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7. Your next patient in general practice is a 25 year
old Mr. John carter who had an ultrasound
examination last week because of a
The report reads: “The right
testicle shows a 4 cm in diameter large, solid,
homogenous, hyperechoic mass which is well
circumscribed. The findings suggest that the lesion
is malignant. The left side appears normal.”
Your tasks are to:
1. Explain the U/S finding to the patient
2. Advise the patient regarding further investigations and
management
3. Answer patient’s questions
AMC Clinical Case for Role
Case 01
10. Table of Contents for Testicular mass case
Know about testicular Mass
Uni /Bilaterial
Testicular
Mass
01
USG of the testes
Blood markers
Diagnosis
02
Lipoma ,Vericocele,
Haematocele ,hydrocele ,Epi
–Orchi , Hernia
DD
03
Breaking bad news famous
hack
SPIKES
protocol
04
Orchidectomy after CT- paraaortic
Follow up –CT
Pre & post CT
Treatmen
t
05
Follow class for this
question
Patient’s
Questions
06
11. Treatment of testicular Cancer
● Treatment: depends on the staging of the tumour:
● STAGE 1: tumour confined to the testicle: Orchidectomy through an inguinal incision removing the
testis with the cord to the level of the deep inguinal ring followed by radiation therapy. (NO scrotal
incision, to avoid spread of tumour!!!!) shahriarAMC copyright
● STAGE 2: metastases have spread to para-aortic lymphglands in pelvis and abdomen +/- metastases
in abdominal organs: Orchidectomy through an inguinal incision removing the testis with the cord to
the level of the deep inguinal ring followed by radiation and chemo therapy.
● STAGE 3: spread above the diaphragm: Orchidectomy through an inguinal incision removing
the testis with the cord to the level of the deep inguinal ring followed by radiation and chemo
therapy.
12. Introduction
Hey this is Dr.Shahriar .I am going to
explain this case on Tesicular cancer /
tesiticular Mass . Before we start AMC
clinical is a tricky exam . All you need
to be focus & do sufficient role play &
SMA class materials will be enough to
clear this exam.
Shahriar ahmed sujoy
13. Candidate’s questions:
● “Is it cancer?”
● “What is the name of the cancer?”
● “What is the prognosis?” (up to 95% cure rate!!!)
● “Do I need any other tests?” (Yes, see above)
● “How about my sex life and will I be able to have children?” (erectile function
unchanged, fertility reduced with radiation therapy and probably infertile with chemo
therapy –consider storing of semen before the procedure for future IVF)
● “What are the side effects of the treatment?”
● “If they remove the testicle, can I have a prosthesis?”
● Why me ?
A
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r
i
g
h
t
s
a
r
e
r
e
s
e
r
v
e
d
t
o
s
h
14. Do & Don’t
● Spike follow
● Pause
● Orchitectomy & SE
● Follow up
● Empathy
● SPIKES protocol not follow
● Inguinal orchidectomy-Mx-
mention
● Incision
● Paraaortic LN
● Unable to Ans patients Q
● Sex life / reproduction
15. Feedback
1. Approach , empathic
2,Explain the U/S finding to the
patient
2. Advise the patient regarding
further investigations and
management
3. Answer patient’s questions
Fail/ pass
Approach , empathic
qCounsel the patient about follow up
q Outcome & Dx & SE
qAnswer his inquiries
qFail / pass
16. Recent orchidectomoy of testicular neoplasm of a
27 years man
Your tasks are to:
qCounsel the patient about follow up & Diagnosis
qOutcome
qAnswer his inquiries
AMC Clinical Case for Role
Case 02
17. Treatment
Surgery Radiotherapy
/Chemo
Inguinal Orchidectomy
( transinguinal approach)
Seminoma – Radiotherapy
Non seminoma -Chemo
**Radio /chemo can cause infertility But
Sexual function usually Ok.
“Surgery wont hamper sexual life
But can hamper fertility “—Dr.shahriar
21. Pain in the testis following mumps in a 25 years old
man .
Your tasks are to:
qAdvice the patient on diagnosis
qAdvice him on Rx and prognosis
qAnswer to the inquiry of the patient
AMC Clinical Case for Role
Case 03
23. Do & Don’t for testicular pain(mumps)
● Tell about mump &
virus ,infectivity & Immunity
● Answer to the inquiries
● Talk about mumps
complication
● Give proper Rx .
● Tracing , contacts
● Answer to Question of patient
● Infertility ***
● Not mentioning Pain control Rx
para/codeine
● Notification
● Mumps imminuzation
● Isolation
● Vaccination of other family a
24. Your next patient in your GP clinic is a 25 yo man who’s c/o fever and
testicular pain. He visited you 5 days ago because of painful swelling on the
side of his face. You diagnosed him as mumps 5 days ago. Left testis enlarged,
twice the normal size, tender and hot.
Task:
• advice about the diagnosis,
• treatment,
• prognosis and
• answer the patient’s questions.
25. Son had mumps recently. Because you had mumps 5 days ago, this
condition is most likely called ,which is an infection
of the testis. It’s one of the common complications of mumps
infection,occur 20-30%. Usually it starts 3-4 days after mumps and
resolves within 1 week time. Very painful, I understand that.
Case discussion
26. To ease the pain :
- Scrotal support
- Elevation of the scrotum will ease the pain (because of the gravity)
- Rest
- Good painkiller like Paracetamol and Codeine
- Increase oral intake especially fluids
- Heat application
- Light diet
- Review
He’s still infectious to kids but to adults less likely.
Usually , there’s a 50% chance to get testicular atrophy
(permanent) - size may get smaller will not be affected provided the other testis is
normal. No chance of increase malignancy.
Each testis has separate blood stream and sac, the other testis will not get affected.
Cause by paramyxovirus that spread by droplets, incubation period 2-3 weeks. Swelling last
for 2 weeks.Patients are infectious 6 days before and 9 days after the mumps ocurs.
(Child should be excluded from school for 9 days)
32. q There is no display of question in AMC
clinical neither
any clock
q To make things realistic we are going to
Remove it from your screen both
Question and Clock . As per new rule
video should be on .So please open you
video camera .
q Are you Ready ?
q Video open ?
34. You are a GP and 21-year-old female Martha came
to you complaining of a lump in the left breast.
Given – 1 cm mobile mousy lump noticed for 1 month with no wt loss and not fixed with
underlying skin ,no other discharge / orange colour
TASKS –
*
*PE will be given
*DIAGNOSIS , DD ,MANAGEMENT & follow up
AMC Clinical Case for Role
Case 05
35. Physical examination
Physical examination finding to
examiner(PEFE) – Keep in
mind ,Zoom based exams PEFE
more cases will be given.
Dr.Shahriar
Tips
Vs CA
Not fixed with underlying
No paud orange
Vitally stable
36. Introduction
Hey this is Dr.Shahriar .I am going to
explain this case on Breast Lump.
Before we start AMC clinical is a tricky
exam . All you need to be focus & do
sufficient role play & SMA class
materials will be enough to clear this
exam.
Shahriar ahmed sujoy
37. History
§ How did you find out?
§ When?
§ What is the of the lump?
§ Is it ?
§ Any change in period?
§ Any lumps in any other part of the body?
§ Any ?
§ Any discharge from the ?
§ Any in the neck or armpit?
§ Change in ?
§ PMHx?
§ Gynecological history?
§ Contraception?
§ Previous pregnancy? Last pap smear?
§ SADMA?
§ FHx?
ü SIZE
ü SITE
ü SHAPE
ü SURFACE
ü BORDER
ü CONTOUR
ü CONSISTENCY TEMP
ü TENDERNESS
ü PULSATILE
ü REDUCIBLE
ü SIGNS OF INFLAMMATION
ü AXILLARY LYMPH NODES
For any types of Lump
40. PEFE
Physical examination finding to
examiner(PEFE) – Keep in
mind ,Zoom based exams PEFE
more cases will be given.
Dr.Shahriar
Tips
Vs CA
Not fixed with underlying
No paud orange
41. Management
:You have a condition called
. It is a common cause of
breast lumps in females 20-30 years old.
They are normally asymptomatic and do
not pose a risk of cancer. It is not
premalignant hence it will not lead to
cancer.
Fibroadenoma, Fibrocystic changes,
cyst, Cancer
monthly self-breast examination(SBE),
and
2-yearly USG until 35 years old.
Don’t let patient go
home with out PE.
Dr.Shahriar
42. John Murtagh 7th
Patient education
Page 83
By Dr.Shahriar
+8801670636131 what’s app for Amc clinical admission
Nor mentioning
Triple therapy is
an error !!
46. Scoring
Global score-
Key steps 1,2,3,4
q Approach______
q organization and sequence
Accuracy of examination___-
q Choice of investigation___
q Dx & MX ______
47. 57 yr old lady presents with breast lump .
Family history of Breast cancer + in case of mother at 46 years .
Task
*Explain the physical examination points to this medical students *,
*DX AND DDs ,
*Mention the relevant Investigations
AMC Clinical Case for Role
Case 06
49. Breast examination
-Introduction and get consent from patient.
-Wear gloves!
On inspection by 3 positions:
no ulcer, no scar, no obvious mass, skin appears normal. Nipples are in same level.
: no new changes or tethering
no new dimpling or tethering
On palpation
●Breast (ask patient to raise hand over the head, examined from normal side):
●Findings: left breast is normal. No tenderness. On right side, I can feel small mass on Rt upper outer quadrant, which is
2*3 cm in diameter, round, seems to be smooth, margin is well-defined, firm in consistency, no tenderness, no
fluctuation, hardly mobile (mannequin is hard to assess mobility).
●Lymph nodes: axillary and supra & infra-clavicular lymph nodes ( )
●Findings: NO LAD ( running commentary )
●Then, I covered mannequin back.
Passed Case
mannequin
50. Breast examination
DDX
Explained my findings and DDx
i. Fibroadenoma
ii. Fibro adenosis (given the location and consistency of lump),
iii. Breast cancer
iv. Breast cyst (less likely as it is a solid mass and no fluctuation),
v. abscess (no fever, no tenderness).
INVx:
● Refer to specialist for triple assessment (patient asked me what it is?). Then, I explained further about physical exam, imaging
which is mammogram, FNAC.
51. Another Handbook Case
Breast biopsy concerns in a 20 year women with a Family history of
breast cancer
Task
Ø Discuss her concerns with her
Ø Advice her on future management
Page 369 page
Condition 60
Case 07
52. Explanation in short
● Premalignant condition ,common , reassurance , Draw pic At this age group 1 in 14 can happen , Its
confirm fibro not cancer ( biopsy taken from several places ) but rarely Ca( less than 1%), No surgery
required ( if insists persuade then take it out ) , talk about family risks
● Reassurance , Excisional biopsy not performed yet but planning to , Triple test Imp to do and further
follow up
● Talk about screening in family
Page 328 Handbook
FNAC vs Core
https://www.racgp.org.au/afpbackissues/2005/200504/200504brennan.pdf
53. Case
Case: You have recently seen a 35-year-old for possible
fibroadenoma of left breast. You did U/S biopsy and the result
showed invasive ductal carcinoma of the breast. HER- 2
receptor are +ve (Herceptin). Human epidermal growth factor
receptor -2. Today she came back for the result of the biopsy.
She has a plan to conceive in one year time with her husband
she doesn’t have children at present.
Task
a. Explain biopsy result and further management
54. Case is about to
display on
Monitor
You are at doorway now
2 min
4
56. Explanation
This Ducts for the milk and this is the
supportive/glandular tissue, The cancer is affecting
the ducts that is producing the milk. It is the most common cancer 70-80%.
(Lobular carcinoma 5-
10%).
- There will be a few things before the treatment
depending on the: Age, Staging, Patient’s
preferences, Tumor size and location, P receptor
and Grading/histology
57. Explanation continues
Refer the patient to the breast surgeon who is going
to take care of the rest of the things.
- Before the surgery the tumor is undergoing staging:
Look for sentinel LN. Inject isotope/blue dye,
dispose to the lymphatic ducts, 1st LN which is most
likely going to have the cancer, take the
sample/pathology see under the microscope see if
there’s any metastasis
58. Explanation continues
Chest X-Ray, CT scan of the chest
and abdomen, CT scan of the brain, Bone scan,
PET scan
- Baseline investigations: FBE, LFTs
- Office test available -NO
59. Surgery: Breast conserving surgery. (Lympectomy,
wide local excision/ clearance of the LN)
- Radiotherapy (Infection, Bleeding, anesthesia
complication, lymphedema). In the form of external
and brachytherapy (radioactive put into the tumor)
how long given is depending on the cancer. Can be
given for 5-6 weeks. Common side effects: Irritation
of the skin, thickening of the skin, tiredness, sore
throat, digestive problems, SOB.
- beyond that the surgeon may
consider chemotherapy.
- New drugs that has been given to the breast
cancer: Anthracyclines, Taxanes. Oral or IV at the
doctor’s office.
60. Treatment
- If the patient has estrogen receptor
positive:
o Tamoxifen (oral) estrogen is helping
to
growth the tumours and tamoxifen is
helping to block the receptors.
o
suppress
the production of
estrogen from the ovaries.
o Aromatase Inhibitors. Block the enzymes
that involved in the process of producing
estrogen.
o S/E: Flushes, libido, dryness of the
vagina, osteoporosis, endometrial
hyperplasia.
- All these receptors promote the growth of
the
cancer: TRASTUZUMAB (Biological agents)
61. Follow up
- From . (For normal
screening)
- monthly: lump, there’s a
change or recurrence: increased in the first 3-
5years. It can be the same breast. If there’s in the
other breast it is mostly likely primary tumor; Skin:
Dimpling, retraction, Redness, eczema, Nipple:
Discharge (bloody)
- Clinically review 6monthly
- Mammogram 1 yearly
62. Role players inquiry
We will do staging and histology. If the cancer confined
to the
breast there will be no problem. Normally it’s not
recommended. Generally the specialist thinks it’s
better to wait for 2 year to watch out for the
recurrence.
of the
pregnancy/first 3months of the pregnancy. The S/E
of the drug is going to cause congenital
abnormalities. If no more than stage 1 or 2 delay
the radiotherapy till the pregnancy is over. If it is
stage 3, 4 no chemotherapy and radiotherapy for
the 1st two months of pregnancy.
? No.
- If the patient is coming with extensive cancer:
Neoadjuvant therapy: Radio/Chemo therapy
Shrink the cancer so it can be operable
- Reconstructive Breast surgery: Some breast
implant (Silicon, saline, prosthesis, muscle flaps)
- S/E of Chemotherapy: Loss of appetite, S/E of
Radiotherapy, Tiredness, Redness/itchiness,
Swelling, Loss of appetite, Nausea, Digestive
symptoms, Dryness of the mouth, Sore throat,
SOB/Cough
- If Bone/vertebral involved: Tx: Bisphosphonates
64. - Patient presenting to you with tingling and numbness in the
hand and
neck pain. Has a history of breast cancer treated with surgery,
axillary clearance and
radiation. (old recall)
Task : History, More Invx, Dx, DDx, Prognosi
Task ??
History, More Invx, Dx, DDx, Prognosi
AMC Clinical Case for Role
65. It is the old recall which normally comes like history p.e and diagnosis , this time they asked to
do more inv ad prognosis , i made the diagnosis of cervical spondylosis
explained the condition, but then also checked of previous mammogram
and screening in history and for inv said we will do ca, vit d , mri,, dexa if needed and will rule
out recurrence of breast cancer though it is unlikely and it is what we call cervical spondylisis but
it is always best to play safe so we will make sure your cancer is not back bt then reassured it is
highly unlikely and what I think it is then she said thank you I was very worried if my cancer is
back since my friend got her breast cancer back and in prognosis and management I said
physio and good prognosis after physio , differential same as old recall and also said I will also
check with my senior if I need to add any more investigations Pre dominant area : management
/ counselling
67. Post breast Ca surgery complication
● A study found that most women who had breast cancer surgery had some type of arm problem (ranging
from mild to severe) even 1 1/2 years after surgery. The research was presented at the 2008 American
Society of Clinical Oncology (ASCO) Breast Cancer Symposium.
● After breast cancer surgery, some women experience numbness, swelling, weakness, or tingling in the
arm and shoulder area on the same side of the body on which surgery was done.
● more likely to happen after mastectomy surgery and less likely to happen after lumpectomy.
● Reason , often Lymph nodes are removed / multiple numbers . ( shahriar’s Medical Academy)
● Research has shown that between 5% and 25% of women develop some lymphedema ( swelling of the
arm ) after breast cancer surgery due to damaged LN after surgery . Lymphedema can cause other
symptoms such as , numbness, stiffness, and weakness.
, both at 6 months and 18 months after surgery
along with pain, tingling stiffness , poor mange of motion . ( shahriar ahmed sujoy Note )
68. Management Lymphedema
● Treatment for Lymphedema
1. Exercise. Exercise helps improve lymph drainage. ...
2. Bandages. Wearing a compression sleeve or elastic bandage may help to move fluid, and prevent the
buildup of fluid.
3. Diet and weight management. ... SMA note
4. Keeping the arm raised. ...
5. Preventing infection. ...
6. Massage therapy.
Breast Cancer: Lymphedema After Treatment | Johns Hopkins ...
https://www.hopkinsmedicine.org › conditions-and-diseases
