenital (Congenital excision)
cyst, Polycystic liver disease) No Distant Mets No distant mets
Secondary Infective No vascular No vascular invasion
(Hydatid, Pyogenic abscess, invasion
Ameobic abscess)
Anatomic Congenital Riedels If Localized and Unresectable disease
lobe
GALL Mucocele, Malignancy, Preoperative Multimodality treatment
BLADDER Distended Gall bladder in Ablative
Obstructive Jaundice Ethanol
KIDNEY & Malignancy, Benign conditions Thermal Microwave, Cryo, RF
ADRENAL TACE, TARE
HEPATIC Intussussception, Malignancy, IMRT, EBRT
COLON Hyperplastic Tuberculosis Targeted therapy Sorafenib.

EVALUATION: Metastatic disease

Admission and Symptomatic Treatment
Blood Ix CBC Anaemia, Leucocytosis, Targeted therapy with Sorafenib
platelets And Systemic chemotherapy with
RFT + Electrolytes, LFT Bilirubin, proteins, Doxorubicin.
enzymes
Blood Grouping, BT/CT/PT INR, Viral HYDATID CYST:
Markers
ECG Chest xray PA , X ray Abdomen erect TREATMENT : PRIMARILY SURGICAL
1. PERICYSTECTOMY
SPECIFIC : USG Abdomen & Pelvis Solid / 2. PARTIAL HEPATECTOMY
cystic, Solitary / Multiple, Content and 3. CYST DEROOFING AND
Extent OMENTOPLASTY
Locate the primary 4. MARSUPIALIZATION PROCEDURES
CECT Abdomen & Pelvis triphasic CT

Dr Pradeep Dhanasekaran |Madras Medical College 21

 Case History and Management Protocol
MEDICAL:
Albendazole or Mebendazole effective in
<50% of patients causing cyst
disappearance

SECONDARIES LIVER :

If Suspected from beginning

Do Colonoscopy
Biopsy the lesion
Or from History of previous colonic cancer
surgery.

Surgery Role only in Colorectal Liver

metastases

Resection of the Colonic Primary along with

Liver Metastases (Resection with 2 cm
margin if Solitary, small, unifocal) in case of
Synchronous Liver metastases

Metachronous Liver metastases, Look for

Liver reserve
Plan for Downstaging therapies with
FOLFOX and VEGF/EGFR Inhibitors,
Selective Portal vein embolization, then go
ahead and resect.

Dr Pradeep Dhanasekaran |Madras Medical College 22

 Case History and Management Protocol

RIGHT ILIAC FOSSA Febrile

Anemia
MASS Icterus
Clubbing
COMPLAINTS: Lower limb edema
Supraclavicular nodes
Abdominal pain
Loss of weight and appetite LOCAL EXAMINATION OF ABDOMEN:
INSPECTION:
ELABORATING PRESENTING ILLNESS:
Umbilicus Normal in position and in
Abdominal pain Site, Mode of onset, midline, Inverted
Nature, Duration, Progression, Radiating, All Quadrants and their Movement with
Aggravating or relieving factors respiration
Associated with abdominal distension or Describe the Swelling Number, Shape,
swelling Size, Site, Extent,
Associated with fever nature, character, Borders, Surface, Movement
associated with night sweats with respiration
Skin over the swelling for colour, texture,
Nausea, Vomiting engorged veins
Diarrhoea, Constipation Plane of the swelling - Carnetts Test /
Hemetemesis, Melena, Hematochezhia Rising test
Easy fatiguability Any other swelling or organs visible
Loss of weight/ Loss of appetite Look for Peristalsis and Pulsations
Micturition disturbances Any Scars/Sinuses/dilated veins in
Any other swelling elsewhere in the body abdominal wall
Trauma Hernial orificies
External Genitalia
PAST ILLNESS: Renal angle and Supraclavicular region for
any fullness
Similar symptoms in the past
Comorbid illness PALPATION:
Any surgery in the past
Exposure to Open case of TB or Previously Local Warmth, Tenderness
treated or on treatment for TB SWELLING Site, Size, Shape, Extent,
Surface, Margins,
PERSONAL HISTORY Consistency (if cystic, fluctuation and
fluid thrill),
Alcohol, Smoking, Tobacco Pitting on pressure, Movement with
High fat diet, Low fiber diet respiration
MOBILITY : Movement in all directions,
MENSTRUAL HISTORY Ballotable or not
MARITAL HISTORY Fertile PLANE OF THE SWELLING Carnetts test,
FAMILY HISTORY: Rising Test, Valsalva
Any similar illness in the family members, PULSATILE Expansile or Transmitted one
siblings and parents Palpate the Organs (Liver, Spleen and
Kidney)
DRUG HISTORY: Insinuation of fingers between Swelling and
Costal margin
GENERAL EXAMINATION: Able to Insinuate fingers between Swelling
and Pelvic bone
Nutrition status Hernial Orifices, External Genitalia
Hydration Renal angle, Supraclavicular region

Dr Pradeep Dhanasekaran |Madras Medical College 23

 Case History and Management Protocol
PERCUSSION: Tumor Markers CEA, CA 19-9
Colonoscopy & Biopsy
Percussion over the Swelling Dull or Diagnostic Laparoscopy
Resonant
Check for Shifting Dullness Ascites / CARCINOMA COLON/CECUM:
Ovarian cyst
Fluid Thrill (if ascites present) STAGE TREATMENT
Cystic Swelling (Fluid thrill over the 0, I Primary surgery alone
Swelling) II Primary surgery alone
Area of Liver and Splenic Dullness to be Role of Chemotherapy with
marked atleast one
Inadequate lymph node sampling
AUSCULTATION: T4 lesions and perforated bowel
Bowel Sounds Poorly differentiated histology
Bruit or Venous Hum III Primary surgery Plus FOLFOX
IV Systemic Chemotherapy FOLFOX
Per Vaginal and Per Rectal Examination plus Targeted Bevacizumab,
Cetuximab and Panitumumab.
SYSTEMIC EXAMINATION: (inhibit EGFR which are
CVS/ RS / CNS overexpressed in 60 80% of
cancers)
DIFFERENTIAL DIAGNOSIS:
STAGE FOLLOW UP
COMMON LESS COMMON 0, I CEA every 3 months for 2 years,
Appendicular Mass Appendiceal every 6 months for 5 years
Ileocecal Tuberculosis Neoplasms Rising CEA CT Chest and
Carcinoma of Cecum Crohns Ileitis abdomen
Iliac Lymph Nodes Impaction of Colonoscopy 1 year after ,
Retroperitoneal Round worms annually
Sarcoma Iliac artery II CEA every 3 months for 2 years,
IlioPsoas Cold Abscess aneurysm every 6 months for 5 years
Amoebic Annual CT Chest, abdomen for 3
typhilitis years
Actinomycosis Annual Colonoscopy
III Same
NON ANATOMIC
Tuboovarian Mass APPENDICULAR MASS:
Ovarian cyst
Unascended Kidney OCHSNER SHERREN REGIMEN:
Undescended Testis 1. Admission, Bed rest
2. Temperature, Pulse, BP Chart
3. Marking of the Mass to monitor
MANAGEMENT PROTOCOL: progression/regression
4. Iv Antibiotics (Cephalosporins and
CBC (Anemia, Leucocytosis, ESR, Platelets) Metronidazole)
Urea, Creatinine, Blood sugar 5. Iv fluids
LFT (Bilirubin, Enzymes and Proteins) 6. Analgesics
Blood Grouping 7. Nil by mouth
Viral Markers Response seen within 48 hours and mass
ECG and Chest X ray PA view reduces in size, temperature pulse
X ray Abdomen Erect becomes normal. Appetite is regained.
USG abdomen and Pelvis Oral diet and oral antibiotics given and
CECT Abdomen and Pelvis patient discharged.

Dr Pradeep Dhanasekaran |Madras Medical College 24

 Case History and Management Protocol
CRITERIA TO DISCONTINUE REGIMEN: ILEOCECAL TUBERCULOSIS

1. Patient becomes more toxic (fever MEDICAL SURGERY

and tachycardia despite treatment) CATEGORY I ATT Obstruction
2. Persistent vomiting Improvement of Perforation
3. Increase / spread of pain Nutrition with TPN Strictures
4. Increased size of mass & Blood transfusion Stricturoplasty
5. Abscess formation in mass

Complicated appendicitis

Perforated or Gangrenous
Appendicular abscess

Phlegmon + small Abscess >4 -

abscess 6cm
Emergent surgery

Antibiotics + Percutaneous
Febrile image guided drainage
Afebrile

Children Adults

Regular diet, Colonoscopy 4

Oral Interval Neoplasm
weeks later
antibiotics Appendectomy

Staging/Colectomy
No Neoplasm

Dr Pradeep Dhanasekaran |Madras Medical College 25

 Case History and Management Protocol
Examination of Regional lymph drainage
regions

SKIN CANCERS Any Underlying muscle wasting or Distal

COMPLAINTS:
Non healing Proliferative Ulcer Region
ELABORATING PRESENTING ILLNESS
ULCER Site, Duration, Mode of onset
Progression, Discharge, Pain, Pigmentation
PAIN Duration, Nature, Character,
aggravating or relieving factors
Discharge Nature, quantity, smell
Pigmentation Black or brown
Fever
Any swelling elsewhere
Any weakness / Loss of sensation in the
Ulcer area
Loss of Weight/Appetite (Malnutrition)
Malaise, Jaundice
Cough with breathlessness
PAST ILLNESS:
Comorbid illness
Previous surgery/ excision of skin lesion
Previous History of irradiation / Burns /
Chronic exposure to sunlight
PERSONAL : Tobacco, Alcohol, Smoking
FAMILY HISTORY
GENERAL EXAMINATION:
Any Obvious disease stigmata of Leprosy /
Syphilis / DM / Vascular or Venous disease
PICCLE
LOCAL EXAMINATION:
Neurovascular changes
PALPATION:
ULCER Same as above + Tenderness,
Edges, Margins, Depth, Base, Mobility,
Bleeding on touch
Surrounding skin Texture, Consistency
Regional Arteries, Veins, Nerves
Neurologic examination Sensory and
Motor
Range of Movements of Joints
REGIONAL LYMPH NODE EXAMINATION
SYSTEMIC EXAMINATION
DIAGNOSIS
Malignant Ulcer SCC/BCC/ Melanoma
MANAGEMENT PROTOCOL:
Routine Blood Investigations
ECG Chest X ray
Dressing of the wound if infected
BIOPSY FROM THE ULCER
Edge biopsy for SCC, BCC
Punch biopsy for Melanoma (if large)
Or Excision biopsy with 2 cm margin
STAGING WORK UP
BCC
No lymphatics involvement, not much role
SCC
Regional Lymph node Ultrasonography
FNAC
Chest X ray PA or CT CHEST
TREATMENT OF SQUAMOUS CELL
CARCINOMA

INSPECTION: WIDE LOCAL EXCISION

ULCER Shape, size, Site, extent, edge, Low risk <2cm Minimum 4mm
Margins, floor, discharge, bleeding, margin
pigmented High risk >2cm and 1 cm margin
Surrounding skin Colour, edema, Dilated >4mm depth recommended
veins
TREATMENT OF METASTASES:

Dr Pradeep Dhanasekaran |Madras Medical College 26

 Case History and Management Protocol
1. Lymph node metastases Block
dissection of the lymph nodal group
2. Palliative Pain control and QOL
Cisplatin and 5-FU and Paclitaxel. ADJUVANT RADIOTHERAPY:

BASAL CELL CARCINOMA Radioresistant, Yet Indications are

WIDE LOCAL EXCISION
1 2 cm clearance on Lateral and Deep
margins. (4mm enough for superficial type
and 1 cm needed for recurrent and
morphoeic types)
1. Extracapsular spread in Nodes
2. Number (1 for Parotid, 2 for Neck &
axilla, 3 for groin)
3. Size (>3cm for neck,axilla and >4cm
for groin)

STAGE IV

MALIGNANT MELANOMA Median survival is 7 months

SITES Brain, Lung, Liver
RECOMMENDED EXCISION MARGINS If resectable Go and resect
Unresectable Dacarbazine and High dose
Tis 0.5cm For Lesions IL-2
T1 1cm Upto 1mm 1cm Stereotactic Radiotherapy for Brain
T2 1 2 cm >1mm 2cm metastases
T3 2cm
T4 2cm

ADJUVANT CHEMOTHERAPY:

Only USFDA drug is High dose Interferon

alpha-2B thrice weekly IV for 1st month and
Subcutaneous for 11 months.
May prolong the time for recurrence,
unlikely to cure.

STAGE TNM WORKUP MANAGEMENT SURGERY

Stage 0 Tis N0 M0 No Preop Biopsy Wide local Excision
No
Stage IA T1a N0 M0
additional
Stage IB T1b N0 M0 Wide Local Excision with
imaging
T2a N0 M0 Block dissection of the
Stage IIA T2b N0 M0 involved Nodal group if
Chest Xray Sentinel Lymph
T3a N0 M0 SLNB is positive
PA view Node Biopsy.
Stage IIB T3b N0 M0
CT CHEST
T4a N0 M0
USG ABD
Stage IIC T4b N0 M0
Stage III Any T any N M0 FNA of the Node Wide Local Excision with
(If Negative, do Therapeutic Nodal
CT or PET
excision biopsy to Dissection if FNA
or MRI
confirm) positive
Brain
Stage IV Any T any N Any M Systemic
Chemotherapy

Dr Pradeep Dhanasekaran |Madras Medical College 27

 Case History and Management Protocol

TREATMENT FOR RECURRENCE:

NODAL RECURRENCE Total Lymph Nodal dissection with Adjuvant ChemoRadiotherapy

LOCAL RECURRENCE Re- Excision with Negative margins
(SATELLITE LESION)
INTRANSIT DISEASE Recurrence is inevitable, Sequential excision of intransit nodules
Local Injection of BCG, Interferon, IL-2 (refractory in-transits)
Hyperthermic Isolated Limb Perfusion Creech using Melphalan.
Isolated Limb Infusion Thompson

FOLLOW UP

STAGE FIRST 3 YEARS NEXT 2 YEARS

0, I, II History & Physical Examination every Annually
6 months
III Every 3 months Every 6 months and annually
thereafter.

Dr Pradeep Dhanasekaran |Madras Medical College 28

 Case History and Management Protocol
EXAMINATION OF
EPIGASTRIC MASS
COMPLAINTS:
Loss of weight .. months
Vomiting months
Epigastric pain . Months
Mass in upper abdomen . Months
PRESENTING ILLNESS:
Patient has Vomiting duration, quantity,
contents, bilious or blood stained, with
regard to food intake (occurs within 10 30
min of consuming food), relation to nature
of foods (more to liquid or solids),
progression
Epigastric pain duration, mode of onset,
nature, character, radiating, aggravating or
relieving factors
Mass in Upper abdomen duration, mode of
onset, progression
H/o Dysphagia
H/o Ball rolling movements in abdomen
H/o abdominal distension
H/o Hemetemesis/melena/ hematochezhia
H/o Diarrhoea, Constipation
H/o Jaundice
H/o hematuria, dysuria
H/o Loss of appetite and loss of weight
(describe whether its significant)
H/o fever
H/o chest pain, breathlessness
H/o backache
PAST HISTORY:
DM/ HT/ BA/COPD/ IHD/ SEIZURES
Previous surgery in upper gastrointestinal
tract or colon
Similar illness in the family
Tell about any inpatient procedures like
scopy done for the patient
PERSONAL HISTORY:
Alcoholic, Smoker
Pan chewer
Dr Pradeep Dhanasekaran |Madras Medical College
FAMILY HISTORY:
TREATMENT HISTORY:
SUMMARY
Elderly male with non bilious vomiting, ball
rolling movements, hematemesis, Mass in
upper abdomen and significant loss of
weight
GENERAL EXAMINATION
Conscious, coherent, comfortable
Febrile, Hydration (important)
Pallor , Icterus , Pedal edema (important)
Clubbing, cyanosis, lymphadenopathy
Signs of superficial thrombophlebitis
VITAL SIGNS
LOCAL EXAMINATION
INSPECTION OF ABDOMEN
Umbilicus Normal in position, midline,
inverted, look for any nodules, dilated veins
Tell about Mass if vague (no need to say
size, borders tell about location alone), if
well defined Size, Shape, Location, Extent,
Borders, Surface
Peristalsis Explain the direction of
peristalsis and Pulsations
Plane of the swelling
Movement with respiration
Look for any other mass visible
All quadrants movement with respiration
Any scars, sinuses, dilated veins
Hernial orifices and External genitalia
Renal angle for fullness
Left supraclavicular region for fullness
PALPATION OF ABDOMEN
Look for Local rise of temperature and
tenderness
Mass single/ shape/ size / location /
extent / surface / borders / consistency
29
 Case History and Management Protocol

Mobility of the swelling X ray abdomen Erect

Movement with respiration
Ballotable or not
Plane of the mass Carnetts test, head
rising test, Left lateral position
Able to insinuate the finger between mass
and costal margins
USG Abdomen & Pelvis Locate the lesion,
Any liver metastases, ascites, pelvic
deposits
Upper GI Scopy Locate the lesion,
morphology, extent and Biopsy

Succussion splash Biopsy confirmed. Staging Workup

Pulsatile or not

Look for liver and spleen CECT Abdomen and Pelvis

Any other mass in abdomen CT Chest
Renal angle Tenderness
Hernial orifices and external genitalia Radiologically Resectable tumor and no
Left supraclavicular region for nodes metastatic disease

PERCUSSION:
Do Staging Laparoscopy
Percuss over the mass
Look for the continuity with liver dullness
Liver span Localized disease
Any shifting dullness or ascites
Renal angle percussion dull / resonant
D2 Gastrectomy and Adjuvant
AUSCULTATION Chemoradiation
Or Preoperative Chemoradiation and
Bruits, Venous hum surgery or Perioperative Chemotherapy
Auscultation with scraping to determine and Surgery
the greater curvature of stomach
In our exams, Mostly mass abdomen cases
PER RECTAL EXAMINATION kept. So it will be mostly T3 or higher

For blummers shelf Depending on Postoperative Resection

margins and nodal status, almost all
SYSTEMIC EXAMINATION patients needed Post operative
Chemoradiation or Chemotherapy alone
CVS , RS , CNS
CHEMOTHERAPY REGIMES
DIAGNOSIS
Perioperative Chemotherapy
Carcinoma Stomach with Gastric Outlet ECF 3 cycles before and after surgery. Cycle
Obstruction every 21 days
Epirubicin 50mg/m2 IV on day 1
WORK UP Cisplatin 60 mg/m2 IV on day 1
5-Flurouracil 200mg/m2 continuous IV on
CBC Anemia, Platelets days 1 21 or oral capecitabine 625mg/m2
Blood Sugar, Urea Creatinine BD daily on days 1 21.
Electrolytes Sodium, Potassium, Chlorine
Bilirubin, Albumin, Liver enzymes POST CHEMOTHERAPY
Blood Grouping and typing
Oral Capecitabine 1000mg/m2 BD on days
ECG 1 14
Chest X ray PA view Cisplatin 60 mg/m2 IV on day 1

Dr Pradeep Dhanasekaran |Madras Medical College 30

 Case History and Management Protocol

Every 21 days for 6 cycles

POSTOPERATIVE CHEMORADIATION

1 cycle before and 2 cycles after 5FU based

Chemoradiation

Cycles 1, 3 and 4
Leucovirin 20mg/m2 IV on days 1 - 5
5 FU 425mg/m2 IV daily on days 1 5
Cycled every 28 days

Cycle 2 with Radiation

Leucovirin 20mg/m2 IV on days 1 4 and
31 - 33
5 FU 400mg/m2 IV daily on days 1 4 and
days 31 33 with Radiation 45- 50 Gy in
necessary radiation fields.

Metastatic

Palliative Chemotherapy depending on PS

If ECOG < or = 2 ,

Docetaxel, Cisplatin and 5 FU

Or
Epirubicin, Cisplatin and 5 FU

5 FU and Cisplatin interchanged with

Capecitabine and Oxaliplatin.

FOLLOW UP:

History and Physical examination every 4

months for 1 year, 6 months for next 2
years and then annually

CBC and Liver profile

Chest X ray, CT Abdomen and Pelvis in
clinically suspicious cases

Annual endoscopy

Dr Pradeep Dhanasekaran |Madras Medical College 31

 Case History and Management Protocol
OBSTRUCTIVE
JAUNDICE
COMPLAINTS:
Vague abdominal pain
Yellowish discolouration of Sclera
Loss of weight and appetite
PRESENTING ILLNESS
Abdominal pain location, duration, nature,
character, radiation, referred, aggravating
or relieving factors
Jaundice onset, duration, progression,
associated with pain or not
H/o yellowish discolouration of urine
H/o pale coloured stools
H/o Itching
H/o Fever
H/o Loss of weight, appetite
H/o vomiting, hematemesis, melena
H/o diarrhoea, constipation, hematochezhia
H/o back ache / altered mental status
H/o chest pain / breathlessness
H/o trauma
PAST HISTORY
Comorbid illness
Previous surgery HPB/Chole/Gastrectomy
Transfusion / Tattoo / Drug abuse / Native
Jaundice at birth
PERSONAL HISTORY
Alcoholic, Smoker , Pan chewer
High fat diet and Meat intake
FAMILY HISTORY
Family history of jaundice
DRUG HISTORY
Androgens and Antipsychotics
SUMMARY
Dr Pradeep Dhanasekaran |Madras Medical College
Elderly male with Painless progressive
jaundice with yellowish urine and pale
stools with itching and loss of weight and
appetite
GENERAL EXAMINATION
Conscious, coherent comfortable
Built nourishment
Febrile Hydration
Pallor
Icterus sclera, undersurface of tongue,
skin, palms and soles
Cyanosis, clubbing and pedal edema
Lymphadenopathy
Scratch marks in extremities and abdomen
VITAL SIGNS
LOCAL EXAMINATION:
INSPECTION OF ABDOMEN:
Abdomen flat/scaphoid
Umbilicus is normal in position, midline and
inverted, looks for nodules / discharge /
dilated veins
Mass Size, Site, shape, extent, surface,
borders, movement with respiration,
Pulsations / Persistalsis
Plane of the swelling Carnetts test
Skin over the swelling
All quadrants movement with respiration
Any scars/ sinuses / dilated veins
Hernial orifices and External Genitalia
Renal angle
Left supraclavicular region
PALPATION :
Local rise of temperature,
Superficial and deep palpation for
tenderness
Mass size, site, shape, extent, borders,
surface, consistency, mobility of the mass,
movement with respiration, ballotability or
bimanually palpable and pulsations
Plane of the swelling Carnetts test
Any other mass / Liver and spleen
Hernial orifices and External genitalia
32
 Case History and Management Protocol

Renal angle Tumor Markers CA 19-9 and CEA

Left supraclavicular region UGI Scopy
PERCUSSION ASSESS OPERABILITY BY CECT

Percussion over the mass and its RESECTABLE :

association with liver dullness 1. T1, T2 lesions
Liver span 2. No SMV-Portal impingement/
Shifting dullness / ascites Abutment/Distortion / Encasement
Renal angle percussion 3. Fat plane preserved between SMA,
Hepatic artery and Tumor
AUSCULTATION
Do Staging Workup
Bowel sounds CT Chest
Arterial bruit / Venous hum Staging Laparoscopy

PER RECTAL EXAMINATION If Localized disease and no metastases, Go

ahead with Surgery after adequate
Blummer shelf preoperative preparation
A Anemia correction
SYSTEMIC EXAMINATION B Bilirubin correction
C Coagulopathy correction
CVS / RS / CNS D Drugs
E Electrolyte correction
DIAGNOSIS :
BORDERLINE RESECTABLE
Palpable GB with Jaundice, Fever, 1. T3 lesions
Intermittent or Progressive 2. Unilateral or Bilateral SMV-Portal
impingement
OBSTRUCTIVE JAUNDICE WITH 3. <180 abutment on SMA
CHOLANGITIS 4. Short segment SMV occlusion
5. Encasement of Hepatic artery
EVALUATION:
Staging with CT Chest
CBC for anemia / leucocytosis EUS guided Biopsy from lesion
Blood sugar, Urea and Creatinine ERCP and Stenting for biliary drainage
Total and direct bilirubin
Liver enzymes Start Neoadjuvant Chemotherapy
Albumin, globulin and ratio Then Surgery
BT / CT / PT-INR
Viral markers UNRESECTABLE
Urine BS/BP and FOBT 1. T4 lesions
Blood grouping and typing 2. Metastatic disease
ECG , Chest X ray PA 3. Ascites
Xray Abd erect 4. More than 180 abutment on SMA

USG ABDOMEN AND PELVIS : Look for
IHBR dilatation, CBD dilatation, Liver, Gall
bladder and spleen, Stones if any
And measure the dilatations.
Ascites and Pancreatic masses
CECT ABDOMEN AND PELVIS (TRIPHASIC
WITH PANCREATIC PROTOCOL)
Staging, EUS Guided Biopsy
ERCP and Palliative stenting
Palliative chemotherapy
Palliative Triple anastomoses
Palliative Celiac block for pain relief.
CHEMOTHERAPY REGIME

Dr Pradeep Dhanasekaran |Madras Medical College 33

 Case History and Management Protocol

5 FU alone or with Gemcitabine or 5 FU (as usual) and VITAL SIGNS

based chemoradiation
VARICOSE VEINS LOCAL EXAMINATION OF LOWER LIMB

COMPLAINTS:
Tortuous vessels in the R/L leg or
lowerlimb
Aching sensation
Non healing ulcer
PRESENTING ILLNESS
Tortuous vessels in the R/L Lowerlimb
extending upto level. Vessels increase in
size during prolonged standing or during
the end of the day or disappears during
lying down and associated pain
Pain- dull aching sensation felt in the LL
during the end of the day, gets worse on
working and relieved by lying down
H/o night cramps
H/o localized or generalized swelling of LL
H/o fever
H/o any local skin changes like dry scaly
skin/ pigmentation/ itching
H/o ulceration spontaneous/trauma and
its progression and any bleeding
H/o abdominal distension / pain / chronic
constipation
H/o cough / chest pain / breathlessness
PAST HISTORY
INSPECTION
Patient in standing posture, limb externally
rotated and knee partly flexed
Varicosities involving which group, along
medial/lateral side of leg and tell about
extent upto which level of thigh
Any generalized or localised swelling
Skin changes redness/pigmentation/
lipodermatosclerosis
Ulcers or scars
Toes and nails
Any cough impulse at the SFJ and look for
GAIT
Look for signs of ischemia (as said in
Examination of Arterial disease)
Examine the lateral and posterior aspects of
lower limb too
PALPATION
Any local rise of temperature, Tenderness
Pitting edema
Thickening of skin
Ulcer describe about it (if any)
TESTS
Trendelenberg Test I and II
Multiple tourniquet test
Modified perthes test
Fegans test
Morrisey cough impulse test

Comorbidites PERCUSSION
Previous major illness required bed rest
Any major fracture / surgery / surgery for Schwartz test
varicose veins
EXAMINATION OF PERIPHERAL PULSES
PERSONAL HISTORY
FAMILY HISTORY LYMPH NODE EXAMINATION

OBSTETRIC HISTORY : CONTRALATERAL LIMB EXAMINATION

H/o white leg during pregnancy SYSTEMIC EXAMINATION

DRUG HISTORY CVS, RS, ABDOMEN

EXTERNAL GENITALIA
H/o OCP intake NEUROLOGICAL Sensory, motor and
proprioception
GENERAL EXAMINATION

Dr Pradeep Dhanasekaran |Madras Medical College 34

 Case History and Management Protocol

DIAGNOSIS :

Varicose Veins involving the Great

saphenous system of the Right or Left lower
limb with SFJ incompetence and Perforator
incompetence with or without ulceration
with CEAP C2, C3 or 4 or 5 or 6 , Ep, A and P

WORK UP

Blood Investigations
Coagulation profile

Duplex scan of venous system in both lower

limb
Arterial Doppler (if pulsations in doubt)

USG abdomen and Pelvis

TREATMENT MODALITIES

As the patient comes to us because of

symptoms and complications, mostly there
will no role for conservative management
except for active ulceration.

Even then, there is role for surgery

Junctional RFA / EVLA

incompetence (no
tortuous vessels)
Tortuous vessels Trendelenberg
with above thigh procedure with GSV
perforator stripping upto knee
incompetence
No Above thigh Just trendelenberg
perforator procedure alone
incompetence
Perforator Stab Avulsion or SEPS
incompetence or Sclerotherapy
Ankle flares/ Sclerotherapy.
Reticular veins

Dr Pradeep Dhanasekaran |Madras Medical College 35

 Case History and Management Protocol

time of consumption of drug by the patient

and its dose (can help in identifying
THYROID SWELLING antithyroid or eltroxin)

GENERAL EXAMINATION
COMPLAINTS
Conscious coherent comfortable
Painless swelling in the front of the neck Febrile and Hydration
Any associated symptoms PICCLE
Palms moist or dry
PRESENTING ILLNESS Eye signs (if any)
Elicit Eye signs (in toxic patients)
Swelling front of the neck, mode of onset,
progression, any recent increase in size VITAL SIGNS
Pulse, BP, Temperature
Associated symptoms
Pain elaborate it LOCAL EXAMINATION OF NECK
Voice change
Difficulty in swallowing INSPECTION
Breathlessness
Syncope Swelling Number, Shape, Size, Location,
Horners syndrome Extent, Surface, Margins, Lower border

Any History suggestive of hyperthyroidism Skin over the swelling for scars / dilated
like Sweating / Loss of weight / veins
Amenorrhea / Heat intolerance / Diarrhea / Movement with deglutition and protrusion
Anxiety / Tremors / Proximal muscle of tongue
weakness / Blurring of vision / Pain in eye / Any other swellings
Palpitations / Chest pain / Dyspnea / Pedal Any pulsations or cough impulse
edema
Tracheal position
History suggestive of Hypothyroidism like Carotids
Weight gain / Lethargey / Menorrhagia /
Constipation / hair loss / Cold intolerance PALPATION

H/o Loss of weight and appetite Local rise of temperature, Tenderness

Bone pain, Dyspnea and Jaundice
Swelling Size, shape, Extent, Surface,
PAST HISTORY Margins, Consistency, Pulsations, Lower
border palpable, Mobility and Thrill
Comorbid illness (if any)
Previous surgery Trachea and Carotids
Irradiation of Neck in child hood
PERCUSSION
PERSONAL HISTORY
Over manubrium (in cases where lower
Diet contains iodized salt or not border not visible in inspection)
Smoking / Alcohol
AUSCULATION
MENSTRUAL HISTORY
FAMIL HISTORY Bruit over upper pole
DRUG HISTORY
SYSTEMIC EXAMINATION
H/o thyroid drugs ask in detail about the

Dr Pradeep Dhanasekaran |Madras Medical College 36

 Case History and Management Protocol

CVS/ RS / ABDOMEN
SPINE & CRANIUM
Oral cavity

DIAGNOSIS

Multinodular Goitre with patient in

Euthyroid State
Solitary Thyroid Nodule with patient in
Euthyroid state
Malignancy of the Thyroid gland with
Cervical Nodal metastases
Multinodular Goitre with patient in Toxic
state

WORK UP

First do TFT

If TSH elevated, Do Anti thyroid antibodies

And Start on Anti thyroid drugs and then
Surgery if patient relapse from medical
management or other indications for
surgery (if to be done, do after 4 6 weeks
after confirming the patient in control state)

If TFT is Normal, Do USG NECK

Multinodular Suspicious Nodule

goitre

USG Guided FNAC

FNA to
rule out
Thyroiditis
Malignancy
Cyst / Colloid Adenoma/
goitre Follicular
Neoplasm Papillary Medullary
TOTAL
Reassurance and if
THYROIDECTOMY
patient needs for
cosmesis
Nodes - Nodes +
Hemi -
thyroidectomy

TT alone TT +
Total Thyroidectomy Prophy
alone Follicular CA TT + SND CCND
(involved
levels)

Dr Pradeep Dhanasekaran |Madras Medical College 37