Chapter 3 Abdomen 77 78 Section 1 Surgical Long Cases

− Aggravating and relieving factors: Food/vomiting/medicines „ Details of loss of weight and appetite: To mention exact figure of weight loss in kilogram and
− Relation with defecation and micturition the duration.
• Details of vomiting: • Details of swelling in the abdomen
− Duration Duration
− Frequency: The exact number Site where first noticed
− Relationship with food intake Size of of the swelling when first noticed
− Character of the act: Projectile or effortless Progress of the swelling
− Character of the vomitus • Details of urinary symptoms: Loin pain/mass in loin/frequency of micturition (diurnal
− Amount and nocturnal)/difficulty in passing urine/any burning during micturition/any urgency
− Color or hesitancy/any history of passage of blood or pus in urine.
− Taste 4. Past History
− Smell
5. Personal History
− Contains any food taken more than 12 hours earlier
− Any blood in vomiting: Suggestive of upper gastrointestinal bleeding 6. Family History
− Any relation with pain 7. Treatment History
• Details of blood vomiting (Hematemesis): 8. Any History of Allergy
− Duration
− Number of bouts of blood vomiting B. PHYSICAL EXAMINATION
− Color
− Amount 1. General Survey
− Whether associated with black tarry stool or not 2. Local Examination of Abdomen
• Details of jaundice: A. Inspection
− Duration (Patient supine with arms kept on sides and exposed from mid-chest to mid-thigh)
− Onset − Shape and contour of abdomen
− Any prodromal symptom before onset of jaundice: Fever/arthralgia/generalized » Normal/Scaphoid/Distended
weakness/loss of appetite/skin rash suggestive of viral-hepatitis − Umbilicus
− Any history of biliary colic preceding the onset of jaundice » Position (normal position lies midway between the xiphisternum and the symphysis
− Progress of jaundice pubis)
− Progressively increasing » Normally inverted/deeply inverted/flushed/everted.
− Diminishing after an initial deepening − Skin over the abdomen
− Waxing and waning » Scar (If operative scar describe as upper midline/lower midline/upper paramedian/
− Static right or left subcostal incision scar) (Fig. 3.1)
− Associated symptoms with jaundice: » Pigmentation
» Pruritis: obstructive jaundice » Striae (white striae found in multiparous women is to be described as striae
» Clay colored stool: Obstructive jaundice albicans)
− History of fever with chill and rigor—cholangitis » Engorged vein (if engorgd veins are
− History of biliary colic present ascertain the direction of
− History of black tarry stool with waxing and waning of jaundice blood flow in the engorged veins)
− Movements
• Bowel habit » Respiratory movements whether all
− What was the usual bowel habit before the illness started? region are moving normally with
− What is the present bowel habit? respiration
− What is the change in bowel habit? » Visible peristalsis
− Any history of bleeding P/R or black tarry stool, passage of mucus in stool » Pulsatile movements Figure 3.1: Scars of different incision
− Any history of sensation of incomplete defecation − Visible swelling
− Any history of tenesmus » Site and extent
 Chapter 3 Abdomen 79 80 Section 1 Surgical Long Cases

» Size • If gallbladder is distended or there is a mass in relation to gallbladder the gallbladder may,
» Shape be palpable—the detail of gallbladder examination is to be recorded
» Surface • Stomach is normally not palpable. In cases with gastric outlet obstruction, the distended
» Margin stomach may be palpable in epigastrium, which disappears with passage of peristaltic
» Moving with respiration or not waves from left to right
» Rising test—whether swelling is parietal or intra-abdominal • Normal pancreas is also not palpable
− Hernial sites • Palpation of any other lump:
» Any swelling − Position and extent in relation to abdominal regions
» Any expansile impulse on cough − Shape
− External genitalia − Size
B. Palpation − Surface
• Superficial palpation: − Margin
» Temperature: Examine all the regions of the abdomen (Compare temperature of − Consistency
abdomen with temperature of chest with the dorsum of finger) − Mobility: with respiration
» Any superficial tenderness. − Mobility from side to side, up and down
» Feel of the abdomen: − Fixity to skin or underlying structure
- Soft and elastic feel is normal − Rising test to confirm intra-abdominal or parietal swelling
- Muscle guard − Knee elbow position and examine the swelling again to decide whether swelling is
- Rigidity intraperitoneal or retroperitoneal
» Lump palpable: Details of the lump are to be described under deep palpation • However, this position is very inconvenient for the patient, now this test is usually avoided.
• Deep palpation: • Hernial sites
• Deep tender spots:Any tenderness over the following sites (Fig. 3.2): • External genitalia.
1. Gastric point: A point in the midepigastrium. C. Percussion
2. Duodenal point: A point in the transpyloric plane − Normal percussion note over the abdomen.
2. 5 cm to the right of midline. − Shifting dullness
3. Gallbladder point: A point at the junction of lateral − Fluid thrill
border of right rectus abdominis and the tip of − Succusion splash over stomach
right 9th costal cartilage. − Upper border of liver dullness
4. McBurney’s point: A point in the right spino- − Upper border of splenic dullness
umbilical line at the junction of medial two-thirds − Percussion over any abdominal lump palpable.
and lateral one-third.
5. Amebic point: Point on left spinoumbilical line D. Auscultation
corresponding to McBurney’s point on right side. − Peristaltic sound
6. Renal point: A point at the junction of lateral − Bruit
border of erector spinae and the 12th rib (see Figs − Venous hum
4.2A and B, Page No. 187). − Any added sound.
• Murphy’s sign: E. Ausculto-Percussion
− Found positive in patient with acute cholecystitis Figure 3.2: Deep tender spots. For 1, − In case of gastric outlet obstruction to delineate the greater curvature of the stomach.
− Usually not demonstrable in chronic cholecystitis. 2, 3, 4, 5 see text F. Per Rectal Examination
• Palpation of organs: G. Per Vaginal Examination
− Liver
− Spleen 3. Systemic Examination
− Kidneys Describe all system.
− Gallbladder is not normally palpable.

38 Section 1 Surgical Long Cases

„ Relation of pain with straining: usually pain increases with straining

„ How is the pain relieved: usually relieved on lying down.
In third paragraph write about any straining factor:
„ History of chronic cough, breathlessness, any history of chronic bronchial asthma
„ Bowel habits: whether normal or there is any history of constipation or straining at stools.
Write in details the usual bowel habit
„ Bladder habit: write in details about bladder habit to exclude any prostatic enlargement or
urethral stricture
• Any dysuria
• Hesitancy/urgency/precipitancy
• Narrowing of stream
• Frequency of micturition, during daytime and nocturnal (ask whether patient has to wake
up at night to micturate)
• Any history of acute retention of urine
„ Mention about any other important systemic symptom.

4. Past History: Any history of similar swelling in the same or opposite side. Any history of
operation.
5. Personal History
6. Family History
7. Treatment History
Whether using truss or not.
8. Any History of Allergy

B. PHYSICAL EXAMINATION
1. General Survey: Same as general scheme of case taking (see Page No. 5, Chapter 1).
2. Local Examination: Examination of both inguinoscrotal regions:
(In majority of hernia cases the swelling gets reduced partly or completely on lying down. So
description of details of the swelling in lying down position will be fallacious. Main part of
hernia examination will be in standing position and patient will lie down while doing some
special tests only.)
In standing position:
„ Inspection (Fig. 2.1):
• Side where the swelling is present—right/left
• Position and extent of the swelling:
− The swelling is seen in the inguinal region
− A swelling is seen in (right/left) inguinoscrotal region
− The swelling extends above upto the inguinal canal and below upto the bottom of
scrotum
• Size: mention approximate size of the swelling—longitudinal and transverse dimension
• Shape: pyriform or globular
• Surface: smooth/irregular
• Margin: rounded/ill-defined
 Chapter 2 Hernias 39 40 Section 1 Surgical Long Cases

• Expansile impulse on cough over the • Deep ring occlusion test:

swelling − Hernia is reduced and the deep inguinal ring is occluded by the thumb and patient is
• Skin over the swelling: any scar/engorged asked to cough. Test is positive when no impulse or hernial bulge is seen medial to the
vein/pigmentation deep inguinal ring on coughing after the deep ring is occluded, suggesting this to be
• Any visible peristalsis over the swelling an indirect inguinal hernia
• Position of penis: any deviation − Test is negative, i.e. an expansile impulse or hernia bulge is seen in inguinal canal medial
• Testis: whether testis could be seen sepa- to the occluded deep ring suggesting this to be a direct inguinal hernia
rately from the swelling or swelling is seen • Palpation of testis epididymis and spermatic cord
all around the testis „ Percussion
• Percuss over the hernial swelling keeping the content out in the hernial sac (Patient in
„ Palpation standing posture)
• Temperature over the swelling − Resonant note over the swelling suggests enterocele
• Tenderness over the swelling − Dull note over the swelling suggests omentocele
• Whether it is possible to get above the „ Auscultation (Patient in standing posture)
swelling (For an inguinoscrotal swelling it Figure 2.1: Inspection of both inguinoscrotal • Bowel sound over the swelling suggests enterocele
is not possible to get above swelling) region in standing position „ Mention about normal side of inguinoscrotal region:
• Position and extent of the swelling • No swelling in the opposite inguinoscrotal region
• Si z e : l o n g i t u d i na l a n d t ra n s v e r s e • No expansile impulse on cough
dimension, to be measured and mentioned, e.g. 5 cm × 4 cm • Testis/epididymis and spermatic cord—normal
• Shape: a complete hernia is usually pyriform in shape. A direct hernia is globular in shape „ Examination of tone of abdominal muscles—good or poor with bulge in the flanks
• Surface „ Per-rectal examinations: it is important in a male patient with symptoms of prostatism.
• Margin 3. Systemic Examination
• Consistency
− Soft and elastic (when content is intestine)
„ Examination of abdomen
„ Examination of respiratory system (emphasize, if there is history of respiratory symptoms)
− Doughy (when content is omentum)
„ Examination of cardiovascular system
− Tense and tender (obstructed hernia) „ Examination of nervous system
• Relation of the swelling to pubic tubercle: „ Examination of spine and cranium.
− The swelling is situated above and medial to pubic tubercle (inguinal hernia)
„ The swelling is situated below and lateral to the pubic tubercle (femoral hernia) C. SUMMARY OF THE CASE
• Relation of swelling to testis: whether testis can be felt separately from the swelling or not.
• Reducibility (to test for reducibility patient has to lie down):
− Whether swelling reduces spontaneously on lying down, partially or completely D. PROVISIONAL DIAGNOSIS
» If not reduced spontaneously—whether swelling can be reduced by manipulation Give a complete diagnosis mentioning:
» Which part of the swelling is easy to reduce—first part or last part „ Side: right or left
- In omentocele, first part reduces easily, but last part is difficult to reduce „ Inguinal or Femoral
- In enterocele, first part is difficult to reduce, but last part reduces easily „ Direct or Indirect
• Invagination test: „ Complete or Incomplete
− The invagination test is usually not done nowadays. The demonstration of this test is „ Reducible or Irreducible
painful.This is no longer necessary to mention about this test in routine examination „ Content: Intestine or omentum
of hernia, unless examiner is specifically interested to know about the test. „ Complicated or Uncomplicated
− On invagination test, comment about the size of the superficial inguinal ring. Normally
For example: This is a case of right-sided reducible complete indirect inguinal hernia containing
the superficial ring does not admit the tip of index finger. When the hernia has reached
intestine without any features of complication at present.
the scrotum, superficial inguinal ring becomes patulous
− Ask patient to cough and assess where the impulse is felt—pulp or tip

68 Section 1 Surgical Long Cases

3. History of Present Illness

„ If the swelling started shortly after the operation then start writing history of present illness
with history of operation including details of postoperative course
„ If hernia developed after a long duration following operation then the operation history may
be described in past history
„ Detailed history about the swelling—mode of onset, progress of the swelling—size at the onset
and approximate present dimension. What happens to the swelling on standing, walking,
straining and lying down
„ Detail history about pain—Onset, duration, site, character, radiation. Relation of pain with
the swelling, any aggravating or relieving factor.
„ If operative history and appearance of the swelling is not a long gap (less than a year), then
details of the operation may be included in the history of present illness, otherwise the history
of operation may be written in past history. The operative history includes, type of operation,
emergency or elective, nature of operation, postoperative recovery, any history of cough or
abdominal distension in the postoperative period any wound infection, any wound gaping
or burst abdomen, whether required secondary suture, duration of hospital stay. Time gap
between the operation and appearance of swelling.
„ Any straining factors like chronic cough, constipation or difficulty in micturition.
„ Details of bowel and bladder habits.
„ Any other systemic symptoms—ask details about systemic symptoms.

4. Past History
Detail history about the operation, if not included in history of present illness.
5. Personal History
6. Family History
7. Treatment History
Whether using abdominal belt.
8. Any History of Allergy

B. PHYSICAL EXAMINATION
1. General Survey
2. Local Examination: Examination of abdomen
Detail abdomen examination: Inspection, palpation, percussion and auscultation
„ To comment about the hernial swelling site, extent, size, shape, surface, margin the patient
should be examined in standing as with lying down the swelling may disappear or may
reduce in size
„ For testing reducibility the patient should lie down and the clinician pushes the swelling
through the gap in the abdominal wall
„ The gap in the abdominal wall should be assessed

3. Systemic Examination

C. SUMMARY OF THE CASE

D. PROVISIONAL DIAGNOSIS
 Chapter 5 Breast 199 200 Section 1 Surgical Long Cases

• Any swelling in axilla and neck—details of the swelling • Skin over the breast
• Chest pain/cough/hemoptysis − Scar
• Appetite/weight loss − Engorged vein
• Any pain in abdomen, any history of jaundice − Pigmentation
• Any history of low back ache − Any redness or shininess
• Any history of aches and pain in limbs − Any skin change dimpling, retraction, puckering, peau d’orange, nodule, ulceration
• Any history of headache/loss of consciousness/vomiting/weakness of any of the limbs (fungation), cancer-en-cuirasse
4. Past History • Any swelling in the breast
− Position in relation to breast quadrant

/ /
5. Family History

ir ir
− Extent
Detailed family history regarding similar illness or any history of gastrointestinal or ovarian
− Size and shape

. .
malignancy in 2–3 generations. Any history of breast carcinoma or gastrointestinal or ovarian
− Surface and margin
malignancy in sibling and cousins, in parents, aunts and uncle and in grandparents.

s s
− Skin over the swelling
6. Personal History

s s
• Any ulcer over the breast or over a swelling in the breast
• Details of menstrual history − Position and extent

n n
• Details of obstetrical history − Size and shape
− Age at first pregnancy

a a
− Margin

i si
− Total number of pregnancy (P2+O) − Floor
− Number of abortion

s
• Any edema of the arm

er r
− Mode of delivery
Inspection of the breast with the arms raised over the head—to look for any nipple deviation
− Last child birth

e
or any skin changes.
− Any history of oral pill intake or hormone replacement therapy.
Inspection with the patient sitting and leaning forward—to look for whether both the breast fall

.p .p
7. Treatment History
forward equally or there is fixity of the diseased breast.
8. History of Allergy
Inspection with the patient sitting and pressing her waist with the hands—to look for any evident

B. PHYSICAL EXAMINATION

vi p skin changes.

vi
Other breast on inspection—normal.
p
// //
1. General Survey Palpation: Normal breast palpated first—describe as normal.

: :
2. Local Examination—Examination of both breasts Diseased breast (right or left):
Inspection: Examination of diseased breast (right or left)

p p
„ Temperature in all the quadrant of the breast

t t
• Symmetry and position of breast in comparison to normal side „ Tenderness over the breast

ht ht
• Size and shape of breast in comparison to normal breast „ Any swelling, palpate, the details:
• Nipple • Position and extent in relation to the breast quadrant
− Position in comparison to the normal side • Size and shape
− Drawn up or pushed down • Surface and margin
− Displaced inward or outward • Consistency
− Size and shape of nipple • Fixity to skin
− Surface of the nipple: Any cracks or fissure • Fixity to breast tissue
− Any nipple retraction • Fixity to underlying pectoral fascia and pectoralis major muscle
− Any discharge from nipple • Fixity to chest wall
− Any ulcer over the nipple • Fixity to serratus anterior muscle for lumps in outer quadrant of breast
• Areola • If swelling is cystic—fluctuation and transillumination
− Size of areola If there is an ulcer over the breast—examination of ulcer:
− Any diminution of size due to retraction • Site
− Any cracks, fissure, ulcer or eczema • Size and shape
− Any discharge • Margin

Chapter 5 Breast 201

• Floor
• Any discharge
• Surrounding area
• Tenderness
• Base of ulcer
• Mobility
Examination of regional lymph node:
Level I: Lymph node include anterior (pectoral), lateral and posterior group of axillary nodes.

i. r/
This group of lymph nodes lie lateral to the lateral border of pectoralis minor.
Level II: Lymph node includes the central group of lymph nodes and lies behind the pectoralis
minor.

s
Level III: It is the apical group of lymph nodes and lies medial to the pectoralis minor.

s
Examination of supraclavicular lymph nodes.
Examination of opposite axillary lymph nodes: Level I to level III lymph nodes.
3. Systemic Examination
n
ia
Examine all the systems

C. SUMMARY OF THE CASE

r s
e
D. PROVISIONAL DIAGNOSIS

.p
E. DIFFERENTIAL DIAGNOSIS

p
F. INVESTIGATIONS SUGGESTED

Write a complete diagnosis.

// vi
Carcinoma of breast right or left

:
„
„ TNM definition of tumor, e.g. T1N1M0/

p
T4bN2M0

t
Staging depending on T, N, M. Stage I/II/

t
„
III/IV, e.g. carcinoma of right breast in a

h
postmenopausal woman—Stage 1 (T1N0M0).
How inspection in different position does
help?
Inspection is done:
a. With the arms by the side of the body (Fig. 5.1A)
b. With the arms raised over the head (Fig. 5.1B)
c. Patient sitting and bending forwards so that
the breasts fall away (Fig. 5.1C)
d. Patient sitting and hands pressed on the waist to
contract the pectoralis major muscle (Fig. 5.1D).
e. Paitent recumbent with 45 degree head end
elevation and both hands lying by the side of Figure 5.1A: Inspection with patient sitting
head (Fig. 5.1E) with arms by the side of body
238 Section 1 Surgical Long Cases Chapter 6 Thyroid 239

− Difficulty in breathing 2. Local Examination: Examination of the

− Alteration of voice, commonly hoarseness Thyroid Region
• Enquire about any symptom of hyperthyroidism or hypothyroidism: a. Inspection (Fig. 6.1)
− Appetite − Position and extent of the swelling:
− Weight loss/weight gain Swelling situated in the front and sides of
− Bowel habits: Particularly enquire about diarrhea the neck in the thyroid region extending
− Chest pain and its relation with exercise laterally up to the sternomastoid, below
− Palpitation up to the suprasternal notch and above
• Any history of dropped beat (if patient can mention in history then only it is to be recorded) up to the thyroid cartilage.
• Breathlessness on exertion If both lobes of the thyroid gland are
• Any trembling of limbs enlarged, describe the extent of each
• Irritability on slight provocation lobe upward, downward and laterally. Figure 6.1: Inspection of thyroid region
• Insomnia Both lobes of the thyroid gland are
• Weakness of limbs enlarged and extend above up to the
• Bulging of eyes: thyroid cartilage, below up to the sternoclavicular joint and laterally up to the posterior
− Duration and progress border of sternocleidomastoid.
− History of redness of eye and watering − Describe the extent of the isthmus in the midline: Upper and lower extent. The isthmus
− History of double vision of the thyroid gland is also enlarged and extends below up to the suprasternal notch
− Loss of vision and extends 3 cm above the suprasternal notch.
• Increased sweating − Shape: If thyroid gland is enlarged as a whole, it may be described as a butterfly shaped
• Heat intolerance swelling. Otherwise describe the shape as it is seen.
• Intolerance to heat or cold. − Size: If both lobes and isthmus are enlarged.
In a patient with thyrotoxicosis, some of these toxic symptoms may be present. If treated with Describe vertical and horizontal dimension of each lobe and vertical and transverse
antithyroid drugs, there may be some improvement. This should be included in history of present dimension of the isthmus separately.
illness. − Surface: Smooth/irregular/nodular.
Enquire about symptoms suggestive of hypothyroidism: Weakness/lethargy/swelling of face, − Margins.
whole body or legs/intolerance to cold/menstrual problems/constipation. − Skin over the swelling: Scar/pigmentation/venous prominence.
− Any pulsation.
4. Past History
− Movement of the swelling with deglutition.
Any history of irradiation in the neck.
− In case of solitary thyroid swelling look for upward movement of the swelling on
5. Personal History/Menstrual History/Obstetrical History protrusion of the tongue to differentiate a thyroid nodule from thyroglossal cyst.
6. Family History − If there is diffuse enlargement of the thyroid gland, movement of the swelling on
Any history of thyroid disease in the family members or the neighborhood. protrusion of the tongue need not be tested as differential diagnosis with thyroglossal
7. Treatment History cyst is not required.
• Enquire about any drug treatment − Comment whether lower border can be seen as such or on swallowing.
− Eltroxin − Any venous prominence over neck or chest wall.
− Antithyroid drugs b. Palpation
− Beta blockers. − Temperature over the swelling
8. Any History of Allergy. − Tenderness
− Movement of the swelling with deglutition. Movement of the swelling on protrusion of
the tongue, if it is a solitary swelling in the thyroid gland
B. PHYSICAL EXAMINATION
− Position and extent of the swelling
1. General Survey − Shape
• Facies: Thyrotoxic facies, myxedema facies − Size
• Neck gland: Thyroid gland is enlarged. Described under local examination − Measurement of circumference of the neck at most prominent part of the swelling
• Pulse rate/minute rhythm regular, described in details in examination for toxic sign. (measure with a tape in centimeters)

240 Section 1 Surgical Long Cases Chapter 6 Thyroid 241

− Surface, margin » Dalrymple’s sign: Visibility of upper sclera due to spasm of upper eyelid. If present,
− Consistency: Hard, firm, soft cystic, variegated the sign is positive
− Any pulsation » Von Graefe’s sign: If lid lag is present, the sign is positive
− Any thrill » Joffroy’s sign: Loss of wrinkling of forehead on looking up—the sign is positive
− Any skin fixity » Möbius sign: If there is failure of convergence on accommodation at a near object
− Mobility: Mobility from side to side and up and down from a distant object—the sign is said to be positive
− Relation of the swelling with sternocleidomastoid muscle » Stellwag’s sign: Infrequent blinking—a stare look. If present, the sign is positive.
− Note the positions of trachea and larynx In advanced case:
» Any shifting to either side by the swelling - Chemosis
JaMeS DV Peyeche - eye signs
− Test for tracheal compression: Kocher's test - Test for eye movement and comment about any palsy
» The swelling is pressed slightly on either side of trachea. If trachea is already - Look for diplopia. In thyrotoxicosis, diplopia may occur due to paralysis of inferior
compressed, or if there is tracheomalacia, patient will have stridor oblique and superior rectus muscle.
» Kocher’s test negative (no stridor)
g. Examination for Retrosternal Prolongation
» Kocher’s test positive (stridor on compression of both lobes)
− Lower margin of swelling. Whether visible or not, as such or on deglutition
− Palpate the carotid pulsation
− Any dilated vein over the neck and chest wall
» Carotid pulsation may be felt at normal site (at the anterior border of
− Pemberton's sign: Ask the patient to raise both upper limbs above the head and keep it
sternocleidomastoid at the level of the upper border of thyroid cartilage)
for 2–3 minutes. If retrosternal prolongation is there, patient will have congestion and
» Carotid pulse is not palpable on the side of the swelling (Berry’s sign positive)
puffiness in the face with respiratory distress. The Pemberton's sign is then positive
» Carotid pulse is palpable but is displaced laterally
− Percussion over the manubrium sterni—normally resonant. Dull note suggest
− In a locally advanced thyroid carcinoma sympathetic trunk may be involved. Look for
retrosternal prolongation of goiter.
signs of sympathetic trunk palsy (Horner's syndrome)
» Enophthalmos 3. Systemic Examination
» Pseudoptosis (slight drooping of upper eyelid) Describe all systems.
» Anhidrosis (loss of sweating)
» Miosis C. SUMMARY OF THE CASE
» Loss of ciliospinal reflex.
c. Percussion: Percussion over the Manubrium Sterni D. PROVISIONAL DIAGNOSIS
− Superior mediastinum is normally resonant. If there is retrosternal prolongation of „ Primary thyrotoxicosis
goiter, the area may be dull. „ Nontoxic solitary nodular goiter
d. Auscultation „ Nontoxic multinodular goiter
− Any bruit audible or not „ Carcinoma of thyroid.
− In thyrotoxicosis, the bruit is audible near the upper pole of the thyroid lobes.
E. INVESTIGATIONS SUGGESTED
e. Examination of Cervical Lymph Nodes
− Examination of all the cervical lymph node groups: If lymph nodes are palpable then 1. Investigation to confirm the diagnosis
describe, which groups of lymph nodes are palpable 2. Investigations to stage the disease in case of carcinoma thyroid
− Number, site, surface, margin, consistency and mobility
3. Baseline investigations.
− Write details about lymph node enlargement.
f. Examination for Toxic Signs F. DIFFERENTIAL DIAGNOSIS
If toxic signs are present write in details:
− Pulse rate, rhythm, volume, any special character—collapsing or not How will you palpate the thyroid gland? Say one method of palpation.
− Tremor in hands and tongue I will palpate the thyroid gland by Lahey’s method.
− Thrill and bruit over the thyroid gland usually present at upper pole Stand in front of the patient. To palpate the left lobe, push the right lobe to the left with the left
− Eye signs: hand so that the left lobe becomes prominent. The left lobe is then palpated with the right hand.
» Exophthalmos: Forward bulging of the eyeball The anterolateral surface and the posterior surface of the left lobe are then palpated (Fig. 6.2).