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by

Peshraw Karim . Shanyar Qadir . Shvan Omar

2014

2

Index

Chapter Page

Chapter 1: Examination of a Swelling 4

Chapter 2: Examination of an Ulcer... 8

Chapter 3: Examination of Scrotal Swelling.. 10

Chapter 4: Examination of an Inguino-Scrotal Swelling 12

Chapter 5: Examination of Intra-Abdominal Lump.... 15

Chapter 6: Examination of a Breast Lump. 22

Chapter 7: Examination of a Thyroid Swelling.. 27

Chapter 8: Examination of Peripheral Vascular Disease (PVD) 31

Chapter 9: Examination of Varicose Veins 36

3

Note:

Although this booklet is intended to be used as a stand-alone resource, the procedures are

better understood if you use this booklet with the accompanying Indian Videos. After all,

this is a transcript of those videos.

Thanks

Please report any ideas, corrections and suggestions to:

clinicalexaminationinsurgery@gmail.com

4

Chapter 1: Examination of a Swelling

Inspection

Site: exact anatomic position

Number: single or multiple

Shape: spherical, oval, kidney-shaped or irregular

Size: measure exact size in cm using a tape measure (measure longitudinal and transverse axis and if

possible the depth)

Surface:

The color: red in hemangioma, black in melanoma

The surface is smooth or irregular

Overlying skin: is it normal? Inflamed? Or ulcerated?

Shiny, smooth skin with prominent veins suggest sarcoma

Black punctum over skin of a swelling is diagnostic of sebaceous cyst

Redness of overlying skin indicates inflammation

Presence of scar of previous surgery suggests that the swelling is recurrent one

An edematous skin with multiple peels like an orange peel (termed as Peau dOrange)

appearance suggests an infiltrating malignant lump blocking cutaneous lymphatics.

Movement (pulsation): can be seen in aortic aneurysm

Site related signs:

If the swelling is over the abdomen or chest or spinal canal ask the patient to cough for an

impulse on coughing. A visible increase in the size of the swelling synchronous with the cough is

termed as impulse on coughing)

If the swelling is in the limb inspect the distal limb for any pressure effects, like edema or nerve

palsy

If the swelling is in the neck, look for movement on deglutition

Review

Inspection 1. Site & number

2. Shape & size

3. Surface & skin over the swelling

4. Pulsatility

5. Site related signs

5

Palpation

Temperature: with dorsum of your fingers compare temperature of the swelling with normal skin. Local

rise in temperature could be due to:

Cellulitis and abscess

Sarcoma

Vascular swelling

Tenderness: usually indicates inflammation

Confirm size & shape

Surface: is it smooth, lobular, nodular or irregular

Edge: palpate with tips of your fingers and note whether it is:

Well-defined and regular (mostly in benign swelling)

Well-defined and irregular (mostly in malignant swelling)

Diffuse and ill-defined (inflammatory swelling like cellulitis)

Slipping edge (characteristic for lipoma)

Consistency: could be soft, cystic, firm, hard, bony hard or variable.

If the swelling is soft or cystic look for the following signs:

Sign of moulding (indentation): press a finger over the swelling for 1-2 seconds then remove it, if the

swelling remains indented this indicates positive moulding sign. Sign of moulding is positive in:

Sebacous cyst

Dermoid cyst

Colonic mass with fecal matter

Fluctuation: transmission of an impulse in two directions at right angles to each other. It implies presence

of fluid in the swelling

Trans-illumination: demonstration of transmission of light through a swelling. It indicates presence of

clear fluid in the swelling. Transillumination is positive in:

Cystic hygroma

Epididymal cyst

Meningocele with thin skin

Ranula

Congenital hydrocele

6

Impulse on coughing: if swelling is likely to be communicating with peritoneal, pleural cavity or spinal

canal ask the patient to cough, if the swelling increases in size or becomes tense (when you grasp it) it

indicates positive impulse or coughing.

Reducibility: try to reduce or return the swelling to its normal cavity, it could be positive in:

Hernias

Meningocele

Varicocele

Saphena varix

Compressibility: when the swelling is compressed it reduces in size but on releasing the pressure it returns

to its original size without straining or coughing. This is characteristic of hemangioma.

Pulsatility: seen in aortic aneurysm. Place four fingers over the swelling as far apart as possible and note

the finger movement, if the fingers move upward and apart from each other this indicates an expansile

pulsation as seen in aortic aneurysm. But if the fingers are raised vertically without moving apart from

each other it is a transmitted pulsation, seen when a mass sits over an artery as stomach malignancies

sitting over the aorta.

Fixity: test fixity to skin, subcutaneous tissue, muscles & tendons, bone

If it is fixed to the skin, the skin over it cannot be pinched off

If the skin can be pinched off over the swelling this indicates that the swelling is under the skin

Ask the patient to contract the underlying muscle:

If the swelling is in the subcutaneous tissue above the muscle the swelling becomes more

prominent and mobile in all directions.

If the swelling is within the muscle itself it becomes fixed and immobile

If the swelling is deep to the muscle it becomes less prominent and difficult to palpate.

If the swelling is fixed to above it becomes totally immobile irrespective to muscle contraction.

Review

Palpation

Temperature and tenderness

Confirm the size and shape

Palpate surface and edges

Note the consistency

If soft or cystic, do specific tests

Fixity to other structures

7

Percussion

Tympanic note indicates presence of gas in:

Entertocele

Pharyngocele

Hydatid thrill in hydatid cyst

Auscultation

Pulsation can be heard in vascular swelling or in swelling with rich vascularity

Focal examination

1. Examination of lymph nodes

Palpate the regional lymph nodes, if they are enlarged then palpate the next group draining the previous

ones for any enlargement.

2. Pressure effect on

Bone: erosion

Artery: weak distal pulse

Vein: edema and dilated veins

Nerve: paresthesia and wasting

3. Joints above and below: look whether their movement is affected or not.

8

Chapter 2: Examination of an Ulcer

Inspection

1) Size and shape of the ulcer (using a tape measure)

2) Number (single or multiple)

3) Location of the ulcer:

Rodent ulcer nose

Tuberculous ulcer neck

Bedsore ulcer sacrum

Ischemic ulcer dorsum of foot and toe

Varicose ulcer medial aspect of lower third of the leg

Trophic ulcer weight-bearing area (e.g. heel of the feet)

4) Margin and Edge of ulcer

Margin is the border or transitional zone of skin around an ulcer. Types:

o Healing margin (outer white central blue inner red)

o Inflamed margin (red, irregular margin with inflamed surrounding skin)

o Fibrosed margin (thickened white)

Edge is the mode of union between the floor and the margin of ulcer. Types:

o Sloping edge healing ulcer

o Punched edge trophic ulcer

o Raised edge rodent ulcer

o Undermined edge tuberculous ulcer

o Everted edge malignant ulcer

5) Floor of ulcer: is the exposed surface of the ulcer, we look for

Type of Granulation tissue

Amount of Slough (necrotic soft tissue not yet separated from living tissue)

Nature of Discharge

6) Surrounding skin: if ulcer is spreading & infected, surrounding skin is shiny, red, and edematous due

to cellulitis

Dark pigmentation & eczema varicose ulcer

Scars and puckering of skin tuberculous ulcer

Hypopigmentation non-healing ulcer

Large scar Marjolins ulcer

Review

Inspection 1. Size & Shape

2. Number

3. Location

4. Margin & Edge

5. Floor

6. Surrounding skin

9

Palpation

1) Surrounding skin: for temperature & tenderness

2) Ulcer: edge, floor, base

Edge

o Soft: healing ulcer

o Firm: non-healing ulcer

o Hard: malignant ulcer

Floor:

o Granulation tissue: bleeding on touch? Healthy granulation

tissue may show pinpoint hemorrhagic spots, while

malignant ulcer may bleed profusely

o Slough: attached loosely or firmly?

Base (tissue on which the ulcer rests):

o Consistency

o Underlying structures (muscle, fascia or bone?)

3) Test the fixity of the ulcer to the structures in its base

Review

Paplation 1. Surrounding skin

2. Ulcer: edge, floor, base

3. Test the fixity

Focal Examination

1. Lymph nodes

Hard, discrete, non-tender malignant ulcer

Soft, tender infective

Non-tender, matted tuberculous ulcer

2. State of arteries, veins, nerves

If ulcer in lower limb: ask patient to stand and look for varicose veins, varicosities, also test for

DVT by calf tenderness (Moses sign) and Homan's sign (pain on passive dorsiflexion of foot).

For any ulcer palpate arteries to rule out vascular disease & arterial insufficiency

Test sensation of skin surrounding ulcer by sharp pin

In trophic ulcer we should

o Map area of anesthesia

o Search features of Leprosy

o Neurologic exam

3. Examine joint around ulcer for active and passive movement

Systemic Examination

CVS: for CHF which delays ulcer healing, R.S: for TB & secondaries, A.S: for splenomegaly

10

Chapter 3: Examination of Scrotal Swelling

Inspection

Inspection of a scrotal or inguino-scrotal swelling should always be done in standing position. Otherwise

direct hernias, varicoceles and full extent of hernias will be missed.

1:

Unilateral or Bilateral?

Scrotal or Inguino-scrotal? (Only in the scrotum? Or does it extend to the inguinal region?)

Relation to Testis (Can the testis be seen separately? or is it incorporate into the swelling?),

Epididymis, Cord, and Penis (is it pushed to the opposite side? Is it buried in the swelling?

2:

Shape and Surface [globular, retard, or irregular]: scrotal swellings (testicular, epididymal and

hydroceles) are globular. Hydrocele has a characteristic constriction around its central portion,

this is diagnostic of a tunica vaginalis hydrocele.

Size (in cms): measure the size in all three dimensions

3:

Overlying skin:

o Rugosities: normal scrotal skin has rugosities that may become diminished in a hydrocele.

Edematous skin is firm and non-tender on palpation, a feature of filarial elephantiasis

(Rams Horn penis is also seen).

o Redness, edema: features of scrotal wall cellulitis or acute epididymo-orchitis.

o Excoriation, vesicles: seen in urinary extravasation.

o Blackening: a feature of Fourniers Gangrene (an idiopathic gangrene of scrotal skin

secondary to infection and cellulitis).

o Ulcers, sinuses, scars: seen in tuberculous epididymitis.

It is important inspect the posterior surface of the scrotum or you may miss a posterior sinus or ulcer.

Lastly, ask the patient to cough and look for visible expansile impulse in the swelling and over both

inguinal canals.

Review

Inspection

1.

Unilateral or Bilateral?

Scrotal or Inguino-scrotal?

Relation to Testis,

Epididymis, Cord, & Penis.

2.

Shape

Surface

Size (in cms)

3.Overlying skin:

Rugosities

Redness, edema

Excoriation, vesicles

Blackening

Ulcers, sinuses, scars

11

Palpation

Temperature and Tenderness

12

Chapter 4: Examination of an Inguino-Scrotal Swelling

Inguino-scrotal swellings extend from scrotum to inguinal region and include: Inguinal hernias, Congenital

hydroceles, Varicoceles, Cord swelling.

Inspection

The patient should be in standing position, stripped below the waist:

To inspect the full extent of the hernia

To inspect direct hernias and varicocele that may not be seen in lying down position

1) Shape of the swelling

Indirect hernias are usually pyriform in shape

Direct hernias are usually globular in shape

Location of the swelling and see whether it is unilateral or bilateral

Measure exact size in cm, the size should be measured when the hernia is fully extended by asking

the patient to cough

2) Overlying skin:

Look for redness, edema, scar or discoloration

Redness, edematous & shiny skin suggest acute strangulated hernia

Scar of previous surgery indicates recurrent hernia

Observe the swelling closely for visible peristalsis: maybe seen in enterocele

3) Cough impulse test:

Positive cough impulse: diagnostic of an inguinal hernia

Hernia with no expansile impulse (negative cough impulse):

1. Omentocele with adhesion

2. Obstructed hernia

3. Strangulated hernia

4) Position of the penis:

A hernia usually pushes the penis to the opposite side

A very large hernia will bury the penis in the scrotal skin

Review

Inspection

1.

Shape, location

Unilateral or bilateral

Exact size (cms)

2. Skin overlying the swelling

Redness, edema

Scar

Discoloration

Peristalsis

3. Inpulse on coughing

4. Position of the penis

13

Palpation

1) Temperature & Tenderness

2) Reach the top of the swelling: Palpate the cord structures between the thumb in front and other fingers

behind, if it is not possible to reach the top of the swelling in the scrotum this indicates inguino-scrotal

swelling

3) Relation of pubic tubercle: Palpate the pubic tubercle and see its relation with the swelling; an inguinal

hernia is medial to the pubic tubercle and above the inguinal ligament, while femoral hernia is lateral to

pubic tubercle and below inguinal ligament.

4) Relation to the testis: Palpate the testis and see whether the swelling stops above it or incorporates

the testis into it:

Acquired hernia always stops above the testis

Congenital hernia includes the testis within its sac

Look whether the testis can be reduced to the abdomen along with other contents of the sac or not. If the

testis is absent and scrotum is empty then it is a case of undescended testis.

5) Consistency:

Softy & elastic: enterocele

Firm & doughy: omentocele

Tense & tender: strangulated hernia

Bag of worms feel: varicocele

6) Impulse on coughing: ask the patient to turn his head to opposite side and cough forcefully, keep your

hand on the swelling and feel for an expansile impulse on coughing, that is the swelling increases in size

and feels more tense during act of coughing

If the hernia is small and not visible keep your hand over the inguinal canal from deep to superficial ring

and then ask the patient to cough and feel the impulse.

Ziemans technique: used to differentiate indirect and direct inguinal and femoral hernias from each

other. Stand on the side of hernia then reduce the hernia and place three fingers: index finger over the

internal ring, middle finger over the external ring, ring finger over the femoral ring. Then ask the patient

to close the nose and mouth on blow, an impulse is felt by:

Index finger in indirect inguinal hernia

Middle finger in direct inguinal hernia

Ring finger in femoral hernia

7) Test Reducibility

14

8) Internal ring occlusion test:

Reduce the hernia and place a finger over the deep inguinal ring (1.25 cm above mid-inguinal point), then

ask the patient to cough, if the hernia is indirect it will not bulge out on occluding deep inguinal ring (this

is a positive occlusion test) but if the hernia is direct it will bulge out medial to the occluded ring at the

time of coughing (negative internal ring occlusion test)

9) Do invagination test, which gives us information about the following:

1. Size of the superficial (external) inguinal ring

2. Direction of the hernia tract

3. Direction of the expansile impulse

4. Sphincteric strength of conjoint tendon

Invagination test contra-indications:

1. If the external inguinal ring is small

2. In a child

Review

Palpation 1. Temperature & Tenderness

2. Reach the top of the swelling

3. Relation to Pubic Tubercle

4. Relation to Testis

5. Note the Consistency

6. Test Reducibility

7. Test for Cough Impulse

8. Perform Internal Ring Occlusion Test

9. Perform Invagination Test

Percussion

Ask the patient to cough to distend the swelling then percuss gently:

Resonant note: enterocele

Dull note : All other swellings

Auscultation

Peristalsis may be heard in enterocele, otherwise auscultation isnt of any diagnostic use in this case.

Examine the opposite side: Palpate testis, epididymis & spermatic cord of the opposite side to confirm

that they are normal

Look for a possible cause:

1. Tone of abdominal wall muscles

2. Scars, ascites

3. Urethra for stricture

4. PR for enlarged prostate

5. Respiratory system for chronic bronchitis, TB

15

Chapter 5: Examination of Intra-Abdominal Lump

Inspection

Position: lying down supine, relaxed, with the legs semi-flexed.

Exposure: expose the abdomen from the nipple to the mid-thigh

Note the contour of the abdomen

To inspect the contour, imagine a line from the tip of the xiphoid process to the symphysis pubis:

Scaphoid: if the abdomen lies below this line and is concave

Normal (flat): if it is along this plane

Distended (protuberant): if abdomen lies above this plane or convex

If the abdomen is distended note if it is uniform or asymmetrical by comparing both sides to each other

Now inspect the abdomen for:

Redness, scars

Striae, Branding marks

Nodule, Distended veins

Redness

Redness over a lump suggests local inflammation

Redness of skin around the umbilicus in an acute abdomen suggests acute hemorrhagic

pancreatitis (Cullens sign)

Branding marks usually suggest chronic or long-standing pain

Hard subcutaneous nodules suggest secondary spread of the malignancy to the skin (e.g. in

carcinoma of stomach)

Dilated veins around the umbilicus with centrifugal flow suggest portal hypertension (caput

medusae)

Vertical femoro-axillary veins are seen in venacaval obstruction

Scars

If there is a scar of previous operation ask about the nature of the operation

A scar at McBurneys point is of appendectomy

A scar below the right costal margin suggests cholecystectomy

A scar in suprapubic (lower midline) region suggests suprapubic cystolithotomy or prostatectomy

A scar in the loin region suggests a kidney operation

Notice the widening of the scar in the central part, ragged white scar suggests wound infection

after operation

16

After inspecting the skin inspect the umbilicus for:

Is it in the center?

Is it stretched / everted?

Is there a hernia?

1) Location of umbilicus

Normally it is in the midline, midway between the tip of xiphoid process and the top of symphysis

pubis

It is displaces upwards by lumps arising from pelvis

In ascites the distance between the xiphoid and umbilicus is more than distance between

umbilicus and symphysis pubis (Tanyols sign)

2) Shape of umbilicus: In ascites it maybe transversely stretched (laughing umbilicus)

3) Hernia: In umbilical hernia the umbilicus is everted, we ask the patient to cough to see if there is an

expansile impulse indicating an umbilical or para-umbilical hernia.

Now we look for abdominal movements

1. Movements during respiration

2. Visible peristalsis

3. Visible pulsations

1) Movements

Note abdominal movement during respiration and compare it with chest expansion

o If thoracic movements are more prominent, it is thoraco-abdominal breathing (common

in males)

o If abdominal movements are more prominent, it is termed as abdomino-thoracic

breathing (common in females)

In peritonitis the abdomen doesnt move during respiration

In localized peritonitis only the affected portion maybe immobile

If there is a visible lump (particularly if it is in the upper abdomen) observe whether it moves up

and down with each respiration

Lumps that dont move with respiration:

o Retroperitoneal lumps

o Intra-abdominal lumps not connected to the diaphragm

2) Look for visible peristalsis: If the peristaltic movement in the epigastrium moving from left to right (this

is a characteristic movement of pyloric stenosis)

Step-ladder pattern of peristalsis showing multiple distended loops rising towards the center, is typical of

low ileal obstruction.

17

3) Visible pulsations

Aneurysm of abdominal aorta is pulsatile

If a lump is in the epigastrium and umbilical region which is overlying the abdominal aorta, it may

transmit pulsations from abdominal aorta, the lump itself is not pulsatile, these pulsations will

disappear in the knee-elbow position when then lump falls away from the aorta.

In a thin patient pulsations of abdominal aorta maybe visible

After that ask the patient to stand up and check for scrotal swelling

An epigastric lump that is due to secondary metastasis to the para-aortic lymph nodes maybe

caused by a right testicular tumor.

Then inspect the hernia orifices; ask the patient to cough and look for a coughing pulse

If a lump is arising from the pelvis or is very large, inspect the legs for edema. Then ask the patient

to sit, and standing behind the patient; inspect the spine for any deformity, gibbus, kyphus,

kyphosis or scoliosis.

Inspect the para-spinal area for any para-spinal swelling or sinus

Paraspinal scar or sinus is very suggestive of TB of spine

Then inspect the renal angle for fullness

Then check the left supraclavicular region for a swelling due to enlarged lymph nodes

Left supra clavicular lymph nodes can be enlarged due to secondary deposits from the malignancy

of stomach, colon or testis (Troisiers sign)

The lymph nodes themselves are termed as Virchows lymph nodes

Remember to inspect the four extra-abdominal sites:

1. Scrotum: while standing

2. Hernial orifices: while standing

3. Spine: from the backside (para-spinal regions, renal angles)

4. Virchows nodes: Left supra-clavicular nodes

Review

Inspection

Note the contour (Scaphoid, Normal, Distended)

Look for localized bulge

o Note the effect of raising the neck- Does it become more prominent or less?

Note the skin over the abdomen

o Redness, Scars

o Striae, Branding marks

o Nodule, distended veins

Note the Umbilicus

o Is it in the center?

o Is it stretched/everted?

o Is there a hernia?

Look for movements

o Movement during respiration

o Visible peristalsis

o Visible pulsations

Inspect the other sites (Scrotum, Hernial orifices, Spine, Virchows nodes)

18

Palpation

Warm your hands by rubbing them together

Note the temperature over the site of the lump and compare it with normal and note if there is

any local rise in temperature suggestive of acute inflammation in the lump

Palpate gently with a flat hand (superficial palpation) for:

o Tone of abdominal wall muscles

o Tenderness (demarcate the exact location)

o Normal abdomen is soft, elastic and non-tender

Superficial palpation

1. Warmth and tenderness

2. Area of tenderness

3. Guarding of rigidity

4. Rebound tenderness

Guarding: contraction of abdominal muscles upon palpation

Rigidity: the state of sustained contraction even if we dont palpate (e.g. in acute peritonitis)

Rebound tenderness: if there is a mild local tenderness check for rebound tenderness. Slowly press

down your hand over the tender area and withdraw suddenly, if there is acute pain on withdrawal

then it is rebound tenderness. Rebound tenderness indicates inflammation of parietal pleura due to

an inflamed underlying organ. In intestinal obstruction rebound tenderness suggests strangulation.

Deep Palpation

1. Palpation of the lump

2. Palpation of the rest of the abdomen

1. Before doing palpation of the lump, you should determine:

A. Intra- or extra-abdominal lump

B. Size, shape, consistency, location

A. Intra- or extra-abdominal: (keep your hand on the lower border of the swelling. If the swelling moves

with respiration then it is intra-abdominal, if it doesnt it can be parietal or intra-abdominal)

Ask the patient to raise the neck:

If the swelling becomes less prominent and difficult to palpate then intra-abdominal

If the swelling becomes more prominent and easier to palpate then extra-abdominal

o If mobile then subcutaneous

o If it becomes fixed on contracting the abdominal muscles then intramuscular

19

B. Palpation in details:

Measure the size in cm

Note its location in relation to:

o Involved quadrant

o Costal margin

o Umbilicus

o ASIS (Anterior Superior Iliac Spine)

o Symphysis pubis

Shape, surface, margin

o Well-defined margin: neoplasm

o Ill-defined margin: inflammatory swelling

C. Consistency:

Soft, cystic, firm or hard

Uniform or variable

If cystic test fluctuation and fluid thrill

D. If in lumbar region palpate bimanually

If it is in the right or left hypochondrium; check if it extends under the costal margin and whether

fingers can be inserted between it and the costal margin.

E. Mobility

If the swelling is in the upper half of abdomen check movement with respiration

Hold the swelling between fingers of both hands and try to move it horizontally and vertically

If mobile then check restriction of movement in any direction (e.g. an ovarian cyst is mobile in all

directions)

If the swelling is in the flanks then palpate bimanually and check anteroposterior movement and

balloatment (only renal lumps are balloatable).

F. Pulsatility

Put two index fingers on the edge of the swelling

If the fingers move up and away from each other (expansile pulsation) then it is an aneurysm

If the fingers only move upwards (transmitted pulsation) then it is a mass

If in doubt put the patient in knee-elbow position, transmitted pulsation will disappear. An

aneurysm will continue to pulsate.

2. Palpation of the rest of abdomen

A. Palpate for liver, spleen and kidneys

B. Note their relation to the lump

20

Liver: Start palpating in the right iliac fossa along the mid-clavicular line with the fingers parallel to the

liver border exerting moderate pressure during expiration. If palpable note the site, border, surface,

consistency and tenderness

Spleen: Start from right iliac fossa towards left costal margin with fingers parallel to the left costal

margin. If palpable note its size in cm, then palpate the anterior border for the splenic notch and note that

the fingers cant be inserted into the costal margin. If not palpable turn the patient to his right side and

do bimanual palpation.

Kidney: Do bimanual palpation in both lumbar regions for renal lump. If abdomen is thin the lower pole

of the right kidney maybe normally palpable

3. Palpate for tenderness over:

Colon (in the flanks), Lower intercostal spaces (in lower chest), Renal angles

Check for the testicular tumor

Note right testicular swelling in a patient with an epigastric lump

Palpate hernial orifices for hernia (feel cough impulse)

If lumps arises from the pelvis or from the retroperitoneal space or it is so large as to compress

the inferior vena cava then examine the legs for edema (due to compression of the vein or

obstruction of lymphatics)

Examine the back

Palpate the spine for deformity and tenderness

Look for renal angle tenderness

Palpate the supraclavicular fossa (especially left) for Virchows lymph nodes

Review

Palpation

Superficial

o Warmth and Tenderness

o Area of Tenderness (mark the exact location)

o Guarding and Rigidity

o Rebound tenderness

Deep

o Palpate the lump

Intra- or Extra- abdominal

Size, shape, consistency, location

If lumbar, bimanual palpation and balloatment

Mobility

Pulsatility

o Rest of abdomen

Palpate for liver, spleen and kidneys

Note their relation to the lump

Palpate for tenderness over colon, lower intercostal spaces and renal angles

Palpate (Scrotum, Hernial orifices, Back-Spine, paraspinal, Left supra-

clavicular nodes)

21

Percussion

Percuss on the lump (solid = dull, retroperitoneal and deep = resonant) e.g. resonant note over a

renal lump

If swelling in upper abdomen, note if dullness is continuous with liver or splenic dullness

Percuss for upper and lower border of liver and measure the liver span

Confirm mobility of diaphragm by tidal percussion

Percuss for spleen in the left 9th intercostal space from posterior axillary line forwards

o If spleen is enlarged the dullness will extend beyond the mid-axillary line

If a renal lump is suspected percuss posteriorly in the loin, just lateral to erector spinae muscle.

Normally this area is resonant due to the presence of the colon. If kidney is enlarged then there

will be a dull note but in other lumps like spleen the note remains resonant.

Percuss from umbilicus to the flanks to detect ascetic fluid. If there is dullness in the flanks try to

demonstrate a shifting dullness. Keep the pleximeter finger just lateral to the border of the

dullness and roll the patient over to the opposite side, wait for 20 seconds and percuss again. If

the note becomes resonant, presence of free fluid in the abdomen is confirmed. Then turn the

patient supine again and demonstrate that the note is dull once again.

If the dullness extends to both flanks and suprapubic regions, it is termed horseshoe shaped

dullness.

If there is a large ascites or a large cystic lump, percuss for fluid thrill.

If the lump is suspected to be a hydatid cyst, try to demonstrate a hydatid thrill or the after-thrill.

Auscultation

Auscultate carefully over the abdomen for abnormal sound and peristalsis

If the lump is pulsatile auscultate over it first for a bruit

Auscultate over abdominal aorta and then on the renal arteries for bruit

If the liver or spleen is enlarged, auscultate them for hepatic rub and splenic rub during deep

inspiration

Auscultate in the peri umbilical area and the right iliac fossa for peristalsis

Lastly do a PR and in females a PV exam

22

Chapter 6: Examination of a Breast Lump

Inspection

Expose the patient from the waist up. First do comparative inspection of both breasts and then inspect

the affected breast.

Position (for comparative inspection)

1. Sitting erect, with both arms by the side.

2. Sitting erect, with both arms raised above the head.

3. With the patient bending forwards. (In carcinoma, affected breast wont fall freely & lags behind).

Do Comparative Inspection for:

1. Visible lump or bulge (note the quadrant in which it is situated)

2. Compare the level of the nipples (the nipple will be at a higher level if its fixed by a malignancy,

this is more pronounced when arms are above the head)

If the breasts are identical, measure the vertical distance from the clavicle and horizontal distance from

the midline (to know the exact displacement of the nipple)

Auchinclosss method: the visible signs of breast carcinoma become more prominent on raising the arms.

In this position inspect the undersurface of the breasts; also inspect both axillae for swelling.

Inspection of the affected breast (nipple and areola)

Nipple

1) Nipple displacement: check to see if it is:

Towards the lump (carcinoma)

Away from the lump (bening lump)

2) Nipple retraction: check to see if it is recent or congenital, it is usually associated with diminished

size of areola. Recent retraction is highly suggestive of carcinoma.

3) Nipple discharge: (check underwear for color and amount of discharge)

Bright red discharge:

o Carcinoma

o Duct papilloma

Blackish red discharge

o Duct papilloma with obstructed duct

Clear watery or greenish discharge

o Fibroadenomas

Mily white discharge

o Lactation

o Galactocele

o Mammary ductectasia

o Galactorrhea

Purulent discharge

o Acute mastitis

o Chronic abscess with ductectasia

23

Areola

Cracks

Fissures

Eczema

o Unilateral with destruction of the nipple: Padgets

o Bilateral and itching: allergic eczema

Overlying skin, inspection of:

1. Redness, shininess, edema (inflammatory) and dilated veins (suggest sarcoma rather than

carcinoma)

2. Retraction and puckering

3. Peau dOrange appearance (due to cutaneous lymphedema with pitting at the site of hair follicles

where the skin is firmly attached)

4. Ulcers and nodules

Lastly inspect the arm for edema

REVIEW

Inspection

1. Inspect both breasts simultaneously

For asymmetry and lump

For level of nipples

2. Inspect the nipple and areola

Nipple

- For deviation, displacement

- Retraction, cracks

- Nipple discharge

Areola

- For cracks, fissures

- Eczema

3. Inspect the sign over the breast

For redness, shininess, edema and dilated veins

Retraction, puckering

Peau dOrange appearance

Ulcers and skin nodules

4. Inspect the arm for lymphedema

Lympatic obstruction in axilla

24

Palpation

Let the patient lie supine on the examination table. Note the skin temperature over the lump comparing

it to the normal breast. Then notice the consistency of the normal breast tissue on the normal side before

palpating the affected breast.

First palpate with a flat hand rolling and feeling the breast between the palmar surface of the fingers and

the underlying chest wall to identify any breast lump. Then palpate between the fingers and the thumb

to note the consistency of the breast tissue. Palpate the four quadrants of the breast and then the tissue

beneath the areola and then the axillary tail.

Once the lump is identified with a flat hand, palpate it between the fingers and the thumb to note its

characteristics:

1. Size of the lump (in cm)

2. Shape

3. Surface: smooth/irregular

4. Edge: well-defined/ill-defined

5. Consistency: soft, firm, hard or cystic

Now press from the periphery towards the nipple in a squeezing action in each of the quadrants and look

for nipple discharge. If this fails to bring a nipple discharge, compress the breast tissue under the breast

and the areola between the thumb and other fingers. Note:

Black discharge in duct papilloma.

Milky discharge during lactation. In a newborn child, a milky discharge maybe expressed for

the first few days due to the effect of maternal hormones on the child (Witchs milk)

If the swelling is soft and cystic as in galactocele, chronic abscess, or cystic hygroma then test for

fluctuation and trans-illumination. Trans-illumination should be carried out in a dark room with a powerful

torch. Place the torch on the undersurface of the breast. Normal breast tissue is translucent. A cystic

hygroma maybe transilluinant, but most other breast swellings are opaque and cast a negative shadow.

Test fixity:

To the skin

To the breast tissue

To the pectoral fascia and muscle

To the chest wall

1) Fixity to the skin

If the skin is puckered, ulcerated or infiltrated then the lump is obviously fixed to the skin. If not,

then slide the skin over the lump and test its mobility. Also, try to pinch the skin over the swelling.

If the skin is not fixed to the lump, move the lump from side to side and see if the skin gets

dimpled. If there is dimpling then the lump is tethered to the skin.

25

2) Fixity to the breast tissue

Stretch and fix the breast tissue over the lump with stretched thumb and middle fingers of the left hand.

Now try to move the lump in all directions with the right hand.

Fibroadenoma is freely mobile and not fixed to the breast tissue. Often it is so freely mobile within

the breast tissue that it is termed as a breast mouse.

A malignant lump that is fixed to the breast tissue becomes immobile when the breast tissue is

fixed by stretching.

3) Fixity to the Pectoralis major and Serratus anterior

Ask the patient to place her hands on her waist. First test the mobility of the lump in the direction

of the fibers of the Pectoralis major and at a right angle to it while the muscle is relaxed. Now ask

the patient to press her hands firmly over the hip. Palpate the anterior fold of axilla to confirm

that the Pectoralis major is contracted and taut. Move the lump again in the same two directions.

Any restriction of mobility on contraction of Pectoralis muscle suggests the fixity of the lump to

the Pectoralis muscle or fascia.

If the lump is in the outer and lower quadrant, it lies on the Serratus anterior, so we test fixity to

Serratus anterior. Let the patient stand at arms length from a wall with the palms resting on the

wall. Test the mobility of the lump in horizontal and vertical directions. Now ask the patient to

push against the wall with outstretched hands, this contacts the Serratus anterior. Now test the

mobility again. Any restriction of mobility indicates fixity of the lump to the Serratus anterior. Now

inspect the scapulae as the patient is pushing against the wall. If there is winging of the scapula

on the affected side, it indicates paralysis of the Serratus anterior due to involvement of the long

thoracic nerve.

4) Fixity to the chest wall

If tumor is fixed & immobile even when Pectoralis major is relaxed then its fixed to the chest wall.

REVIEW

Palpation:

1. Temperature and tenderness

2. Size, shape, surface and edge of the swelling

3. Consistency

4. If cystic: fluctuation and trans-illumination

5. Nipple discharge

6. Fixity to surrounding structures

26

Examination of Lymph Nodes

With the patient in sitting position ask her to keep the arm hanging loosely by the side.

First palpate against the medial wall of the axilla (along the chest wall) for the central group of

lymph nodes.

Move the hand higher up for the apical group.

Then palpate under the anterior axillary fold for pectoral group of lymph nodes and under the

posterior axillary fold for the subscapular group.

Now palpate the lateral wall of the axilla against the upper end of humerus for the brachial group

of nodes.

Then palpate below the clavicle in the deltopectoral groove for the deltopectoral (infraclavicular)

group.

Now stand behind the patient and palpate the base of the anterior triangle of the neck behind

the middle of the clavicle. Lift the patients arm with the other hand to relax the muscles and the

cervical fascia. This is the supraclavicular group of lymph nodes.

Next palpate the opposite axilla in the same manner. If any one or more groups of lymph nodes

are palpable note their site, number, consistency and mobility.

If the lymph nodes are enlarged examine the arm, forearm and dorsum of the hand on the

affected side for edema and compare it with the opposite arm. Edema of the arm indicates

lymphatic obstruction in the axillar or axillary vein thrombosis.

Systemic Examination

1. Abdomen for hepatomegaly and free fluid

2. Per-vaginal and Per-rectal examination

3. Chest for effusion and consolidation

4. Bony swellings and tenderness

27

Chapter 7: Examination of a Thyroid Swelling

Thyroid is located in front of the neck, with its 2 lobes on either side of the trachea connected by isthmus

Inspection

Make the patient sit on stool with neck slightly hyperextended. Asking the patient to swallow makes the

thyroid move prominent for inspection

1) Size, Shape and Situation (Midline, both sides of the midline, one side): measure by measuring tape

2) Location

3) Borders in relation to the sternomastoid muscle and the suprasternal notch

4) Surface

Smooth simple goiter, single nodule

Nodular, Bosselated Multinodular goiter

5) Skin over thyroid

Redness and edema suggestive of inflammation

Scar of previous surgery

Sinuses thyroglossal fistula

Dilated vein

6) Pulsation

7) Upward movement on deglutition and protrusion of tongue

Thyroid swelling moves in deglutition but we have other condition where swelling moves in

deglutition:

o Thyroid

o Thyroglossal cyst

o Pre-tracheal Lymph Nodes

o Subhyoid bursa

o Extrinsic carcinoma of larynx

But lipoma does NOT move during deglutition because it is not attached to the pre-tracheal fascia

If swelling is a nodule which is close to the midline we must test its upward movement on protrusion of

the tongue. Thyroglossal cyst and Thyroglossal fistula move upwards with tongue protrusion.

28

Palpation

Methods for palpation:

1) Standard method: test temperature of swelling with back of fingers, then look for any tenderness

2) Laheys method for palpation of the deep surface of thyroid

3) Criles method for palpation of small nodules in the thyroid

In palpation we look for

1) Size and shape

2) Borders: we check for a retrosternal goiter by palpating the tracheal rings in the suprasternal notch

3) Surface: smooth / bosselated

4) Consistency: nodules

If entire gland or lobule is enlarged, note:

Surface: smooth, bosselated

Consistency: soft (colloid goiter), firm (multinodular goiter), hard (carcinoma, Riedel's thyroiditis)

Retrosternal extension?: palpate the lower border during deglutition

If single nodule

Location: lobe or isthmus

Size and Shape

Consistency: soft, firm

o Cyst in thyroid is firm

o Solid swelling (adenoma) soft

Is the rest of the thyroid gland palpable?

Normally the rest of the gland is not palpable (solitary nodule), if it is palpable then it is considered

a multinodular goiter with a single large nodule

5) Thrill: Put finger gently on the upper pole of each side to check for a thrill if positive it is diagnostic

of primary toxic goiter

6) Fixity: Test for fixity and mobility fixity in any direction suggests + malignant infiltration or thyroiditis

7) Trachea: Deviation, Kochers test for scabbard trachea

Kochers test: Ask patient to take heavy deep breath and open mouth and compress swelling from

both sides, if there is hoarseness of voice (indicate narrowing of trachea). It is seen in carcinoma

and multinodular goiter

8) Carotids: we check for Berrys sign (for obliteration of carotid pulsation): in a benign goter, carotid pulse

is well felt, though displaced backward. In malignant goiter, carotid pulse is weak or absent

29

Percussion & Auscultation

Percuss on manubrium sternii

Normal = Resonant

Retrosternal Goiter = Dull

In auscultation: we auscultate over the swelling, paying more attention at the upper poles for a systolic

bruit which is diagnostic for primary toxic goiter and it is due to increased vascularity.

After examination of thyroid look for

Sign of thyrotoxicosis

Sign of myxedema

Sign of retrosternal extension

Sign of metastasis

Sign of thyrotoxicosis

1) Eye signs Looking for Exophthalmos

Lid retraction (Dalrymples sign), Lid lag (Von Graefes sign) & Infrequent blinking (Stellwags sign)

Actua l bulge (Naffzigers method), and sclera seen inferiorly

Absence of wrinkling and inability to converge:

o No forehead wrinkles Joffroys sign

o Difficulty everting the upper eyelids in thyrotoxicosis Giffords sign

o Note convergence of eye by holding finger one meter from the eyes and ask patient to

look, then slowly move finger towards midpoint of eyebrows of the patient, the patient

cant converge the eyes in exophthalmos (Mobiuss sign)

Progressive Exophthalmus:

1. Further bulging of eyeballs

2. Conjuctival congestion and edema

3. Corneal ulcers, diminished vision

4. Ophthalmoplegia

2) Tremors: Fine tremor of out-stretched hands and protruded tongue (positive in thyrotoxic patient)

3) Tachycardia

Radial pulse: count pulse rate in early morning at 4 am during sleep (Sleeping Pulse Rate)

Palms & feet: warm and moist

Legs: pretibial myxedema with thickened, hyperpigmented skin and coarse hair

4) Bruit, thrill

30

Sign of myxedema

Edema of face and legs

Hoarseness of voice

Lethargy

Delayed relaxation of deep reflexes

Sign of retrosternal extension (RSE)

Palpate tracheal rings: inability to palpate suggest RSE

Percuss manubrium sterni: dull sound suggests RSE

Thoracic outlet obstruction: Pemberts sign

Horner syndrome: ptosis, miosis, enophthalmus, absent cilio-spinal reflex and anhydrosis (in RSE

or malignant goiter)

Sign of metastasis

Hard cervical lymph nodes

Hard nodules on skull

Long bone metastasis

Nodular liver & ascites

Chest effusion/consolidation

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Chapter 8: Examination of Peripheral Vascular Disease (PVD)

Presentation: gangrenous (already dead) or ischemic limb.

If gangrene present, examine it first, then proceed to examination of the ischemic limb.

Inspection

Gangrene:

Dry gangrene: shows a dark discoloration with a shriveled and mummified appearance. There is a

clear demarcation between the gangrenous & the normal limb. With time the dry gangrene will

separate itself by the process of aseptic ulceration & the ulcer will be covered up by skin.

Wet gangrene: shows black discoloration and the tissue is edematous & swollen. There is no clear-

cut demarcation between the gangrenous and the normal limb.

Proximal limb:

Evidence of proximal spread of gangrene & infection

Redness & Edema in proximal skin suggests active infection as in a wet gangrene

Blebs, Ulcerations & Skip areas in the proximal skin suggests proximal spread of the gangrene

Skip areas: are areas of blackening, in the proximal limb, independent from the gangrene.

Evidence of chronic ischemia

Dark discoloration in the limb suggests chronic ischemia (compare with the other limb)

A marked pallor will indicate sudden arterial obstruction (embolism, Raynauds phenomenon)

Pale, thin, shiny limb with scanty hair and brittle nails suggests chronic ischemia

Trophic ulcers in the tips of the fingers and toes

We measure the girdle of both limbs at the same level and compare them to demonstrate and record limb

wasting. Measurement should be over main muscle masses; 3 inches above and below the knee joint in

the lower limbs, 2 inches above and below the elbow joint in the upper limbs.

Inspect the veins over the dorsum foot while the patient is lying down, if they are easily palpable, it

indicates good circulation. If they are collapsed and gutter-like, it indicates severe ischemia. If the patient

has a previous amputation or long-standing ischemia, look for scar of lumbar sympathectomy (a

transverse lumbar scar at the level of the umbilicus).

If the toes are affected, look for a constriction at the base of the toe as seen in Ainhum (a constriction at

the base of the fifth toe which gradually deepens over several years till the toe separates).

Review

Inspection of a Gangrenous area

1. The Extent of the gangrene

2. The line of demarcation

3. The type of the gangrene: dry or wet

Inspection of the Proximal Limb

1. Infection: Edema, Redness

2. Spread: Blebs, ulcers, skip areas

3. Chronic Ischemia: thin shiny skin, wasting, brittle nails

32

Palpation

First palpate the gangrenous area.

Dry gangrene: the skin is cold, non-tender, hard and greasy. It has no sensation

Wet gangrene: the skin is turgid, edematous with loss of sensation but it may be tender if

gangrene is not fully established.

If the skin is edematous palpate carefully all over the gangrenous and proximal area for

crepitations to rule out an anaerobic infection like gas gangrene.

Palpation of proximal ischemic limb

Check the temperature of the skin with the back of your fingers and proceed proximally comparing

it to the temperature of the other limb at the same level. Note the level up to which the limb is

cold. In a severe peripheral vascular disease, it may be cold up to the mid-thigh. Skin temperature

is a good indicator of the state of skin circulation and is important in deciding the level of

amputation if required.

Now palpate the gangrenous and proximal limb for tenderness

Next palpate along the line of major vessels for tenderness; that is along the popliteal and femoral

arteries in the lower limbs and along radial, brachial and axillary arteries in the upper limbs.

Tenderness indicates recent thrombosis or embolism.

Focal Examination

1) Arteries: palpate the arterial pulse at various levels in all the limbs.

2) Lymph nodes: palpate the inguinal region for enlargement of lymph nodes.

3) Joint movements: test the movement of different joints in the gangrenous area. Gangrenous

portion of the limb will lose its movements

33

Methods of palpation of the arterial tree:

LOWER LIMB

Capillary circulation in the nails: blanch the nail by pressing its tip, release the pressure, and note

the time taken by the nail bed to turn pink again. This gives a rough idea about the rate of blood

flow in the capillaries.

Dorsalis pedis artery: at the proximal end of the first metatarsal space just lateral to the tendon

of extensor halluces longus against the navicular and middle cuneiform bones.

Palpate the posterior tibial artery: midway between the medial malleolus and Achilles tendon

against the calcaneum, keeping the foot dorsiflexed and inverted.

o If dorsalis pedis and posterior tibial arteries are well-felt, it implies that the proximal pulses

are normal.

Popliteal artery: in the popliteal fossa against the upper end of tibia or lower end of femur. With

the patient in supine position, keep the knee flexed at 135. Keep your thumbs over the tibial

tuberosity and insert the fingertips into the lower part of the popliteal fossa palpating from lateral

to medial side till the neurovascular bundle is felt, now palpate the artery against the upper end

of the tibia. If not felt in supine position, turn the patient prone, flex the knee to 90, and palpate

the artery in the midline in the upper part of the popliteal fossa against the lower end of femur.

If the popliteal pulse is still not felt (it is difficult to locate in obese patients) then perform the

Fuchsigs test.

o Fuchsigs test: ask the patient to sit at the edge of a table and cross the affected leg so that

the popliteal fossa rests on the opposite knee. Ask the patient to keep the leg completely

relaxed. Look for oscillatory movements of the hanging leg synchronous with the patients

pulse. If oscillations are seen, it mean the popliteal pulse is normal. If oscillations arent

seen, it means that the popliteal pulse is absent. The test is of great significance when

femoral pulse is normal but dorsalis pedis & posterior tibial arent palpable.

Femoral artery: with the patient lying supine keep the legs slightly abducted and externally

rotated to relax the deep fascia and palpate in the line of mid-inguinal point just below the

inguinal ligament. Femoral artery is felt against the head of femur.

Abdominal aorta: to the left of the midline in epigastric and umbilical areas against the spine

Palpate the pulsations in the opposite limb.

UPPER LIMB

Capillary circulation in the nails: by pressing the nail tip until it blanches and noting the time taken

by the nail bed to turn pink again.

Radial artery: at the flexor aspect of the wrist just lateral to the tendon of flexor carpi radialis

against the lower end of the radius.

Brachial artery: in the lower half of the arm just medial to the biceps tendon against the shaft of

the humerus and in front of the elbow medial to the biceps tendon.

Axillary artery: in the axilla against the head of the humerus.

Subclavian artery: in the supraclavicular fossa in mid-clavicular line against the first rib.

Common carotid artery: against the transverse process of the 6th cervical vertebra between the

upper portion of the trachea and sternomastoid.

Superficial temporal artery: in front of the tragus of the ear against the temporal bone.

Facial artery: against the lower border of the mandible, at the anterior border of the masseter

muscle. (Ask the patient to clench to identify the anterior border of the masseter muscle).

o Superficial temporal & facial arteries arent important in a case of peripheral vascular disease.

34

Auscultation

By palpation you can note the level of the block

Auscultate along the entire length of the artery for a systolic bruit of stenosis, partial obstruction

or aneurysm.

Routinely auscultate over the major arteries (abdominal aorta, femoral, popliteal, axillary, and

carotid arteries).

Special tests for PVD

TESTS FOR LOWER LIMBS

1. Buergers test: with the patient supine, raise the legs (knees-extended) to about 90, if the limb

shows marked pallor then the test is positive. In severe disease the pallor appears within 2-3

seconds while in mild disease it might take minutes for it to appear. If the test it positive, lower

the limb, let it resume its normal color, then raise it gradually to note the angle at which the pallor

appears. This angle with the horizontal is called Buergers Angle of Circulatory Insufficiency.

Buergers angle of < 30 is indicative of very severe ischemia

2. Capillary filling time: with the patient supine, raise the legs till the affected leg becomes pale. Ask

the patient to sit at the edge of the examination table and hang the legs down. Note the time

taken by the affected leg to resume its normal pink color. In PVD this time may be prolonged to

15-30 seconds. Then let the patient sit with the legs hanging for 2-3 minutes. The leg will assume

a purple red, cyanotic color termed as dependent rubor indicating impaired circulation. A normal

leg doesnt show any color change in raised or dependent position.

TESTS FOR UPPER LIMBS

1. Reynauds phenomenon: if this phenomenon is suspected, dip both hands in ice-cold water and

watch for blanching (pallor) of the fingers. If the fingers become blanched take the hand out of

the water, the fingers will become swollen and cyanosed. Gradually as the spasm of the arteries

wears off, the fingers become red and engorged due to flow of blood into the dilated capillaries.

Then perform the tests for thoracic outlet obstruction.

2. Adsons test: with the sitting on a stool, feel the radial pulse of the affected hand. Ask the patient

to turn the head as much as possible towards the affected side then take a deep breath. If the

pulse becomes feeble or is obliterated, then the Adsons test is positive. The forced inspiration

contracts the scalenus anterior (an accessory muscle of respiration) which elevates the first rib

and compresses the subclavian artery at the thoracic outlet. This test can also be performed by

asking the patient to turn the head to the opposite side and take a deep breath, then by keeping

the arm extended and pulling it downwards noting whether the pulse diminishes or not.

35

3. Elevated arms stress test: ask the patient to abduct the shoulders to 90 with maximum possible

external rotation keeping the elbows flexed at 90, thus raising the arms above the head. Now

ask the patient to close and open the fists slowly for a period of 3 minutes. If the patient symptoms

of radiating pain, cramps, paresthesia or Raynauds phenomenon appear, forcing him to sop then

the test is positive for thoracic outlet obstruction. A normal person will only feel some fatigue in

the forearm muscle.

4. Allens test (degree of patency of radial & ulnar arteries): ask the patient to clench the fist tightly,

then compress both the radial and ulnar arteries at the wrist. Then ask the patient to clench and

release the fist till blanching occurs. Now ask him to open the fist, and release the radial artery.

Note the time taken by the hand to regain the normal pink color. Then repeat the test, after

blanching of the hand release the ulnar artery noting the time taken by the hand to regain its

normal pink color. If any of the arteries is blocked, the palm will remain blanched for a longer time

when the pressure over the arteries is released.

Review

Special tests for PVD

Lower limb

1. Buergers test

2. Capillary filling time

Upper limb

1. Raynauds phenomenon

2. Adsons test

3. Elevated arms stress test

4. Allens test

36

Chapter 9: Examination of Varicose Veins

A varicose vein is an elongated, dilated and tortuous vein, in the subcutaneous layer.

Inspection

A) Inspection of the vein

In standing position

Note the site and extent of the varicosity and its relation to long or short saphenous veins.

Examine the leg from all the sides.

Long saphenous varicosities run from the front of medial malleolus upwards along the antero-

medial aspect of the leg, knee and the thigh to end at the saphenous opening just below the

inguinal ligament.

The short saphenous varicosities run over the posterior aspect of the calf to converge and end at

the center of the popliteal fossa.

Some varicosities may not conform to these anatomical pathways and are termed stray

varicosities.

Inspect the length of the varicose vein for a blowout (a localized bulge in the vein) indicating

incompetent perforator. Mark the blowouts with a pencil.

Inspect the saphenous opening below the inguinal ligament for a Saphena Varix (a blowout over

the sapheno-femoral junction) which indicates a sapheno-femoral wall incompetence. If a

Saphena Varix is present ask the patient to cough and look for a visible cough impulse.

Look for dilated veins over the lower abdomen above the inguinal ligament converging onto the

saphenous opening. These are the superficial circumflex iliac, superficial inferior epigastric and

superficial external pudendal veins which enter the long saphenous vein just before it joins the

femoral vein

Raise the leg to 60 and check whether the varicosity collapses or not. Uncomplicated varicose

veins will always collapse on raising the leg. But if it is secondary to pelvic vein thrombosis or

arterio-venous fistula in the leg then it will not collapse when the leg is raised.

Morrisseys test: holding the leg to 30 or more ask the patient to cough and look for a cough

impulse at the saphenous opening. If a Saphena Varix is present it will be seen to bulge out and a

retrograde venous pressure wave will be seen to rise in the vein and fall slowly. Positive test

indicates incompetent sapheno-femoral wall.

B) Inspection of ankle and foot

Inspect the medial aspect of the ankle for Ankle or Venous Flare (a diffuse soft swelling or fullness

with small subcutaneous dilated venules around the ankle, filling the hollow between the medial

malleolus and the heel). Ankle Flare is seen in association with incompetency of ankle perforators.

Inspect the skin over the medial aspect of the lower third of the leg for pigmentation, edema,

oozing or ulceration. These are changes in the skin due to the back pressure in the veins and

capillaries which forces the RBCs out of the vessel wall. The RBCs are broken down by

37

macrophages and from breakdown products of hemoglobin; hemosiderin produces black

pigmentation while biliverdin produces irritation and itching leading to dermatitis.

(Gator area?) A varicose ulcer is more commonly seen after deep vein thrombosis (DVT) and

sometimes with primary varicose veins. DVT damages the wall of deep veins of the leg so the

blood is pumped into the superficial veins particularly on the medial side where the perforator

veins are situated. Varicose ulcers are superficial, painless ulcers with ragged, irregular edges and

unhealthy granulation, they never penetrate the deep fascia.

If varicose ulcer or severe dermatitis is seen note if the foot has a talipus equinus deformity (due

to contracture of the soft tissue on the medial aspect of the ankle) and whether the patient walk

limping on the toes.

Review

Inspection A. Inspection of the vein

1. Site, Extent & Anatomical relation

2. Blowouts, Saphena Varix and dilated veins over abdomen

3. Collapsibility

4. Morrisseys test

B. Inspection of the ankle and foot

1. Ankle flare

2. Hyperpigmentation of skin, edema, dermatitis

3. Ulcer

4. Talipus equinus deformity

Palpation

In standing position

Palpate the length of the vein for warmth and tenderness. Superficial thrombophlebitis in acute stage will

be warm and tender.

Mark the course of the vein with a skin pencil. Make the patient lie down. Raise the leg to 30 and empty

the vein.

Fegans method: Now palpate the deep fascia along the course of the vein more carefully at the site of

blowouts, if any, to look for pits (felt as a circular defect with sharp edges) in the deep fascia. A pit indicates

the site of a dilated perforator. If a pit is felt, mark it with a cross, with a skin pencil.

Keep your hand gently over the saphenous opening which is located 3.8 cm below and lateral to the pubic

tubercle and ask the patient to cough. A cough impulse indicates sapheno-femoral wall incompetence.

Cruveilhiers sign: If saphena varix is present a thrill will be palpable as the patient coughs as if a jet of

water is entering and filling the varix.

38

Ask the patient to turn to the opposite side when he is coughing. Note again the expansile impulse in the

saphena varix when the patient coughs.

Schwartzs test: with the patient standing place the fingers of the left hand over the saphenous opening

and tap over the most prominent part of the varicosity in the leg with the right hand. If the impulse is felt

by the palpating fingers it indicates that there is a continuous blood column between the two points and

the vein walls are incompetent.

Brodie-Trendelenburg test (for sapheno-femoral valve competency): with the patient lying down supine,

elevate the leg to 30 and empty the vein completely. Occlude the saphenous opening by tying a rubber

tourniquet around the upper thigh, just below the saphenous opening. Keeping the sapheno-femoral

junction occluded, ask the patient to stand. Observe the vein for 15-30 seconds with maintained pressure.

The vein will remain empty if it is purely a sapheno-femoral incompetence. But if there is a perforator

incompetence, the vein will fill slowly from below upwards. Then release the tourniquet and watch how

the varicosity fills rapidly from above. If sapheno-femoral wall is incompetent the varicosity will fill very

rapidly from above downwards. If sapheno-femoral wall is competent there will be no retrograde feeling.

Negative-positive result: that is negative with maintained pressure and positive on release of pressure

indicating a pure sapheno-femoral wall incompetence. Positive-negative (positive with maintained

pressure, negative with release of pressure) result implies only perforator incompetence. Positive-positive

(positive with maintained pressure, positive with release of pressure) implies incompetency of both

sapheno-femoral wall and the perforators.

Multiple tourniquet test: with the patient supine elevate the leg and empty the veins completely by

milking them down. Now, apply three rubber tourniquets; one just below the saphenous opening, second

just above the knee and third just below the knee. This divides the long saphenous vein into four

segments, each with one constant perforator (sapheno-femoral valve, adductor canal perforator below

knew perforator, and ankle perforator). The tourniquets should be tight enough to only occlude the

superficial veins, now ask the patient to stand up and observe for 15-20 seconds for appearance of

varicosities in each segment. Rapid appearance of a varicosity or a blowout in any of the segments

indicates the incompetency of the related perforator. In the segments with competent perforators the

vein remains collapsed.

Pratts test: this test is performed to locate incompetent perforators more accurately. With the patient

supine, raise the leg to 30, empty the veins and apply an elastocrib bandage from the toes to the mid-

thigh with gentle pressure to occlude the superficial veins only. Now apply a rubber tourniquet below the

sapheno-femoral valve to occlude retrograde flow from the sapheno-femoral wall. Now ask the patient

to stand and release the bandage from above downwards. After releasing each turn, observe the vein for

filling. The moment the turn of the bandage over an incompetent perforator is unwound, the vein will fill

rapidly.

39

Review

Plapation 1. Warmth & Tenderness

2. Pits by Fegans method

3. Cough impulse & Cruvilhiers sign

4. Schwartzs test

5. Tests for incompetent perforators

a. Brodie-Trendelenburg test

b. Multiple tourniquet test

c. Pratts test

Examination of the deep veins

Modified Perthes test (for checking patency of deep veins): with the patient supine elevate the limb and

empty the vein. Apply a rubber tourniquet over the upper thigh to occlude the superifical veins, then ask

the patient to walk around briskly for 5 minutes. If the deep veins are blocked the varicosities will become

turgid and the patient will experience throbbing pain in the calf (positive test). If the deep veins are patent,

the varicosities will remain collapsed and there is no calf pain. A positive Perthes test is an absolute

contra-indication for ligation and stripping of the veins and it must be routinely performed before surgery.

If the same test is performed by applying an elastocrib bandage from the toes to the thigh is the original

Perthes test.

Checking for Active Deep Vein Thrombosis

Look for tender calf swelling: flex the knee to 90 to rest the foot. Press the calf muscles against

the tibia to compress the posterior tibial veins, if this is not tender gently squeeze the calf muscles

from side to side; if painful this is a positive Moses sign. If the calf muscles are tender, do not

perform the test, as squeezing calf muscles can potentially dislodge a thrombus in the deep veins

and result in pulmonary embolism

Homans sign: let the leg rest with the knee fully extended. Dorsiflex the foot passively, the

resultant stretching of the calf muscles and the posterior tibial vein will illicit pain if the deep veins

are thrombosed.

Palpate for tenderness along the course of the veins (femoral, popliteal, posterior tibial veins).

Remember: in active DVT, these tests should be peformed gently as they can potentially dislodge a

thrombus and cause pulmonary embolism.

40

Review

Checking for DVT

1. Tender calf swelling

2. Tenderness along the course of the veins

3. Homans sign

4. Moses sign

Focal and General Examination

1. Palpate the inguinal lymph nodes which may be enlarged with varicose ulcers and deep vein

thrombosis.

2. Examine the opposite leg for varicose veins.

3. Palpate the abdomen for any lump pressing on the pelvic veins.

4. Examine the scrotum in standing position for varicocele and testicular tumor.

5. Peform proctoscopy to rule out co-existing hemorrhoids.

Enough of armchair medicine. Now to the wards.