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Thursday, August 31, 2017

Examination of Ulcer: How to describe.



Examination of an Ulcer
(The description below does not match with the images given beside the text. The images are only for illustrative purposes.)

Inspection

Ulcer over the medial aspect of foot extending into the sole.
Ulcer over the sole.
On inspection of the right leg, the leg is slightly elevated on the pillow and slightly flexed over the knee joint. (Attitude of the limb).

A single (number), irregularly shaped (shape) ulcer of size around 10 cm x 5cm (size) is present over the dorsum of the foot (site), extending from the lateral malleolus up to the base of the toes (extension).

The floor of the ulcer is pinkish to red (color) with minimal (amount) serous (type of discharge) discharge. No slough, foreign bodies or any other debris (Content on the floor). Multiple tendons are visible towards the distal end (base).

The edge of the ulcer is sloping type (character), with healthy pink granulation tissue (content) and the margin is sharp and regular.

The surrounding skin is exfoliated upto the level of ankle joint. The skin around the ulcer is non-erythematous, and non-edematous. No scars, abnormal pigmentation, or excoriation marks present.

The joint mobility of the proximal and distal joint along with that of the entire limb is not impaired. (Gross motor status and Range of motion of the affected joints)

Palpation
Ulcer over the dorsum of left foot.
Ulcer over the dorsum of foot

On palpation, there is local rise in temperature and mid tenderness over the ulcer.

The edges are not indurated and the base of the wound are also not indurated. The ulcer is 3-4mm deep, does not bleed on touch, and mobile over the underlying base.

The skin around the ulcer has mild rise in temperature locally with tenderness present. The skin is freely mobile on the underlying structure.

Dorsalis pedis artery, anterior tibial and posterior tibial artery are palpable and bilaterally symmetrical. Capillary refill time over the distal phalanges is more than 2 s.(Gross vascular status)

Active and passive range of motion over the limb is not restricted. Sensation is grossly intact over the area distal to the ulcer. (Gross Neurological status and range of motion)

The draining lymph nodes over the left inguinal region are not palpable significantly.



Ulcer examination is incomplete without draining lymph nodes palpation. 



Mnemonics: Breast Cancer causes

Risk Factors for Development of Breast Cancer (A to G Guide)

For easy remembrance of the risk factors that can cause breast cancer, it is grouped into 7 major titles that start from A to G, and under each heading both protective factors or factors that has least causative effect and factors that has strong risk are classified and described.
Risk Factors for development of Breast Carcinoma




Risk
Protective
A
Age
Old age
>90 years (~20%)
Rare <20 years
B
Benign Breast Conditions
Hyperplasia (1.5-3 fold)
Papilloma (1.5-3 fold)
Ductal / Lobular Atypical hyperplasia (5 fold)

C
Cancer
Cancer of contralateral Breast (3-4 fold)
Cervix
Ovary
Colon
Prostate
Radiation Therapy for Hodgkin's Lymphoma

D
Diet
Alcohol
Phytoestrogen Deficiency
Vitamin C
E
Estrogen
(Conversion of Steroid hormone to estradiol in the body fat)
Nulliparous
Obese Postmenopausal Women
Exogenous Estrogen (OCP, Mixed prep HRT)
Breast feeding
Late Menarche
Early Menopause
Early age at 1st child birth
F
Familial History
2-10 fold risk in family history of Breast, Colon, Ovarian and Prostate Carcinoma

G
Genetics
BRCA 1 (Breast Ovarian, prostate and Colorectal Ca )
BRCA2 (Male Breast Ca)
p53
HER 2

G
Geography
African american
(Western world 1-3 % of all death of women )
Rare in Japan and Taiwan
Source: Bailey and Love’s Short Practice of Surgery.

Digital Rectal Examination: How to describe

Describing a rectal examination and prostate

(Per Rectal examination is a part of abdominal examination and no per rectal examination is complete without perineal examination, per rectal examination and examination of supraclavicular node (Nodes of Virchow) along with renal angle tenderness. The following describes a normal finding of per rectal examination. If any abnormality or significant findings it must be described 
accordingly.)

Inspection
On inspection of the perineal area, no redness, no any perianal mass or tag, no fissure, no ulceration or any sinus opening seen.

Palpation
No palpation of the perineal area, there is no local rise in temperature, no tenderness felt. No any palpable mass present.

Digital Rectal Examination
The tone of the sphincter is normal with no tenderness is present.
The anal canal is empty and no hard masses, impacted fecal material and polyps are palpable.
The mucosa overlying the anal canal is soft and mobile. There is no any palpable ulceration and fungating mass on examination of the walls of anal canal.
The prostate is enlarged and the upper border can not be palpated. The consistency is firm, the surface is smooth and borders are regular. The median sulcus can be palpated well and the mucosa overlying the prostate is freely mobile.
No blood stain was present on the tip of the finger at the end of digital Rectal Examination.



Wednesday, August 30, 2017

History Writing: A case of Premature rupture of Membrane

(All the patients may not have the same symptoms at presentation and the same risk factors, so history taking should always be INDIVIDUALISED than generalised to a standard sets of check list.It is always RECOMMENDED to ask the patient their problems and the question associated with the problem as per the need.

Interpersonal variations are always exists in the way the history is taken and written. Pattern, format and style of history taking and presenting are subject to change as per institutional protocol and region.Please kindly follow the system that is acceptable in your context.)


Patients Particulars (to be enlisted rather than written in text)
Name: Sita Koirala
Age: 28years
Address: Dhulikhel
Religion: Hindu
Marital status: married to Ram Koirala
Married for 7 years
Occupation: Housewife
Date of admission: 2016/03/05
Place of presentation: Emergency Department
Date of examination: 2016/03/07

(Mrs Sita Koirala, 23 years lady, a housewife from Dhulikhel, married for 7 years, presented to DH emergency with)

Complain of
Cessation of menstruation for 8 months
Pain abdomen for 1 day
PV leak for 3hrs


Menstrual History
Last Menstrual Period 2015/07/01
Expected Date of delivery 2016/04/07
Period of gestation: 36 WOG
Menarche: 13 years
Regularity of cycles and its length: Regular every 28 days
Duration of menstrual flow 3-4 days
Passage of clots (-)
Dysmenorrhea (-)
Number of pads changed per day and its soakage.(3 pads/day, partially soaked)
(She attained her menarche at the age of 13 years with regular cycles of 28 days and menstrual flow of 3-4 days. She changes 3 partially soaked pads per day with no history of passage of clots and severe crampy pains during her menstruation)


Obstetrics History
Marital History
Duration of marriage 7 years
Age at marriage 21years

Parity Index (G3P1A1L1)
She is a Gravida 3 Para 1 Abortion 1 and Living 1 lady and was 23 years at the age of her first child birth.
She has a 5 years old boy, delivered normally at Dhulikhel Hospital with birth weight of 2.8 kg. Antenatal, natal and postnatal period was uneventful.

She had a spontaneous abortion 1 year back at 10 weeks of gestation for which she underwent suction and evacuation at Dhulikhel hospital. No complications were noted.

Contraceptive history
She used OCP immediately after her marriage but discontinued after 3 cycles of use. 3 months after the delivery of her child she inserted cupper T. She removed copper T one year back. She had regular cycles during the use and no complications were noted in between.

History of Present pregnancy
First Trimester
She confirmed her pregnancy after 1.5 months of cessation of menstruation at local clinic by urine pregnancy test. She had complains of nausea and vomiting but was not severe enough to get hospitalized. She also complains of urgency and frequency but no burning micturition. Mild soreness of breast was present. But she does not give history of fever, pain abdomen or per vaginal bleeding.
She had 1 ANC visit in the 1st trimester where her blood and urine examination was done and was told to be normal. She took Tab Folic acid. USG was not done. No exposure to any radiation or intake of any other non-prescribed medication.

Second trimester
Cessation of menstruation continued. There was progressive enlargement of abdomen and breast.
Quickening was experienced at 5 months of gestation.
She had 3 ANC visits. She had routine checkup and was told to be within normal limits. She took tab iron and tab calcium regularly. Tab Albendazole was taken at 5th month of gestation. 2 doses of TT vaccination was taken month apart. Blood test after consumption of glucose and water was done which was told to be normal. USG was done at 5th month and told to be normal.
She had no complains of urgency, frequency and burning micturition. No complains of headache, blurring of vision, shortness of breath. No history of fever, PV bleeding or PV discharge.

Third trimester
Cessation of menstruation continued. There was progressive enlargement of abdomen and breast. She gained a total weight of 10 kg during her pregnancy. She is perceiving fetal movements.
She had 4 ANC visits, continued the intake of tab Iron and calcium.
No complains of urgency frequency, No swelling of limbs and shortness of breath. No complains of headache, blurring of vision, fever, PV bleeding or PV discharge.

History of Present illness
According to the patient she was apparently well 1 day back, then she gradually developed lower abdominal pain which was insidious on onset, on and off. No radiation of the pain. No aggravating and relieving factors were present. She also gives history of per vaginal leaking 3 hours back which was plenty enough to soak her clothes which aggravated her abdominal pain. The fluid was clear and not stained with blood or green colored discharges.
She is perceiving fetal movement.
She does not give history of PV bleeding.
No history of fever, no urgency frequency or burning micturition.
No PV discharge.
No history of nausea, vomiting, diarrhea or abdominal distension.
No history of trauma.
No cough, cold or chest pain.

History of Past Illness
No history of chronic illness like Hypertension, Diabetes Mellitus, Epilepsy, Rheumatic Heart Disease, Bronchial Asthma, or Hypothyroidism. No past history of tuberculosis or jaundice.
No prior surgeries done. Not under any medication for any chronic illness.
No known allergy to any food, drug or other substances.

Personal History
She is a non- smoker and does not consume alcohol. She consumes non vegetarian diet. She has normal bowel and bladder habit and has adequate rest.

Family History
No history of chronic illness in the family. No history of congenital anomaly in the family. No history of consanguinity. No history of multi-fetal pregnancy or recurrent abortion in the maternal lineage.

Socioeconomic History
She belongs to a well sustained middle class family with good relation in the society. She has completed class 12.She lives in a modern house with good provision of clean drinking water and sanitary latrine.

My Provisional diagnosis based upon history is
G3P1A1L1 at 36 WOG with Premature Rupture of Membrane.

Have problem with gravida para. Try some problems 


*** Disclaimer : This is a hypothetical case and is not a real life scenario. However, the condition is so common and prevalent, it is a coincidence if it matches with the life of any. This case is solely for educational purpose with no intentions meant otherwise.*** 

History Writing: A case of COPD

(Italicized words and parenthesized words and  sentences are for readers purpose only not to be read when presenting a case. The letters In Blue are points of special interest to be discussed later.

All the patients may not have the same symptoms at presentation and the same risk factors, so history taking should always be INDIVIDUALISED than generalised to a standard sets of check list.It is always RECOMMENDED to ask the patient their problems and the question associated with the problem as per the need.

Interpersonal variations are always exists in the way the history is taken and written. Pattern, format and style of history taking and presenting are subject to change as per institutional protocol and region.Please kindly follow the system that is acceptable in your context.)

A case of COPD

Patient Particulars
Name : Mr Magar
Age :  68 years
Sex: Male
Religion: Hindu
Occupation : Farmer
Marital Status : Married
Address: Ramechhap

Date of admission : 24th August 2017
Date of examination : 29th August 2017
Mode of admission: Emergency Room

(Mr Magar, 68yrs gentleman, a married, hindu, farmer from Ramechhap presented to XYZ hospital emergency 5 days back with )


Chief complaints

1.     Shortness of breath x 12 years aggravated for last 5 days
2.     Fever x 5 days

History of Present illness
According to the patient,  he was apparently well 12 years back, then he graduallly developed shortness of breathe which was initially present while walking uphill (MMRC grade 1) and gradually progressed over time and had to stop while walking about 100m on level ground (MMRC grade 3) in 12 years time. But for the past 10 days, the shortness of breathe is severe enough to compromise his daily activity (MMRC grade 4). Mild improvement was seen after use of inhalational drug.Patient uses 2 pillows to sleep (orthopnea) and gives history of occasional sudden awakening at night with severe air hunger and has to stand up and open window before the symptoms are relieved(PND). The shortness of breath is associated with cough and sputum production. He has bouts of cough more in the morning, on and off, aggravated by smoking and exposure to dust and cold and has mild chest pain. The patient also gives history of sputum production which is thick , mucoid, whitish in color, about a tablespoon full and non foul smelling. There is no blood in the sputum. But for the last five days the sputum is more copious, around a cup full and the color has changed from white to yellow.

The patient gives history of high grade fever for 5 days, insidious in onset, on and off,  more in the morning, associated with chills but no rigor and sweating. The temperature was not documented at home.  Patient complains of generalised weakness and muscle pain. No history of rashes, sore throat, headache.
The patient does not gives history of palpitation, lightheadedness and central chest pain. No complains of bluish discoloration of face and lips at the bouts of coughing (No cyanotic spell at end of cough). No swelling  of the limbs and adbomen (No corpulmonale).

No history of weight loss, no anorexia and easy fatigualbility. (Generalised symptoms)
No diarrhoea, vomiting, pain abdomen or abdominal distension. No dark colored stool or yellowish discoloration of skin. No history of burning micturition, urgency or frequency. (No Other foci of Fever )
No abnormal body movement, excessive drowsiness or confusion. No complains of headache (No chronic CO2 retention), photophobia and stiffness of the neck. (No other foci of fever)
No joint pain, pus draining sites or history of trauma.

History of past illness
The patient gives history of similar illness 2 years back for which he was hospitalized and was managed with oxygen and Iv medications. He had TB for which he completed a course of 6 months of treatment  15 years back. No other chronic illnesses like DM, HTN, Epilepsy. No history of any surgical intervention.

Personal history
Patient is a chronic smoker and has consumed about 40-45 pack years of cigarette (including bidi and hookah) for the past 50 years. But has stopped smoking for the last 2 years . Patient was a chronic alcoholic and consumed around 1 manas of locally made  alcoholic beverage (local unit = 500ml, assuming 30-40% of alcohol) which corresponds to for 1.5-2 units of alcohol for the  last 40 years but has stopped consuming for last 2 years.
He is non vegeterian and has normal bowel and bladder habit.
Sleep pattern is occasionally disturbed by sudden onset of severe shortness of breathe.

Family history
He has 8 members in the family.
No similar illness in the family.
No chronic illness like DM, HTN, TB or any cancers in the family.

Socioeconomic history
He belongs to a poor family. He uses fire wood and cattle dung cake for cooking food. The ventilation is inadequate and there is  congestion of smoke inside the house. The roof is thatched and they store grain in the same room they use for daily purposes. They have adequate provision of clean drinking water and toilet facilities.

Drug and allergy history
He has been taking from inhalation drug prescribed 2 years back but is not fully complaint with drug. No use of any drug for prolonged duration.  No known history of allergy to any drug, food or other substance.

Summary

58 years chronic smoker with 40 packs years of smoking, with previous history of PTB 15 years back, presented with SOB with MMRC grade 1 initailly, progressed to MMRC grade 3 over 12 years, associated with mucoid, scanty sputum more in the morning. But recently  SOB has been worse (MMRC grade 4 ) with high grade fever and purulent sputum for the last 10 days.  The patient is a chronic alcoholic, uses firewood to cook and has been taking inhalational medication irregularly. Patient gives history of similar episode 2 years back.
(We generally do not include negative history in the summary. This includes only the positive points)


Provisional Diagnoses based upon history
Acute exacerbation of COPD

Differential diagnosis
Pneumonia
Pulmonary Tuberculosis
Interstitial Lungs disease
Bronchial asthma
Lungs carcinoma


The following table show what is the significance of most of the points mentioned in the history described above. Parenthesized are the point of interest in that specific condition. The positive (+) and Negative (-) sign here are to signify the presence or absence of the symptoms or history is favoring or rejecting any of the differential diagnoses. The greater the number of signs, the stronger is the favoring point or rejecting point .

History
Points of interest
AE of COPD
Pneumonia
Pulmonary TB
Asthma
Interstitial Lungs Disease
Lungs Cancer
Patient particulars
Age 65 yrs
++
+/-
+/-
-
++
+++

Occupation
+
(Exposed to dust )

? labourous job … undernutrition (poor)
++
(exposed to dust, allergen, pollen, animal danders)
++
(Exposed to dust )

Chief complain
SOB x 12 yr
+++
-
-
+
+++
+/-

Increased for past 5 days
+++
(Acute on chronic )
+++
(precipated under some underlying condition)
+
+
-
-

Fever for 5 days
+++
(acute exacerbation otherwise absent)
++++
(active infection )
+
(Chronic infection)
-
-
-
HOPI
MMRC Grade 1 to 3 in 12 years
+++
(insidious onset )
-
+ (insidious onset but 12 years too long )
++(
+++
(insidious onset )
++
(insidious onset but 12 years too long )

MMRC grade 4 in 5 days
+
+++
(rapid progression)
+
+++
---
(Rarely acute exacerbation)
++

Mild improvement with inhalational drug (? SABA)
++


+
(Good improvement seen in early stages of the disease)



Orthopnea
? Corpulmonale



Exposed to dust


PND/ night symptoms
++


+++
(Rather night symptoms)
++


Cough in morning
+++
(Chronic Bronchitis)
+
+
+
(More on night)
+


Mucoid non purulent scanty
++
-(Purulent)
++
++
+
+/-(Serous /  Mucoid)

Recently purulent, copious and yellow
-
+++
+++
_
---

-

High grade fever

++
(Active Infection)
+
(Low grade fever for prolonged duration)

-


Generalised weakness
+
Chronic poor respiratory effort
++
+
+
+
(Chronic poor respiratory effort)
+++
(more generalised symptoms)
Neagtive hsitory
NO hemptysis

+/-
---
(Commonly seen)


--- (Commonly )

No weight loss


---
Commonly seen


----
Commonly seen

No anorexia


---
Commonly seen


----
Commonly seen
Past history
Similar illness in past
++
(recurrent infection)

+
Risk factor
+++
Acute exacerbations of asthma



PTB and ATT therapy
Risk factor

Risk Factor




No DM ( not immuno compromised)

Risk

Risk



Personal history
40 pack years smoking
+++

++
++
++
++++

Alchohol

+(aspiration)
++


+

Disturbed sleep
PND


Night symptoms


Family history
8 member


Overcrowding




TB
Risk

Contact history absent



Socioeconomic
Poor family


Risk factor 




Indoor pollution
++++
Precipitates

++
Risk factor
++
Risk factor

Risk factor

Thatched roof and grain storage (? Fungal Allergen)



--
Risk factor


Drug allergy
Inhalational drug
++
? Salbutamol for acute exacerbation


++
? Salbutamol fro acute exacerbation

++
Bronchodilators


No prolonged Drug therapy
(Steroids, NSAIDS, aspirin , immunomodulators)


--
Reactivation of TB (steroid, immunomodulator drugs)
--
Aspirin, NSAIDS precipitates
--
Use of bleomycin, amiadarone, metho-trexate can cause pulmonary fibrosis


History of Atopy



---
STRONG RISK FACTOR



DISCUSSION

Why do you think this is COPD?
All the point mentioned in Summary are the points are in favor of acute exacerbation COPD most likely secondary to a bacterial infection. Always tell your point in the same fashion you presented your history and just do not jump directly to the Chief complains or the history of present illness. Because age, occupation is of equal significance. The presence of past infection, risk factors such as previous history of PTB that can cause cavitary changes in lungs and other damages to lung parenchyma causes COPD. Risk factors such as smoking, use of firewood all those should be mentioned from TOP to BOTTOM.

Why not other condition?
Though TB has insidious onset and progression, but duration as long as 12 years may not be seen in PTB and Cancer. The patient may not last such a long duration with such active and significant morbidity.  Active TB develops generally over months to rarely few years. TB has low grade fever arising for more than 15 days or more and high grade fever only if there is a super infection upon the immunocompromised state of TB. But no other gross foci of fever are seen in this condition other than the lungs. Presence of Diabetes would have precipitated PTB.

The sputum was initially mucoid and whitish suggesting a chronic lung condition, which when precipitated by active infection may cause change in the sputum amount and color, most likely pneumonia than TB. The presence of hemoptysis could have strongly suggested TB but on its absence we can not rule out TB. The more generalised symptoms of weakness is present but anorexia is absent. The sudden aggravation of shortness of breath can not be justified unless there is development of pulmonary effusion in PTB.

However we do not see orthopnea, PND in TB. Rather PND, Orthopnea develops if the patient has left sided heart failure, and some times in pulmonary HTN.  Cor pulmonale secondary to COPD can cause pulmonary HTN and left sided heart failure to cause PND and Orthopnea. PND type acute bouts of SOB can be seen in Bronchial asthma as its night symptoms but asthma is less likely seen in elderly but  we can't say its Unlikely. The cough is more in the evening and night rather than morning but asthma can be precipitated with cold and dust.

The risk factor such as previous history of PTB treated with antitubercular therapy, overcrowding, poor socioeconomic condition can support the diagnosis of TB. Similarly, presence of risk factors like chronic cough aggravated with dust and smoke favors asthma. Absence of atopy is however against the asthma.
Interstitial diseases are insidious onset and progresses over a long duration of time. However there is rarely any features of acute exacerbation, rather they develop signs of pulmoary hypertension and Orthopnea, PND and right heart failure would be more signifcant. Similarly, the risk factors such as farming, use of smoking and exposure to indoor pollution can favor the diagnoses.

Carcinoma can be ruled out in the presence of more acute symptoms and more very very long onset of symptom which may not justify the presence of Carcinoma. No hemoptysis, no weight loss, No other systemic complains besides generalised weakness may not also favor malignacy. But for his age we just can not rule out maligncancy.

This discussion is incomplete and just a review of how things can be done. Depending upon what you have written in your history you have to support your provisional diagnosis. Answering a examiner would not be a big deal if you can sort out the informations in your mind, thesame way I have presented in the table, the points that favors any diagnosis and what was needed or absence of which make any of your provisional diagnosis unlikely.

Since, history taking can not be sufficient to rule out all other differential diagnoses the examination is must. So we don not have to worry if we can not  make a single provisional diagnosis just from history. But you should be able to rule out 2-3 differential diagnoses by the time you complete your history. Even on the completion of examination, it may not be crystal clear but still you can rule out more of diagnoses. Still we have diagnostic tools to come to conclusion. So , history taking is just a part of this process and not a complete process in itself. So, Don’t worry even  if you confuse yourself or examiner at the end of history taking.


*** Disclaimer : This is a hypothetical case and is not a real life scenario. However, the condition is so common and prevalent, it is a coincidence if it matches with the life of any. This case is solely for educational purpose with no intentions meant otherwise.***