Cancer Oesophagus
Age
Sex
Chief complaint : difficulty in swallowing
bringing up of swallowed food
something obstruction in throat
History of persent illness :
Time : ဒီလို ျဖစ္တာဘယ္ေလာက္ ၾကာၿပီ လဲ ( short = CAE )
Site : ဘယ္ေနရာေလာက္မွာလဲ ( throat = upper 1/3 ) ( nek =middle 1/3 ) ( retrosternal =lower 1/3 )
Onset : ရုတ္တရက္ေပၚလာသလား ျဖည္း ျဖည္းေပၚလာသလား
Type : အစမွာ ဘယ္လို အစာမ်ိဳး မိ်ဳ ရ ခက္တာ လဲ ( အရည္လား = achalasia cardia အဖတ္လား =CAE)
solid .,semisolid , liquid ?
အခုေရာ ?
ကိုယ္ တ ေတြး ကို ေရာ မိ်ဳ ႏိုင္ ရ ဲ ့ လား
ဆက္ တိုက္ ျဖစ္ သလား ၾကားထဲမွာ ျပန္ေကာင္း ေသး လား (intermmittent = achalasia cardia ,or progressive = CAE )
Pain : အစာမိ်ဳ ရင္ နာ လား (inflammatiory or corossive )(painless = CAE )
Regurgitation : အစာစား ၿပီး အန္ လား - တလုပ္စား တလုပ္အန္ = mozel type = upper oesophagus
စား ၿပီးၿပီး ခ်င္း အန္ = lower oesophagus
အေတာ္ ၾကာမွအန္ တာ လား
ထိုးအန္တာလား (regurgitation ) , ပိ်ဳ ့ ၿပီး မွ အန္ တာ လား ( vomitting )
အရ သာ ဘယ္လို ရွိ လဲ ( tasteless = CAE )
Choking : စား ရင္း နဲ ့ သီး တတ္လား ( TE fistula )
Time : ညေန မွာပို ဆိုး သလား ( similar to myasthenia gravis )
System review :
GI -- loss of weight
vomitting of blood and passage of bloodtary stool (cancer stomach )
RESP -- အသက္ရွု ရ ခက္ တာ ေမာ တာ ရွိ သ လား (trachea )
ေခ်ာငး္ ဆိုး သလား ( infection )
အသံ ေၿပာင္း သြား လား
CVS -- ရ င္ တုန္ လား ေမာ လား
CNS -- headache , fit
Past medical history :
- အစာအိမ္ နာ ျဖစ္ဘူး လား ( PU , Ca stomach )
ေလ ျဖတ္ဘူးလား - လံုး ၀ေသ သြား တာ လား အားနည္းရုံပဲ လား -မ်က္ႏွာပါလား - ဘယ္ေလာက္ၾကာေတာ့ေပ်ာက္သြား လဲ ။
ရင္ပူလား( heart burn ) = reflux oesophagitis
ႏွလံုးေရာဂါ - valvular heart disease = cardiomegaly ( LA )
ဆီးခ်ိဳ ေရာဂါ - DM = candidiasis
အက္ဆစ္ေသာက္မိဘူးလား = corossive poisoning
အေရျပား အေရာင္ေျပာင္း ၿပီး မာတဲ ့ ေရာ ဂါ ရွိသလား - sclerodarma
ၾကြက္သားအားနည္း တဲ့ေရာ ဂါ မိ်ဳး စကားေျပာရင္ေလလံုး မကြဲတာမိ်ဳး ရွိလား - myasthenia gravis
အသား၀ါ အလံုးေပၚ ေသြးအားနည္း အန္ ၄၀ေက်ာ္ မွ အစာမေၾကျဖစ္ ၇င္ - ca stomach
ေသြးအားနည္း လ်ွာေယာင္ မိ်ဳ ရ ခက္ - Plumar-vinson syndrome
Personal history : smoking
betel chewing
alcohol taking
salty food liking ( အငန္ ႀကိ ုက္ )
spicy food liking ( အစပ္ ႀကိ ုက္ )
barbecued food ( အကင္ ႀကိ ုက္ )
Drug history : စြဲ ေသာက္ေန တဲ့ေဆး
မတည့္တဲ့ ေဆး
ဗမာေဆး
Social history : ဘာလုပ္ လဲ
farmer
bank manager ......etc
Diagnosis : dysphagia probably due to cancer oesophagus at lower 1/3
Point for diagnosis : old age
male
painless progressive dysphagia with short duration
regurgitation
cough on swallowing
smoking alcohol taking betel chewing
Loss of weight
differential diagnosis : benign stricture
cancer cardia of stomach
achalasia cardia
ဘာၾကည့္အံုးမလဲ ဘာလုပ္အံုးမလဲ
Investigation : OGD scopy and biopsy
Barium swallow x-ray
Exfoliative cytology by oesophagial washing brushing
Treatment : curative -- surgery - Mckeown's opertiom , Ivor-lewis operation ,Allison's operation
-- radiology
Palliative -- surgery
-- radiation
-- tube insertion
-- laser theraphy
--stent insertion
Cancer Oesophagus Examination
Lipoma , Sebaceous Cyst and Dermoid CystExamination
ထိုင္ ခိုင္း ပါ ။
General : well and alert
no dyspnoeic
Local : INSPECTION
swelling : number
site
size
shape
surface
skin over swelling - sign of inflammation ( + / - )
margin
Puntum
swelling in other part - normal or not
( ေခ်ာင္း ဆိုး ၾကည့္ ပါ။ ) - cough impulse ( + / - )
distal to that swelling - oedema ,sensation , wasting of limb
PALPATION
temperature
tenderness
site
size
shape
surface
skin over swelling - sign of inflammation ( + / - )
margin
consistancy - hard
firm
doughy
soft / cystic - fluctuation test
transillumination test
Other tests -PINCH test
puntumရွိရင္- skin attachment ရွိမယ္--puntum ရွိေၾကာင္းအရင္ေျပာ
အလယ္ နဲ ့ ေဘး ၂ ဘက္ ဆြဲ ၾကည့္ -skin attachment ရွိမ ရွိ ေျပာ
SLIPPING sign
margin ကို အေပၚ က ေန index finger နဲ ့ ဖိ- slip ျဖစ္ရင္ ( + )
( It means subcutaneous lipoma )
( if there is bone defect it is congenital dermoid cyst and there is also cough impulse )
LOBULATION test
thumb and index fingers နဲ ့ ေဘး ၂ ဖက္ က ေန ဖိ ကိုင္ လိုက္ရင္ - အခ်ိဳင့္ ေလး ေတြ ေပၚလာ ရင္ ( + )
(Pinch test and lobulation positive mean it is LIPOMA )
MOULDING sign
index and thumb နဲ ့ ဖိ ဖိ ၾကည့္ လို ့ တန္းျပန္ မ ေပ်ာက္တဲ့ အခ်ိဳင့္ေတြေပၚ ရ င္ ( + ) ပံုသြင္းလို ့ရ တဲ့သေဘာ ကို ေျပာခ်င္တာ ။
( If positive it mean SEBACEOUS CYST )
EMPTYING sign
အေပၚ က ေန index fingerနဲ ့ ဖိ ၾကည့္ လို ့ ေပ်ာက္သြား ၿပီး ခဏေန မွ ေပၚ လာ ရင္ ( + )
Others : lymphnode
regional lymphnode ေတြ စမ္း ေပး ပါ ။
DIFFERENTIAL DIAGNOSIS :
LIPOMA ( universal common ) - lobulation sign ( + )
slipping sign ( + )
fluctuation test ( + )
transillumination test ( - )
SEBACEOUS CYST - Puntum present ( purplish black spot in middle of swelling )
moulding sign ( + )
emptying sign (+ )
slipping sign ( - )
fluctuation test (- )
transillumination test ( - )
DERMOID CYST - i t occured after injury
fluctuation test ( + )
transillumination test ( - )
Treatment : Excision under Local Anasthetic - complete removal
Avulsion under Local Anasthetic - better scar but recurrent present
Parotid Gland Examination
Parotid Gland
INSPECTION
Swelling : Site - below , behind , slightly infront of lobule of ears
Extention - up - pushing ear lobe upward
down - each to upper part of neck
posterior - upper part of postrior triangle
anterior - mandible
Angle of mandible can't seen or normally seen
Size
shape
surface - nodular and if there is fistula , ulcer, sinus ornot
Scar - with stitches ( superficial parotidectomy scar ပဲ ျဖစ္ေလ့ရွိ )
ညီ ညာ ၇င္ biopsy ယူ ထား တာ ။
triangle ဆို ရင္ ဗမာ ေဆး ဆ၇ာ လက္ ခ်က္ျဖစ္ေလ့ရွိ ၊။
Oral cavity : dumb-bell tumour (+/-) ( အျပင္ ၁ ခု . အ တြင္း ၁ ခု )
parotid duct opening ( + / -) and stone presentor not
internal opening describe လုပ္ ပါ ။
Face : facial palcy ( + /- )
Temporal mendibular joint : ပါးစပ္ဟပါအံုး - ဟႏိုင္ရင္ - no malignant involvement of joint
PALPATION : Temparature
Tenderness
site
size
shape
surface
Consistancy - hard ( if cystic test fluctation test and transilluminatin test )
Fixity - skin involvement- if scar present , attachment present as usually )
masseter muscle involvement - လက္နဲ ့ စမ္း
အံက်ိတ္ခိုင္းၿပီး လက္နဲ ့ စမ္း
လွုပ္ လို ့ မ ရ ရင္ fixity present
Others : other parotid gland examination - inspection and palpation
Cervical lymph nodes palpation
Diagnosis : Parotid gland probably due to pleomorphic adenoma
Differential diagnosis : Pleomorphic adenoma
secondary lymph node
Investigation : fine needle aspiration cytology
Excisional biopsy
Treatment : If adenoma ,Superficial Parotidectomy .
If cancer , total conservative parotidectomy ( if small and mobile )
, radical parotidectomy and facial nerve grafting with great auricular nerve
, radiology ( if large and fix )
If lymph node , enbloc removal (if mobile )
, radiology ( if fix )
Tracheostomy Examination
Head and mouth ( upper air way obstruction ကိုexclude လုပ္ ခ်င္လို ့ )
neck ( tracheostomy ကို စမ္း ပါ ။ )
Throx
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(1) INSPECTION : Well conscious , no dyspnoeic , no accessory muscle working ,
Head : head inury
facial oedema,injury , burn
eyes - pupils are equil
ear - discharge
nose - discharge
Mouth : Lips - crack ,ulcer
Teeth & gum - helathy or not
Tongue -
Tonsil
Posterior pharyngeal wall - inflammation
Uvula , soft plate & surrounding structures - healthy or not
Mandible - fracture or severe double fracture
(2) Neck : Swelling ( # lewis angina has massive swelling )
Trachea trauma
Cutthroat injury ( # sucidal ( -) /homicidal ( vessels inury +)
Throid surgery scar
Burn injury
Radiation mark
Trocheostomy tube : site -midline , lower part of neck
type - metal ( aspiration risk + ) / non-metal ( Platic with cuff, no need string, 100% no aspiration )
Parts - outer tube and inner tube ( ျဖဳတ္ျပ ႏုိင္ )
tracheostomy wind (2) ( ေတာင္ ပံ ၂ ခု )
tracheostomy soulder (rare) ( စကားေျပာရ လြယ္ေအာင္ လုပ္ထား ရ တယ္။ ဒါမပါဘဲစကားေျပာလို ့ရ ရင္ non functional tube ပဲ)
tracheostomy tape ( string ) ( ၾကိဳး )
ၾကိဳး နဲ ့ လည္ပင္း ၂ ခု ၾကား လက္ညိုွ း ထည့္ၾကည့္
There can insert one index finger (oedema မရ ေအာင္ ေခ်ာင္ေအာင္လုပ္ထားတာ ။)
Nod of tape - R / L side of neck( ဘယ္ညာ မညီပဲ တဘက္မွာပဲ ရွိ ရ မယ္ ။)
Tie - by securely
လက္ကိုအေပါက္ေရွ့ထား ၿပီး ေခ်ာင္းဆိုးၾကည့္ပါ ။ အသက္ ျပင္း ျပင္းရွုၾကည့္ပါ။
tube is funstioning
Dressing က ိုျဖဳတ္ၾကည့္ရင္ - scar ( longitudinal = elective or vertical = emergency )
stitch ( not equal pattern for afraid of surgical emphysema)
(3) chest - intercostal resection
surgical emphysema
trauma ( flail chest ) ဒီ ၃ ခု ကို သိ ခ်င္ ။
Inspection
Palpation - rib ေတြ ဖိၾကည့္--emphysema (+)< 10 days is normal ( from under the jaw to inguinal ligamant)
Percussion
Auscultatioin စမ္းပါ ။
.......................................................................................................................................
Others : Tracheostomy Tray ( Night Patient မွာ ပဲ ရွိ မယ္ ။ )
၃ ခု ပါ ရ မယ္ ။ ၁ -- Tray - tracheostomy tube ( အပို ၁ ခု)
Cissors ျဖဳတ္ ဖို ့
Tracheostomy dilator
Suction mechine & suction tap
Water
oxygen ( ready )
၂ -- Book and pen
၃ -- Bell ( for emergency call by patient )
ဘယ္ေတာ့ ျဖဳတ္မလဲ ? indication မ ရွိ ရ င္ ျဖဳတ္ မယ္ ။( temporary tube )
Ca lung and Ca Larynx မွာဆိုရင္ ( permanent ထား ရ မယ္။ )
Tracheostomy weaning ၃ ရ က္လုပ္ရမယ္။ ပထမရက္ - ခဏ ေလး ခဏ ေလး
ဒုတိယရက္ - ၁ နာရီ စီ က်င့္ေပး ။
တတိရရက္ - ၁ ညလံုး
ညအိပ္လို ့ရရင္ ေနာက္ေန ့ န ံ နက္ ဆရာႀကီးေတြ စံုခ်ိန္မွာ ျဖဳတ္လို ့ ရ ၿပီ ။
အေပါက္ပိတ္ ဖို ့ မ လို ပါ ၊ သူ ့ ဘာသာ ျပန္ ပိတ္ မယ္ ။
ျပဳတ္သြားရင္ ဘာလုပ္ မလဲ ? < 24 hours ဆို ရ င္ OT ျပန္ပို ့ ။
မနက္ ထည့္ ည ျဖဳတ္ မ လုပ္ ရ ။ 24 hours ထား ရ မယ္ ။
Fistula well formed ျဖစ္ မွ ျဖဳတ္ ရ မယ္ ။
Indication : To relief upper airway obstruction
To redue dead space
Artificial respiration
As a part of surgery in Ca larynx ( parment tube )
Complication : Immediate - haemmorage
injury
Early - surgical emphysema
tube obstruction
dislodgement
infection
pronation difficulty
feedinf difficlty
Late : stenosis
dependence
ICD tube Examination
chest
Tube
bottle ( 3 important things top exam )
......................................................................................................................
General : well conscious , dyspnoea,respiratory distress , / confortable
fever ( န ဖူး )
cyanosis ( လွ်ာ ၊ လက္ )
clubbing ( လက္ )
Local
Chest : အကႌ်ခၽြတ္ ပါ ။ ပက္လက္ အိပ္ ခိုင္းပါ ။ ေျခ ရ င္း မွ ၾကည့္ ပါ ။
Inspection : respiratory rate and type
shape of chest
movement - normal or decrease on R / L side or paradoxical movemant
accessory muscle movement - working or not
TUBE - plaster --- site ,size
A tube is commingout from that plasterဆို ၿပီး tube အေၾကာင္းဆက္ေျပာ ။
tube --- site - inserted at 5th and 6 th ICS mid axillary line
size - little finger size( serous fluid ) or large size ( empysema )
ကို္င္ ၾကည့္ျပီး texture - soft or ragid
color - clear or not
length - not too long or not too short
အသက္ျပင္းျပင္းရွုခိုင္ၿပီး tube is functioning or not
Anchor stitch --- present
Tube is connected to the under water sealed system bottle
BOTTLE - air/pus ( turbid)/ blood ( red) is seen in bottle about ________ ml
base of bottle is wider or not
air exist /air tube present or not
amount marker ( tape usually )present or not
a plasterid marked at ___ ml ( 2-4 cm from bottle base )
Palpitation :
trachea --- at midline / deviate to R / L
Apex beat ---5th ICS midclavicular line
respiratory movement ----decrease on R / L
chest expension---
vocal fermitus ---
palpable ronchi , pleural rub
surgical emphysema ( ပိုက္ထြက္ေပါက္ ကေန ၿပီး လည္ပင္း ထိ စမ္း ။ လည္ပင္းမွေန ဗို္က္ထိ ႏွိပ္ႏွိပ္ ၿပီးစမ္း ။ ကိြစိကိြစိ ျမည္မယ္ ။
Chest compression test
Percussion : Normal resonance on other side
Hyper resonance( air =pneumotorax ) / stony dullness( fluid =pleural efusion ) on that side
Start from ___th ICS
to ___ th anteriorly
to ___ th laterally
to ___ th posteriorly
Auscultation : (1) normal Vesicular breath sound overthe other side
desrease breath sound on that side and VBS
(2) additional sound - ronchi( ေရ = pleural effusion )
creptation (ျပည္ = emphysema ။ ေလ = pneumothorax)
(3 ) vocal resonance - decrease
Other System: Abdomen : liver , spleen
DIAGNOSIS : R / L sided
intercostal drainage tube
connecting tounder water sealed bottle probably due to R/L - Pneumothorax ( ေလ )
haemothorax (ေသြး )
Emphysema ( ျပည္ )
COMMENT ေပးပါ ဆိုရင္ site ,tube ,bottle ေျပာ ပါ။
Site : 5th and 6th ICS midaxillary line -ၾကိဳက္ ပါ တယ္
most dependent part until supine
all time pleural cavity
confortable
cosmetic
muscle မထူမပါး
wider ICS
7th and 8th ေလာက္ဆိုရင္ - potential space and pleural reces မို ့ အ ျမဲ မ ရိွ ႏိုင္။
ေရွ့မွာဆို ရ င္ - ေဖာက္ ရ ခက္ ၊ ေသြး ထြက္၊ cosmetic မေကာင္း ၊ လက္ လွုပ္ လိုက္ လွုပ္
ေနာက္ မွာဆိုရင္ - muscle ထူလို ့ေသြးထြက္ မယ္ ၊အိပ္ ရ င္ အ ဆင္ မ ေျပ ၊ kinking ျဖစ္မယ္ ၊
Tube : anchor stitch present ( good)
colour - clear ( good )
texture - medium ( good) thick =trauma, soft =kinking
diameter - more wider is better
length - not too long ,not too short ( good)
အဆက္ - ၁ခု ( good)
Bottle : colour - clear ( good)
base - wide ( good )
marker - present ( good )
tube - in the wate ( good )
cap - air exit present ( good)
stand present ( good )
ဘယ္ေတာ့ ျဖဳတ္မလဲ ? indication မရွိ ရင္ ျဖဳတ္ မယ္ ။
Recheck X-Ray-----lung expension
lung pathology
tube postion
Clinically ---- general condition - stable , no dyspnoea
chest - no sign of fluid or air
tube - no air / fluid
စစ္ၿပီး လို ့ ေကာင္းရ င္----နံနက္ေစာေစာမွာ ဆရာႀကီးေတြ ရွိခ်ိန္ မွာ ျဖဳတ္ မယ္
လူ နာ က အဲ ဒီ ျဖဳတ္ တဲ့ အခ်ိန္ မွာ အသက္ မ ရွု မထုတ္ ဖို ့ လို အပ္ တယ္
ဆ၇ာ၀န္၂ ေယာက္---၁ ေယာက္ က ပိုက္ ကို ဆြဲ ထုတ္
၁ ေယာက္ က purse string suture လုပ္
SAFETY TRIANGLE : Anterior axillary fold - P . major
Posterior axillary fold - Lettisimus dorsi
Superior border of 5th rib
Incisional Hernia Examination
General : Obese
fever
anaemia
jaundie
Oedema
Local:
Inspection : Abdomen - flat / diastanded
move with respiration
flanks are normal or full
umbilicus is ____
visible peristalsis present or not
old striae present or not in female
Old scar : type - lower midlie incision /.../......
size - ___ cm long
suture - by alternative stitch / continuous
healing - primary / secondary union
stitchs are out or not
swelling : beneath or beside of old scar
reducibility present or not
ေခ်ာင္း ဆိုး ၾကည့္ ခိုင္း - visible cough impulse present or not
ulcer
discharge
skin discolouration
Test : Raising test - postive or not
Palpitation : Light palpitation - 9 regions ကို နာ တဲ့ ေန ရ ာ ရွိ လား အ ရ င္ ေမး ၿပီးမ ရွိ မွဆက္ စမ္း ပါ ။
tenderness
mass
size of hernia neck
defect in anterior abdominal wall ( hernia အရင္း က အေပါက္ မွာ လက္ ညွုိးနဲ ့ လွည့္ပတ္စမ္း ပါ ။)
test : raising test - umblical hernia ၇ွိ ရ င္ ေပၚလာ မယ္ ။
Percussion : shifting dullness and fluid thrill စမ္း ေပး ပါ ။ ( လို အပ္ တယ္ ထင္ မွ သာ )
Auscultation : bowel sound ( normal or increase )
Other system ဘာ စမ္း ခ်င္ ေသး လဲ ေမး ရ င္ Chest for respiratory ( cough )
vaginal examination ( ovarian tumour )
perrectal examination ( BPH )
Diagnosis : 40 or more YEAR obese female with incisional hernia ( female မွာ အ ျဖစ္ မ်ား)
Point for diagnosis : moe than 40 year
female
swelling protrudes form old scar
cough impalsepresent
raising test positive
scar is secondary union
Treatment : (1) conservative treatment with abdominal belt
( 2) surgery - simple apposition ( cattle's operation )
- complex apposition ( Mayo or Keel Operation)
- Hernioplasty by Mesh Repair
Veginal Hydrocele Examination
မတ္တပ္ ရပ္ၿပီးစမ္း ပါ။
Inspection : swelling ; site - (is in inguinal region on R orL side )
size -( __x __ cm in geeatest dimention )
shape(globular ပဲ ၿဖစ္မယ္။ )
extent
surface ( smooth ortense )
ဟိုဘက္လွည့္ ၿပီး ေခ်ာင္း ဆိုးၾကည့္ပါ။ ( cough impalse present or not )
Other side မွာ လည္း ရွိမ ရွိ ေျပာ ပါ ။
skin overswelling - peristalsis waves
-rugaes
-scar (............)
-dilated veins
-ulcers (........)and discharges
-sing of inflammation
Penis - deviated to R orL side and totally sink in huge swelling
Palptation : swelling : temperature
tenderness
Finger can get above above swelling ( hernia မ ဟုတ္ဟု ေျပာ ခ်င္ )
swelling ကို describe လုပ္ပါ ။
...........................................................
consistancy - cystic ( serous fluid ပါ တယ္ ။)
flutation test - positive ( 2 direction by 2finger )
Transillumination test - positive ( see with 180 degree to light source)( ေနာက္ က မီး ထိုး ၿပီး ေရွ့ က ေန ၾကည္ ပါ ။ )
..............................................................
testes : felt separately from swelling ( testiticular tumour မ ဟုတ္ ဟု ေျပာခ်င္ )
normal size and shape
Epididymic & Spermatic cord ; Normal
...................................................................
On other site : no swelling testes can felt normally ( ရွိ ရင္ ေတာ့ ေျပာ ရ မည္ ၊။ )
inguinal Lymph node : not enlarge
left supraclavicular lymph node : not enlarge
..............................................................
Other system ဆက္စမ္း မယ္ ဆို က abdomen ကို စမ္း ပါ ။ paraaortic lymph node and mass ေတြ ရွိ မ ရွိ ေျပာ ရ မည္ ။
........................................................................................................................................................................................................
Diagnosis : _ year old man with ( R /L ) vaginal hydrocele
Differential diagnosis : varicocele
inguinal hernia : reducibility (+)
cough impalse (+)
cannot getabove swelling
Treatment : Transillumination test (+) = thin wall ----> Joboulay,s operation or Peter Lord's operation
Transillumination test (-) = thick wall ----> radical cure by subtotal excision
Complication : ( ဒါ ေတြ ေၾကာက္ လို ့ွ Surgery လုပ္ ရ တယ္ ။)
Torsion
Rupture
Haemorrhage
Infection
Herniation of the sac
Calcification of cyst wall
Testes atrophy
Infertility
Skin ulceration
Fracature neck of Femur Examination
General : Age - old
Sex - female
Others : skeletal traction , bed sore
Local : pelvic must be square
two limbs must be identical
Inspection : Altitude : Anterior dislocation - flex
- abducted
- external rotation
- shortening than other side
Posterior dislocation -flex
- adducted
- internal rotation
Swelling
Bruise
Movements - flex ,extension , abduction , adduction ,external rotation, internal rotation
Palpation : local bony tenderness - mid inguinal point ( #NOF )
- greatrochenter point ( # trochenteric )
head of femur - dorsum ilic ( posteror type )
- groin ( pubic type )
- perinium ( obturator type )
Measurement : (1) Apparent length of Right and Left ( no need square postion )
- xiphisternum to lower border of mellolus
(2) Real length ( must in square postion )
- ASIS to tip of medial malleolus
( 3 ) Bryant triangle ( must draw both legs)
- first line . ----- ASIS ကေန ေအာက္ ကို မ်ဥ္းမတ္ဆြဲ
second line .----- ASIS ကေန greater trochanter အ ထိ ဆြဲ
third line. ------greater trochanter ကေန line အ ထိ ဆြဲ
ERRORS : sencond line error ---greater trochanter diplacementanterior or posterior
third line error --- fracture neck of femur
separation of epiphysis
(4) Nelton'sline ( ေဘး ေစာင္း ဆြဲ ရ တဲ ့ မ်ဥ္း )
- Ischial tuberosity to ASIS မ်ဥ္း ေျဖာင့္ဆြဲ ။ ေပ ႀကိဳး နဲ ့ ဆြဲ လည္း ရ သည္ ။
Normal - greater trochanter is below this line
Fracture neck of femur _ greater trochanter is above this line
(5) Schoemaker 's line
- greater tronchanter to ASIS umbilicus
normal ----at umbilicus or above umbilicus
cross at midline
fracture neck of femur -- under the umbilicus
cross to normal leg side
(6) Chiene's test
ASIS to ASIS
Greater tronchanter to greater trochanter
normal ---- parallel of two line
fracture neck of femur ----converge at effected leg side
Diagnosis : Fracture at proximal part of femur probably due to fracture neck of femur
Classification : Garden's classification
fracture incomplete incomplete complete complete
displacement no no partial fully
trabeculae intact align not align disrupted
blood supply normal normal damage ischaemia
VIVA : greator trochanterအ ေပၚ တက္ တာ gluteus medius and gluteus menimus muscle ေတြ ဆြဲ လို ့ တက္ တာ ပါ ။
lesser trochanter ကို ileo-psoas တြယ္ပါ တယ္ ။
Treatment depend on ----age
displacement
associated desease
Treatment ------------reduction
retaining of reduction
rehibilitation
Complication : nonunion
avascular necrosis of head
bedsore
thromboembolism
bronchopneumonia
Inguinal Hernia Examination -continue
Land Mark Points
Deep Ring - 1.25 cm above the inguinal ligament
midway between ASIS and pubic symphysis
Superficial Ring - 1.25 cm above and medial to Pubic Tubercle
Saphenous Ring ( femoral ring ) - 3.75 cm below and lateral to Pubic Tubercle
Tests
Reducibility test - ( Taxis by doctor )
ပက္ လက္ အိပ္ ခိုင္း
ဒူး ေကြးေထာင္ ၿပီ း အ တြင္း နဲ နဲ ယိုင္ ထား
Superficial Ring ကို Left hand လက္ ညိွုး လက္ မ နဲ ့ ထိန္းထား ၿပီး
Right hand က content ကို အ ဲ ဒိ လက္ ၂ ေခ်ာင္း ၾကား ကို ထိုး ထည့္ ပါ ။
Palpable cough impalse - ျပန္သြင္း ပါ ။ ၿပီး ရ င္
Superfucual ring မွာ လက္ ဖ၀ါး တ ခုလံုး ထား
cough ခိုင္း ရ င္ impalse ရ မယ္ ။
Deep ring occlusion Test - မတ္တတ္ရပ္ခိုင္းၿပီး Landmark ကို soft pen နဲ ့ မွတ္ ။
ျပန္သြင္း ပါ ။ ၿပီး ရ င္
Deep ring ကို လက္မနဲ ့ ပိတ္ ( က်န္ ၄ ေခ်ာင္း က ခါး ေနာက္ မွာ ။ )
cough ရ င္
ထြက္ လာ မ လာ ၾကည့္ ပါ။
Three Fingertest Test- ျပန္သြင္း ပါ ။ ၿပီး ရ င္ မတ္တတ္ရပ္ခိုင္းၿပီး
3 fingers for 3 openings ထား
ေခ်ာင္းဆိုးခိုင္း ပါ
index finger လာထိ ရ င္ indirect inguinal hernia
middle finger လာထိ ရ င္direct inguinal hernia
ring finger လာထိ ရ င္ femoral inguinal hernia ဟု မွတ္ ပါ ။
Little finger invagination test - အိပ္ ခိုင္း ပါ။
ျပန္သြင္း
လက္သန္းကိုပက္လက္ထားၿပီးswelling ေအာက္အေနာက္ဘက္ကေနfundus of swelling to pubic tubercle သို ့ ထိုး
ring ထဲ ေရာက္ၿပီး ရင္ လက္ သန္း ကို ေမွာက္ လိုက္
ၿပီး ရ င္ ေခ်ာင္း ဆိုး ခိုင္း
လက္သန္းရဲ ့ Tip လာထိရင္indirect inguinal hernia
လက္သန္းရဲ pulp လာထိရင္direct inguinal hernia ဟုမွတ္ပါ ။
Inguinal hernia ( 3 ) types : bubonocele ( deep ring to superficial ring )
funicular type ( deep ring to above of scrotal sac )
complete type ( deep to scrotal sac )ဒီ ၁ မ်ိဳး ပဲစာေမး ပြဲ မွာ ေပးမယ္ ။
Inguinal Hernia Examination
Inguinal Hernia
supine or standing စမ္း ႏိုင္ ေပ မယ့္ Supine နဲ ့ ပဲ စမ္း သင့္ ပါ တယ္ ။
nipple line to mid thigh အထိ ျမင္ ရ ေအာင္ အ ၀တ္ ခြ်တ္ ပါ။
Inspection : Swelling : Site- in inguinoscrotal region ( R / L )
Extent - completely reach to bottom of scrotum / not
Size - ___ x __ x__ cm in greatest dimention
Shape - Pyriform shape ( unilatral ပဲ ျဖစ္ ေလ့ ရ77777ွိ )
Spherical shape ( bilateral ျဖစ္ ေလ့ ရွိ )
Surface - smooth
ေခါင္းဟို ဘက္ လွည့္ ေခ်ာင္ း ဆိုး ပါ ( ၂ ခါ ) : visible cough impulse ( + / -)
On other side has visiblecough impulse ( + / -) -) cough impulse ( + / - )
Skin over swelling : Peristalsis waves
Atrophy
Scar
Signs of inflammation
Dilated veins
Rugaes
Penis : deviated to other side
Palpation : Temperature
Tenderness
Finger cannot get above swelling ( There is sparmatic cord and other structures )
Swelling ( describe and confirm the inspection အတိ အ က် ထပ္ ေျပာ ပါ။ )
Consistancy : soft and cystic ( small intestine မို ့)
Firm and elastic ( intestine )
Doughy ( Omentum )
Reducibility Test - Swelling is reducible with gargling sound
ျပန္ သြင္း လိုက္ ၿပီး ေခ်ာင္း ဆိုး ခိုင္း ၿပီး စမ္း ပါ - Palpable cough impalse ( + )
..........ဒီ ၂ ခု က Superficial Ring ၿဖစ္ ေၾကာင္း ျပ တာပဲ ။..........
Deep ring occulusion test - swelling appear / not
(( DRO ကို Indentify with MARKER ( ASIS , Pubic Symphisis , Pubic Tubercle , Deepring ) လုပ္ ၿပီး မွ စမ္း ျပ ပါ ။ ))
Three fingers Test - Impulse felt at Index finger ( Indirect Inguinal Hernia လို ့ သိ ရ ၿပီ ) or
Middle finger ( Direct Inguinal Hernia လို ့ သိ ရ ၿပီ ) or
Ring finger ( Femoral Inguinal Hernia လို ့ သိ ရ ၿပီ )
Little Finger Invagination Test - impalse felt on Tip of figer ( Indirect Inguinal Hernia ) or
Palp of finger ( direct Inguinal Hernia )
Testes : felt separetly from swelling
Normal size and shape
Percussion : Resonance ( intestine ) or
Dull ( Omentum )
Auscultation : Bowel sound present in hernia
ဘာ ဆက္ စမ္း ခ်င္ ေသး လဲ ေမး ရ င္ Abdomen ( increase intra abdominal pressure by free fluid ,scar , mass သိခ်င္ လို ့ )
PR Examination( benign prostatic hyperplasia ရွိ မ ရွိ သိ ခ်င္လို ့ )
Chest ( cough ရ တတ္ လို ့)
စမ္း သင့္ ပါ တယ္ လို ့ ေျဖ ပါ ။
Diagnosis : R / L Bilateral
complete incomplete
reducible unreducible
*** indirect direct
inguinal hernia of
entrocele type or intestinal type
with nocomplicaton or complicatoin
Point for diagnosis : male
swelling in inguinoscrotal region
painless
pyriform / spherical
cannot get above swelling
reducible and cough impulse present
results of 3 tests
Diferential Diagnosis : indirect inguinal hernia ( pyriform shape )
direct inguinal hernia ( spherical shape)
femoral hernia ( retort shape )
vaginal hernia ( canget above swelling )
spermatocele
varicocele
psoas abscess ( cold abscess , TB )
inguinal lymph node( firm in consistancy and more tha none swelling )
Epididymal cyst ( multiple cystic lesion )
တျခား သိ ထာ း သင့္ တာ ေတြ ကို ဒီမွာ ေရ း ထား တယ္ ။
Goitre Examination
Goitre
Sitting position နဲ ့ စမ္ း ပါ ။
GENERAL : young
female
thin
average height
look anxious and restlessness
dyspnoeic
(1) Hair - normal dictribution or alopecia
(2) Eyes - pallor
jaundice
chemosis , lid oedema ,corneal ulcer
- Naff -ziger's method ေနာက္ ကို သြား ၊ ေခါင္း ကို လက္ေထာက္ ၊ ေမာ့
မ်က္လံုး ျပဴး ထြက္ ရ င္ - exophthalmos (+)
- Stellwag's sign ေရွ့ ကို တည့္ တည့္ၾကည္ ခိုင္း
upper limbus and sclera ျမင္ ရ ရင္ lid rectraction (+)
- Von Grarfe's sign လက္ ညိုွးကို အေပၚမွေအာက္ သို ့ လိုက္ ၾကည့္ခိုင္း
မ်က္ခြံ မ ဖံုး ႏိုင္ ရ င္ - lid Lag ( + )
- Jafroy's sign ေအာက္ ငံု ့ ၿပီး အ ေပၚ ၾကည့္ ခိုင္း
န ဖူးမတြန္ ့ႏိုင္ ရင္ - Jaffory 's sign (+ )
- Moebius ' sign မ်က္လံုးကို လက္ညိွုး အား အ ေ၀း မွ အ နီး သို ့ ၾကည့္ခိုင္း
မစုႏိုင္ရင္ လွုပ္ေနရင္ - loss of convergence
H ပံုစံ လိုက္ ၾကည့္ခိုင္း
၂ရိပ္၂ထပ္ျမင္ရင္ - diplopia ( + )
It is said Ophthalmopia present if these two present .
(3)Tongue - ထုပ္ခိုင္းလို ့လွုပ္ေန ရင္resting tremor present ( primary )
(4)Upper Limb - Pulse rate and charctor
warm and moist hand ( bounding pulse )
clubbing , cyanosis , onycholysis
hyprpigamented spot , virtiligo
fine tremor ( လက္ ၂ ဘက္ ဆန္ ့ တန္း ၊ လက္ေခ်ာင္း ကား ၊ မ်က္လံုး မိွတ္ ခိုင္း )
(5) Lower Limb - Pretibial myxoedema ( ေျခသလံုး ရုိးေပၚ လက္မနဲ ့ ဖိ ၾကည့္ )
Proximal myopathy (ထိုင္ထ လုပ္ၾကည့္ေပး ခိုင္း )
hyperreflexia ( jerk ေခါက္ )
LOCAL :
Inspection : swelling - number
site -infront of neck / both side of neck / R or L side of neck
size - ___ am in greatest dimention
shape - butterfly / nodular
surface - smooth / nodular
skin over swelling - normal / scar
dilated veins
(ေရငံုထားေပးပါ ၊မိ်ဳ ခ်ဆိုမွ မိ်ဳ ခ် ေပး ပါ ။)
swelling move upward with deglutation and lower border is seen
( ပါးစပ္ ဟ ေပး ပါ ၊ လွ်ာထုတ္ ဆိုရင္ ဇတ္ကနဲ ထုတ္ ေပးပါ ၊ )
swelling not move upward with protruding of tongue (thyroglossal cyst မဟုတ္ေတာ့ )
( လက္၂ဘက္ကို နားရြက္ကို ထိတဲ့အထိ ေျမာက္ေပးပါ ) penberton's sign
no facial congestion and distress ( restronal elongation သိ ခ်င္လို ့ )
Palpation :ေရွ့မွ - Trachea
Tempracture
Tenderness
Thrill on upper pole
Kocher's test ( swellingကိုဖိရင္ distress ရ လား ၾကည့္)
( ေနာက္ က စမ္း ပါရ ေစ )
ေနာက္ မွ -swelling - site , size , shape, skin over selling ( တဖက္ကို တြန္းၿပီး Lahay method နဲ ့ စမ္း )
margin
consistancy - firm
ေရ ငံုထားေပးပါ ၊၊ မ်ိဳ ခ်ဆိုမွ မ်ိဳ ခ်ေပး ပါ ၊၊
swelling move upward with deglutation and lower pole is felt
Berr's sign - carotid artery pulsation present or not
Percussion : sternum - resonance
Ausculation - upperpole မွာ နားေထာင္- bruit ( superior thyroid artery နားေထာင္ )
Cervical lymph node examination :ေနာက္မွစမ္းပါ ။
submental
submendibular
jugular chain
supraclavicular
posterior triangle
posterior auricular
pre auricular
Diagnosis : Thyrotoxicosis probably due to Grave's disease
Simple / toxic solidatry thyroid nodule
Simple / toxic nodular goiter
Investigation : thyroid function test
USG neck
FNAC
neck x-ray
indirect laryngoscopy
Treatment : simple - euthroid ---> Surgery ( subtotal thyroidtomy )
toxic - ------------------>medical + surgical
recurrent after 40 ----> Radio-iodine treatment
Surgical complication : tension haematoma due to reactionary haemorrhage
tracheomalasia
respiratory obstruction
nerve injury ( recurrent laryngeal nerve ,superior laryngeal nerve )
keloid scar
hypoparathyroidism
thyroidcrisis
hypothyroidism
Cancer Breast Examination
Cancer Breast
General : Age
Weght
Height
Siting on the bed /Chair
eye
nose
neck
extremities - ( browny ) oedema ( lymphadema )
Local : Exposed to the wrist
Inspection - လက္ေဘးခ်ၿပီး ထိုင္ပါ ။
both breasts are same size/ not
NIPPLE - both beast are _ same level / not
_ same size / not
_ shape is normal / retracted / prominent
_ Others _ crack
_ulcer
_discharge
လက္အေ ပၚေျမွာက္ေပးပါ ။
Both nipples are _ same level / raised on R / L
လက္ေဘး ျပန္္ ခ် ေပး ပါ ။
AREOLA - level _ same / not
- size _ equal / not
- surface _ crack / ulcer / discharge
LUMP - visible on R / L side breast
site - upper outer quadrant ( mostly )
size - ___ x ___ x ___ cm in greatest dimention
shape - globular
surface - smooth
margin - well defined margin
SKIN OVER BREAST - colour - normal / red
dilated veins
dimplilng
Peau d' orange
singn of inflammation
Others - scar ( ရွိ ရ င္ ဆက္ ေျပာ ---)
ulcer ( site ,size , shape , margin , edge, floor, discharge )
discharge
ကိုယ္ ကို ေရွ့ ကိုင္း ေပး ပါ ။
R / L side breast is left behind ( Ca ျဖစ္ တဲ့ဘက္ က က်န္ခဲ့မယ္ )
More proinent of dimpling
Palpation : ( စာထဲ မွာက Normal breast ကို အရင္စမ္း ဆိုေပမယ့္စာေမးပြဲ မွာ Abnormal breast ဘက္ပဲအရင္စမ္းပါ။ )
( Palm of fingerနဲ ့ 4 quardran ကို စမ္း ပါ ။ )( လက္ ဖ၀ါး တျပင္လံုး နဲ ့ စစမ္းၿပီးမွ လက္ေခ်ာင္း ျပင္နဲ ့စမး ရ မယ္ )
Temparture
Tenderness
LUMP - site - upper outer quadrant
size - __ x __ x __ cm
shape - globular ( fidroadenoma ဆိုရင္) / irregular ( Ca ဆိုရင္ )
surface - smooth ( bedign ) / irregular ( Ca )
consistancy - cystic ( Fluctuation test ဆက္စမ္းေပး-----)
firm ( fibroadenoma )
hard ( Ca )
margin - well defined / irregular
Tests ----------
Skin fixity by Pinch test - အေရျပားကို ဆြဲံၾကည့္ပါ။ တေနရာမက ဆြဲ ၾကည့္ဖိုလိုအပ္တယ္ ။
there is fixity or tethered
Fixityto breast tisue - breast tissue ကိုလက္နဲ ့axillary fold ကို ကိုင္ထိန္းထား ၿပီး Lump ကို ဘယ္ညာ တြန္းေရြွ့ ၾကည့္ပါ။
fixity to breast tissue present or not
Fixity to underlying fascia and muscle -(1) ခါးေထာက္ခိုင္းပါ - ၿပီးရင္ -Lumpကိုalong and perpandicular to P.major တြန္းေရႊ ့ၾကည့္ပါ ။
-(2)ခါးကို အားပါပါေထာက္ ခိုင္း ပါ။ ကို ကိုင္ၾကည့္ၿပီး တင္းေနတာေသခ်ာပါေစ ။
ၿပီးရင္ -Lump ကို along and perpandicular to P.major muscle အတိုင္း ထပ္ၿပီး တြန္းေရႊ ့ၾကည့္ပါ ။
fixity to underlying fascia and muscle present or not
( Lower outer quadrant LUMP ဆို ရင္ Serratous Anterior muscle fixity စမ္းဖို ့-လက္ဆန္ ့တန္းၿပီး နံရံ ကိုတြန္းသလိုလုပ္ခိုင္း -ၿပီးမွ fixity စမ္းပါ ။
fixity to chest wall သိဖို ့- ပက္လက္အိပ္ ခိုင္း ၿပီး ကို ရင္ဘတ္ေပၚ မွာ တြန္းေရႊ ့ ၾကည့္ပါ ။ )
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Axillary Lymph node and Supraclavicular lymph node ေတြစမ္းေပးပါ ။ - site
numbers
size
consistancy - firm
surface
#mobility
Other breast and axillary ေတြဆက္ စမ္း ေပး ပါ ။
တျခား ဘာစမ္းခ်င္ေသးသလဲ ဆုိ၇င္ - Chest
Abdomen ( liver , spleen, ascites , krukenberg 's tumour )
Vaginal examination
Per-Rectal examination
Diagnosis : Left sided Ca breast Manchester staging 2 ,T N1 M0
Difeential Diagnosis : fibroadenoma
fibroadenosis
fibrosystic disease
mammary duct ectasia
traumatic fat nacrosis
Staging :
(1) Manchester staging
Stage 1 - tumour confined tho the breast
no skin ,muscle ,lymph node involvement
Stage 2 - 1 + ipsilateral mobile axillary lymph node involvement
Stage 3 - 2 + ipsilateral fixed axillary lymph node involvement
ipsilateral supraclavicular lympnode involvement or
attach to pectoralis majour muscle or
estensive skin invlovement
Stage 4 - chest wall fixation
contralateral breast / axillary lymphnode / clavicular lymph node involvement
lympoedema
distant metastasis
(2) TNM staging
T is - cancer insitu
T 1 - less than 2 cm
T 2 - 2 to 5 cm
T 3 - more than 5 cm
T 4 - skin involvement
N 0 - no lymp node involvement
N 1 - mobile ipsilateral axillary lymph node
N 2 - fixed ipsilateral axillary lymph node
N 3 - supra clavicular Lymph node
M 0 - no metastasis
M 1 - metasis
Invetigation : for diagnosis - FNAC
needle biopsy
USG
MRI
for staging - chest x ray
USG abdomen
Treatment : Stage 1 and 2 - early breast cancer - locoregional treatment
Stage 3 and 4 - adbanced breast cancer - systemic theraphy - chemptheraphy
homornal theraphy
- radiotheraphy
- toilet mastectomy
- treatment of metastasis
General
Genearl
mass ၁ ခု ေတြ ့ ရင္ ေတြ ့ တဲ ့ ေန ရာ ေပၚ မူတည္ စဥ္းစားပ ါ ။
ဥပ မာ :: right iliac fossa မွာ ေတြ ့ ရင္ ဒါ ဟာ Appendicular mass , Ca cacum ,Amoeba , Iliocaecal TB , Psoas abscess MEsentric cyst , mesentric lymph adenitis စ သျဖင့္ ျဖစ္ ႏိုင္ ပါတယ္။
Epigastrium မွာ ေတြ ့ ရင္ stomach (ca) , Pancreas (cyst , ca head ) , transverse colon ,liverleft lobe enlargement ,retropreitonum organs enlargement (aortic aneurysm , lymph adenopathy ) ေတြ ကို စဥ္္း စား ရ ပါမယ္ ။
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Detail ေျပာ ၇ မွာ ေတြ က
Lymph node or mass ၁ ခု ခု ဆို ရင္ ဆက္ ေျပာ ရ မွာ ေတြ က -number , site , size , shape : surface margin ,edge( consistancy ;skin over swelling surounding swelling ) move with respiration ,raise on raising test (prominent or less)temperature tenderness စမ္း
scar ၁ ခု ခု ဆို ရင္ ဆက္ ေျပာ ရ မွာ ေတြ number site size healed by primary union orsecondary union shape (irregular orregular) nsicional hernia (present or not )temperature tenderness စမ္း
wound ၁ ခု ခု ဆို ရင္ ဆက္ ေျပာ ရ မွာ ေတြ ကnumber site(extendendingfrom - to _ )size _ stitches discharge visible granulation tissue surroundinig inflammation temperature စမ္း
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ံHISTORY ေမး ရ င္ လဲ
pain ဆို ရင္ sudden(perforation haemorrhage ..စသျဖင့္ျဖစ္ႏိုင္ )
gradual (hollow organ distension ,peritoneal distension ..စသျဖင့္ျဖစ္ႏိုင္ )
Character ေမး ရင္ (aching,throbbing , colicky, stabbing ,constriction, burning,heavy,diffuse,dull)စသျဖင့္ဆက္ေမးရပါမယ္။
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Chief Complaint မွာ
dysphagia , regurgitation ဟု medical term ျဖင့္မေရး ရ။ dificulty in sollowing bringing up of swallow food စသျဖင့္ ေရး ရမည္။
