Surgery

Physical

Examination

Yazan Addasi Qussai Sha’aban

Aseel Al- Da’ajah Abdallah Bani-Melhem

Ahmad Matarneh Farah Al-Haj Oweis Khrais

Nisreen Bassam Batool Sabri Al-Anoud Odwan

Hamzeh Shourbaji Mahmoud Shraideh

Maryam Nidal Rawan Badran

INDEX

1- Examination of a lump 3

2- Abdominal lump 7

3- Neck examination 9

4- Thyroid examination 16

5- Breast examination 18

6- Ulcer examination 20

7- Lower limb examination 28

8- Male external genitalia examination 36

9- Female external genitalia examination 38

10- Stoma examination 40

11- Incisions 42

12- Surgical drains 43

13- Post operative evaluation 49

14- Abdominal exam checklist (Prof. Kamal) 52

Examination of a lump

Introduce your self

Wash your hands

ensure privacy

Take permission

Examine the lump

1- Number

2- Position

3- Color and texture

4- Temperature

5- Tenderness

6- Shape

7- Size

8- Surface

9- Edge

10- Composition (consistence/fluctuation/fluid

thrill/translucency/resonance/pulsatility/compressibility/bruits)

11- Reducibility

12- Relations to surrounding structures

State of regional lymph glands

Local circulation

Nerve supply

1- Number : - multiple neurofibromatosis/ multiple lipomatosis

2- Position:

*use a tape-measure to describe the distance from a bony point

*some lumps has special sites :

-past auricular dermoid behind ear

-thoracic meningiocele in the back midline

-external angular dermoid lateral of eye brow

3- Colour and texture

(smooth and shiny VS thick and rough)

Colour : -capillary hemangioma > red

-malignant melanoma > black

Texture: -papilloma > filiform

-SCC > cauliflower

Skin : -shiny skin with prominent veins > sarcoma

- Punctum > sebaceous cyst

- Red edematous > inflammation / infection

- Previous scar > recarrant

- Peaudorange > malignant

4- Temperature:

*by dorsal surface of your fingers

Hot >> abscess / cellulitis / sarcoma / vascular

5- Tenderness :

*feel the non tender part fist *watch patient's face

+ >> inflammation / neurofibroma

6- Shape:

*3D (sphere – hemisphere – pear shaped – kidney shaped )

*circle is not 3D .. don't use it !!

7- Surface:

(smooth – irregular – nodular – lobular )

8- Size :

*(length- height-depth) if symmetrical

*use diagram if asymmetrical

9- Edge:

-defined regular > benign

-defined irregular > malignant

-indistinct > inflammatory

-slipping edge >> lipoma

10- Composition:

-solid > cells

-cystic> urine- serum – synovial fluid – extravascular blood

-gas

-intravascular blood

Consistence (hard/rubbery/spongy/soft)

Fluctuation

*feeling at least 2 other areas while pressing on a third

*test done twice "in 2 directions"

*fluid bulge in every other direction / solid doesn't but may bulge in one direction

and this is not considered fluctuation

Fluid thrill

*tapping one side of the lump and feeling the transmitted vibration

*hand in midway if the lump is large

Translucency

*use the point light in dark place

(+) if water/serum/lymph/plasma/highly refractile fat

(-) if blood

Resonance

-dull if solid or fluid / resonant if gas

Pulsatility

*put finger to see if pulsatile

*if pulsatile put 2 fingers one from each hand

-if pushed apart >> expansile pulsation (aneurysm / vascular tumor)

-if pushed upward in the same direction >> transmitted pulsation from nearby artery

Compressibility

*lump disappear with compressing then reforms spontaneously when removing

hand (differ from reducibility)

>> venous vascular malformations

Bruits

-vascular lumps > systolic bruit

-containing bowel > bowel sounds

11- Reducibility :

*compress then ask to cough

-cough impulse >> hernia / some vascular lumps

12- Relations to surrounding structures :

*move the skin above it

*tense the muscle and see if reduced lump mobility so the lump is within or deep to

contracting muscle

lymph nodes

-limbs and trunk > axillary and inguinal LN

-head and neck > cervical LN

-intra-abdominal > pre – para aortic LN

Local circulation

Nerve supply

Abdominal lump

Introduce yourself

Identify the patient name and take consent

wash your hands

Ensure privacy and warm

Appearance of patient

Inspection

1-site

2-size

3-shape

4-surroundings

5-surface

6-edges

7-transillumination

Palpation

1-temperature

2-tenderness

3-consistency

4-mobility

5-pulsatile

6-fluctuation

7-reducibility and compressibility

Examine regional lymph nodes

*Pulsatile: assess with 2 fingers;

-transmitted pulse = when fingers move in the same direction

-expansile = when fingers move away

Percussion: dull vs resonance

Auscultation: bruits

*Site: -single vs multiple -relation to any bony protuberance

*Surroundings: remote surrounds then local

*Surface: -smooth vs rough vs indurated -scars -skin

*Edges: -well defined (neoplasm) -poorly defined (inflammatory)

*Temperature: feel with back of fingers

*Consistency: soft vs firm vs hard

Mobility :

Neck examination

Dear colleagues , according to our syllabus we are supposed to own the skills of physical

examination of the neck including :

1. Cervical lymph nodes..

2. Thyroid examination.

3. Cystic hygroma.

4. Examination of other neck masses.

5. Carotid artery pulsations and carotid body tumor

6. Position of trachea.

** all of the above are covered in this sheet, except for 2 which is discussed separately.

Neck examination :

- introduce yourself.

-gain consent & corporation.

-check privacy.

-make sure that the room is warm.

1- inspection : patient’s neck should hold his head erect & mid-line , with symmetrical muscles

with no swelling or masses.

- observe the carotid artery for visible pulsations.

2- asses the neck active range of motion : by having the patient :

Touch his chin to his chest.

Turn his head to the right and left.

Tip his head to his right and left shoulders.

Tilt his head backward.

- all of these movements should be smooth and painless.

3- assess the spinal accessory nerve : apply resistance to the patient’s shoulders as he shrugs

them , the shoulder muscles should be symmetrical & overcome your resistance.

4- have the patient to turn his head to one side as you applying resistance against the ipsilateral

side of chin.

- note the contraction of the opposite SCM every time , the contraction of both muscles should

be equally strong.

5- palpate for the cervical lymph nodes :

pre-auricular , posterior-auricular , occipital , sub-mental , sub-mandibular , tonsillar ,

superficial cervical , deep cervical chain , posterior cervical , supra clavicular.

- note the size , shape , consistency, movability and tenderness of the nodes.

-be sure to compare one side to another.

If you detect swelling or tenderness ; search for a possible cause.

-Lymph nodes are small , soft . Non tender and movable in normal conditions.

6- identify the trachea by localizing the sternal notch and sliding your fingers to each side of it ;

Trachea should be mid-line and symmetrical.

7-stand in front of the patient , by the fingers of your left hand , push the thyroid gland to the

right , then insert the fingers of your right hand between trachea and SCM muscle, then ask the

patient to extend his neck & swallow ; you should feel the thyroid move up & down as he

swallows.

- palpate the thyroid gland from behind ; place the fingers of both hands on the patent’s neck

with your index just below the cricoid , palpate the both lobes and isthmus.

- instruct the patient to sip & swallow during the examination; look for size , shape and

consistency.

-auscultate for bruits = blowing sound caused by turbulent blood flow.

If you detect any thyroid abnormality ; go through specific thyroid examination..

8- observe carotid artery for visible pulsation

- gently palpate the carotid artery using your index and middle fingers.

-remember to palpate each carotid artery separately in order not block blood flow to the brain.

-DO NOT press hard on carotid sinus which located higher in the neck to avoid vagal stimulation

which slows the heart rate.

-auscultate for bruits which are normally absent.

9-with the patient in the supine position and his head is elevated 30 degrees and by the aid of

light source , jugular vein distention become visible.

-check jugular vein pulsations which are normally not prominent and decrease with inspiration.

While you are examining the neck generally, if you find a swelling (lump) ; you have to go

through lump examination which is discussed in details in the” lump sheet “ ; here we will go

thrugh special consideration about “neck lump” .....

First of all ; most surgical conditions in the neck present as swelling.

””SITE”” determine if the lump is in the anterior or posterior triangle.

-anterior triangle is bounded by anterior border of SCM posteriorly, lower edge of the jaw and

mid-line.

-posterior triangle is bounded by posterior border of SCM anteriorly , anterior edge of trapezius

muscle and clavicle.

- to define the triangles it is necessary to get the patient to tense the neck muscles.

** the SCM muscle is made to contract by putting your hand under the patient’s chin and

asking them to nod their head against the resistance of your hand. This tightens both SCMs.

**the trapezius muscle is made to contract by asking the patient to shrug their shoulders

against resistance.

“”RELATIONS TO MUSCLES””

feel the lumps in the neck with the muscles relaxed then again with them contracted. If the

lump is deep to a muscle , it will become impalpable when the muscle contracts.

“”RELATION TO THE TRACHEA””

Assess the relationship to the trachea of every lump in the neck by watching to see if it moves

with the trachea during swallowing.

“”RELATIN TO THE HYOID BONE””

Ask the patient to open their mouth, when the jaw is still, ask them to protrude their tongue, if

the swelling in the neck moves when the tongue protrudes , it must be fixed to the hyoid bone.

- go through examination of the lump ( size , shape , surface, skin around , etc....)

Cystic hygroma

A cystic hygroma a congenital collection of a lymphatic sacs which contain clear , colorless

lymph.

Examination : you examine the lump as any lump in the neck following the detailed lump

examination in the “lump sheet” , here is the findings:

- found commonly around the base of the neck , usually in the posterior triangle , but they can

be very big an occupy the whole of the subcutaneous tissue of one side of the neck.

-temp. And tenderness ; they are not hot or tender , and the overlying skin is normal.

-shape : lobulated and flattened.

- size : range from few centimeter to the size that occupy one side of the neck.

Composition : soft and dull to percussion.

Brilliant translucence

Large cyst>>fluid thrill

Can be compressed.

Can NOT be reduced.

- relations : cystic hygromata develop in the subcutaneous tissue. Thus they are superficial to

the neck muscles and close to skin but rarely fixed to it. however it is essential to perform a

thorough examination to oropharynx, as a cyst in the posterior triangle may extend deeply

beneath the SCM muscle into the retropharyngeal space.

-local tissue is normal.

-regional lymph gland should not be enlarged ; if they do so ; reconsider the diagnosis.

Carotid body tumor

- site : upper part of the anterior triangle.

-not tender or hot and overlying skin is normal.

-shape : early : spherical , as it grows it becomes irregular.

Composition : solid and hard

**called potato tumors because of consistence an shape

** sometimes pulsate.

**can be compressed.

Relations : the lump is deep to the cervical fascia and beneath the anterior edge of SCM muscle.

**the common carotid artery can be felt below the mass , and the external carotid artery may

pass over its superficial surface. Without this this relationship to the arteries; the tumor is

indistinguishable from an enlarged lymph node.

**because of their intimate relationship with the carotid arteries , these tumors can be moved

from side to side but not up and down.

Thyroid examination

Introduce yourself

Check the patient’s name

Ensure privacy /warm room

Gain consent/Explain what you are going to do

Notice the patient voice Say if it is normal or there is hoarseness(malignancy>> invasion to the recurrent laryngeal nerve)

General inspection -Nervousness/anxiety/lethargy/tiredness/weakness -muscle wasting/general weakness -Under-clothed and sweaty/wearing large number of jumpers but still cold -loss of hair especially the outer two thirds of the eyebrows.

Look at the hand -feel the pulse: tachycardia(>90)>>thyrotoxicosis(and may be the pulse be irregular if there are extrasystoles or atrial fibrillation. Bradycardia(40-60)>>myxoedema -sweaty hand? -fine tremor(ask the patient to hold his/her arm and separate his/her fingers >>>put a paper on both hands)

Examine the eyes -Lid retraction and lid lag: caused by over-activity of the involuntary part of the levator palpebrae superioris muscle the upper eyelid is higher than normal and the lower lid is in its correct position, the patient has lid retraction When the upper lid does not keep pace with the eyeball as it follows a finger moving from above downwards, the patient has lid lag. -Exophthalmos: caused by increase in retro-orbital fat, oedema and cellular infiltration Sclera becomes visible below the lower edge of the iris (the inferior limbus). -Ophthalmoplegia :caused by weakness of the ocular muscles(usually superior and lateral rectus and inferior oblique muscles) -chemosis: is a swelling of the conjunctiva caused by the obstruction of the normal venous and lymphatic drainage of the conjunctiva by the increased retro-orbital pressure.(red eye)

Inspect the neck -Ask the patient to drink water: Thyroid gland attached to the pretracheal fascia so it will move with swallowing. - Ask the patient to protrude his/her tongue: Thyroglossal duct attached to the hyoid bone.

-site/size/shape/colour/relations to surrounding skin /distended vein/

Palpate the neck from the front

- to confirm your visual impression of its size, shape and surface,

and to find out if it is tender.

Check the position of the trachea by feeling with the tip of two

fingers in the suprasternal notch. The trachea should be exactly central at this point.

Palpate the neck from behind the patient

-place your thumbs on the ligamentum nuchae and tilt the

patient’s head slightly forwards to relax the anterior neck muscles. - A small lobe can be made prominent and easier to feel by pressing firmly on the opposite side of the neck. -tenderness/ temperature /site/shape(spherical ,irregular) /size/surface(smooth, nodular) /Edge (clearly defined, indistinct) /consistence (soft, spongy, hard)/ skin attachment - Palpate the whole of the neck for any cervical and supraclavicular lymphadenopathy.

Percussion - to define the lower extent of a swelling that extends below the

suprasternal notch by percussing along the clavicles and over the sternum and upper chest wall.

Auscultation Listen over the swelling. Thyrotoxic and vascular glands and lumps may have a systolic bruit.

Thank the patient

Breast examination

First of all, you must look at the pictures in Browse because this subject is most likely to be in the miniOSCE and

not in the examination station

I advice you to look at the tables present in Browse also because they are short and important and will not take time

Lets start...

In the history after you start with the patient profile and the chief complaint and the history of presenting illness, you

should consider and ask about these things

1- consider the age of the patient

2- ask about the menstrual pattern: menarche, menstruation ( regularity, duration, quantity of bleeding)

number of children and breastfeeding

Menopause

Relation of the lump appearance or the pain to the menstrual cycle (changes during the cycl

e )

3- ask about medications: contraceptives and hormonal therapy ( post menopausal oestrogen )

4- ask about the family history

Examination

- exposure: fully undressed to the waist

- position: the patient lying down on the examination couch and the upper body raised 45° to the legs

There is 3 positions for the hands:

I. beside the patient

II. above the head

III. on the hip bone

As you inspect you ask the patient to put her hands above her head so the skin tethering and puckering and the asy

mmetry becomes more obvious

When the patients put their hands to the hips the pectoralis muscle becomes contracted and tense

Sometimes the patient report that there is a specific position the lump appears in it, then you have to examine it

-Inspection: I will talk about examining the breast in general but if you find a lump you should examine it like any l

ump in any other place and I will write some special notes I read in Browse

Size:

symmetry: if there is minimal difference then this is normal but if there is significant diffe

rence with recent onset it is usually pathological

skin: look for any puckering ( indicates cancer ), oedema ( peaud' orange by obstruction o

f skin lymphatics by cancer ), discoloration, nodules, ulcer

nipples and aereolae: color normally changes with age

darkening during pregnancy, aereola normally corrugated ( montgonery tubercles)

see if the nipple inverted ? slit appearance ? ( duct ectasia)

any fluid leak ? Eczema?

duplication: accessory nipple ( along the mammary line from axilla to groin) , ectopic bre

ast tissue in the anterior axillary fold

look at the axilla, arm, neck, supraclavicular fossa for grossly enlarged lymph nodes or di

stended veins or lymphoedema

- Palpation:

Palpation is done with the flat of the fingers not the flat of the hands because the fingers are more sensitive

Begin always with the normal side and Do not forget the axillary tail

If you find a lump examine it like any other place ( site, size, shape, consistence, edge, tenderness, color, tem

perature, surface,...)

● Relations to the skin: we have 2 terms:

Fixation: cannot be moved without moving skin

Tethering: deeply situated and distorting the ligament of cooper and pulls the skin inwards but remains seperate fro

m the skin ( its like that the lump is tied to the skin by a piece of string, it can move freely and independently of the s

kin within the limits determined by the length of the string but pulls the skin when moved beyond these limits )

● Relations to the muscles

● nipple:

If there is inversion try to evert it by gently squeezing its base or ask the patient to do so

It is normal if the nipple is easily everted

Unilateral inversion is more significant than bilateral

• Discharge: gently press the aereola around the base of the nipple and observe whether any fluid comes from one

or many duct orifices

Character of discharge should be noted

● examine the lymph drainage in the axilla and supraclavicular fossa

● examine the neck

● do general exam ( to check for metastases in the cancer cases )

Ulcer exam

Introduce yourself

Gain consent

Ensure privacy and wear gloves

Ask the patient to lie down

-Inspect : 1. Number

2.Site

3.Size

4.Shape

5.Edges

6.Depth

7.Floor

8.Discharge

9.Skin around it

-Palpate: 1.Base

2.Tenderness

3.Temp.

4.Adhesion to other structures

5.crepitus

-Assess movement of related joints

-Palpate regional lymph nodes

-assess arterial status a-capillary refill

b-pulses

c-temperature

-assess venous status

-assess nervous status and muscle tone a-light touch

b-pin prick

c-vibration

d-proprioception

-test the mobility of the near joints

-Cover the pt. and say thank you

LOCAL examination…

On inspection you should include the following :

1-number of ulcers (single or multiple)

2-size of the ulcer in two dimension

3-site : exact anatomical location of the ulcer:

-right or left leg

-dorsal or plantar

-medial or lateral

-proximal or distal

many ulcers have a characteristic site where they occur :

a-venous ulcer: in the lower medial third of the leg above the medial malleolus

b-arterial ulcer (ischemic ulcer ) :dorsum of the foot and toes

c-neuropathic ulcer: pressure areas (ischemia with no sensation) usually called trophic ulcer

d-rodent ulcer :can be found in the face above the line joining the mouth to the ear lobule

(nose )

4-shape : regular, irregular, circular, oval

5- margin and edge:

-margin is the skin border around the ulcer, it’s the line demarcating the ulcer from the

surrounding skin

-edge is the place where the floor joins the margin of the ulcer (the junction between the

healthy and diseased tissue ) takes characteristic forms with the underlying disease :

a-Sloping edge → healing ulcer

b-Punched edge → trophic ulcer

c-Undermined edge → tuberculous ulcer

d-Everted edge→ malignant ulcer

e-Raised edge → rodent ulcer

**floor is what you see base is what you feel

6-floor of the ulcer : is the exposed surface of the ulcer note the following :

1-granulation tissue: red in color (mainly near the edges)

. 2-dead tissue: necrotic, dark in color.

3-discharge: -type:

serous. Sanguineous. Serosanguinous. Purulent discharge (pus): green (klebsilla), yellow

(staph.aureus)

*a healthy ulcer shows healthy granulation tissue ,no slough and small amount of serous

discharge

7-surrounding skin :if the ulcer is infected the surrounding skin will be red ,hot and edematous

**dark pigmentation and eczema skin is typical of varicose ulcer

**multiple scars and puckering of skin around the neck are suggestive of tuberculous ulcer

**Hypopigmentation → non-healing ulcer

** Large scar→ Marjolin’s ulcer (ulcer in large scar (burn)

palpation:

1-surrounding skin for temperature(with the dorsum of the hand) and tenderness

-tenderness suggest inflammation

2-over the edge and floor of the ulcer :

-Soft: healing ulcer

-Firm: non-healing ulcer

- Hard: malignant ulcer

3-over the granulation tissue and note whether it bleeds or not

*Healthy granulation tissue may show pinpoint hemorrhagic spots, while malignant ulcer may

bleed profusely

4-the base :the tissue at which the ulcer rests.

-palpate to know the consistency and to know the underlying structure (muscle or fascia…etc)

5- test the adhesion to the structures in the base of the ulcer

FOCAL examination…

*examination of regional lymph nodes depends on the site of the ulcer

-e.g. popliteal , femoral and inguinal lymph node if in the lower limb

-Hard, discrete, non-tender → malignant ulcer

-Soft, tender → infective

-Non-tender, matted(tangled in mass like) → tuberculous ulcer

*in arterial feel the pulses related on both sides to rule out vascular disease and measure the

capillary refill time, also check the temperature on the surrounding skin :

1-dorsal pedis :lateral to extensor hallucis longus between 1st and 2nd metatarsals on navicular

bone

2-posterior tibial : 2cm below and posterior to the medial malleolus between flexor digitoru

longus and flexor hallucis longus

3-popliteal :posterior to knee joint deep in the popliteal fossa not easily palpable, if it’s then

think of popliteal aneurysm

4-femoral : 1cm below the inguinal ligament between vein and nerve (VAN)

If the ulcer is situated in the leg ask the patient to stand and look for VARICOSE veins associated

with venous ulcer

Then test the sensation in this skin surrounding the ulcer by sharp pin to have an idea about the

sensations

if the sensations are diminished particularly in weight bearing area ulcer (trophic) you have to

do detailed neurological exam.

INVESTIGATIONS:

1-fasting B.S. and random B.S.

2-urine analysis

3-CBC

4-plain X-ray

5- swap for culture.

6-Biobsy for malignancy. It is taken from the edge of the ulcer.

7-arterio and angiogram.

Differential diagnosis :

1-ischemic ulcer

2-venous ulcer

3-traumatic ulcer

4-neoplastic (BCC, SCC)

5-trophic (neuropathic)

5-infectious(tb…)

COMPLICATIONS OF ULCERS:

1-keloid: hypertrophic persistence scar

2-hypertrophic scar

3-hyper- or hypo – pigmentation

4- chronic benign ulcer SCC

Diabetic ulcer exam :

Introduce yourself

gain consent

explain exam

ensure good exposure

--Inspect

Colour – pallor / cyanosis /erythema

Skin – dry / eczema / shiny / hair loss / haemosidrin staining

Ulcers – inspect between toes & behind legs

Deformities in the joints – Charcot’s joints

--Palpate

Temperature across the two legs – cool / hot

Pulses – dorsalis pedis / posterior tibial\popliteal

Capillary refill – normal = < 2 seconds

Soft touch sensation – use cotton– assess lower limb dermatomes (compare L/R)

Pain sensation(sharp and dull) assess lower limb dermatomes (compare L/R)

Vibration sensation

1. Ask patient to close their eyes

2. Tap a 128hz tuning fork

3. Place onto patients sternum & confirm patient can feel it buzzing

4. Ask patient to tell you when they can feel it on their foot & to tell you when it stops buzzing

5. Place onto the distal phalanx of the great toe

6. If sensation is impaired, continue to assess more proximally – e.g. proximal phalanx etc

Monofilaments:

1. Ask the patient to close their eyes & inform you when they feel their foot being touched

2. Place the monofilament on 5 areas across each sole

3. Press firmly so that the filament bends

4. Hold the monofilament against the skin for 1-2 seconds

Proprioception

1. Hold distal phalanx of the great toe by its sides

2. Demonstrate movement of the toe “upwards” & “downwards” to the patient (whilst they

watch)

3. Then ask patient to close their eyes & state if you are moving the toe up or down

4. If the patient is unable to correctly identify direction of movement, move to a more proximal

joint

Ankle jerk reflex

1. Dorsiflex the foot

2. Tap tendon hammer over the achilles tendon

3. Observe the calf muscle (posterior leg) for contraction – normal reflex

Ankle jerk reflex may be absent in advanced peripheral neuropathy

-assess the gait : make the patient walk in front of you to observe the symmetry and gait

References:

Check the Indian guy video

also see this video for diabetic ulcer exam: http://www.youtube.com/watch?v=p20gAwHNKgU

and refer to browse 4th edition-page 32

Lower Limbs examination

Introduce yourself

Take Consent

Check Privacy Make sure that room is warm

Examination of Arterial circulation

1.color : *purple-blue skin : excessive deoxygenation of the blood in skin capillaries. But blue fades to white within few sec when pt. lies down *Blue streaks around white patches : ischemic leg. When cyanosed become fixed its an irreversible ischemia *Blue/Black : gangrene "start in toes"

1.inspection

2.Skin changes

*scar/striea *rashes/hypo or hyper pigmentation

*bruising *superficial veins *scaling *callosities "raised" : piece of skin become thickened as a result of repeated contact and friction Corn "depressed. Hyperkeratosis

3. Toes :

*polydactyly : supernumerary toes *oligodactyly : less than 5 toes

*amputation : describe the site *note nail thickening

4. Lumps and swelling

5. muscle wasting "pulps of toes"

6.pressure area : "ulcer"

bottom , back , lateral aspect of heel ball of the foot skin over malleoli : venous ulcer "most in medial malleolus base of 5th metatarsal head tips of toes : arterial ulcer between toes Describe ulcer Pressure necrosis : thickening of skin purple or blue discoloration blistering ulcer , black patches gangrene

7. Hair distribution

براوز حاكي انو ما بتدل عاشي بس بمصادر اخرى مذكورة ischemiaانو مهمة بال

8.vascular angle "Burger's angle": angle to which the leg has to be raised before become white.

*Normally: toes stay pink even when raise it to 90 degree *Ischemia : raise it 15 or 30 degree for 30-60 sec cause pallor *severe ischemia : if angle < 20 degree

9. Capillary filling time : ask pt. to sit and dangle his leg after elevating"يدلّي"

*normally : remain healthy pink *ischemic : from whit "after elevating" pink purple *15-30 sec. it’s a severe ischemia

10.Venous filling : in a warm room :

*normally : dilated filled with blood veins

*ischemic : Collapse and sink veins below the skin surface look like "blue-gutter. Called "guttering of the veins"

1.Temperature :

* you have to expose both limbs for 5 min. to allow the skin temp. to adjust to the temp. of the surrounding air. *assess temp. by backs of the fingers *assess whole limbs compare distal vs. proximal compare Rt. Vs. Lt.

2.Palpation

2.Capillary refilling : press on the tip of a nail or the pulp of the toe for 2 sec then observe then observe the the time taken for blenched area to turn pink after u have stopped pressing ."normally 2 sec"

3.feel all pulses :

A. Femoral pulse : mid-inguinal point "in groin region halfway between symphysis pubis and SIS B. Dorsalis Pedis : lateral to flexor hallucis longus "mid-way between malleoli towards cleft between first and sec. metatarsals bone. C.Posterior tibial artery : 1/3 of way between medial malleolus and tip of heel , easier to feel 2.5cm higher up just behind medial malleolus D. Popliteal pulse : 1. Most convenient by extend pt. knee your thump in tibial tuberosity and tips of your fingers behind knee 2. Flexing the knee 135 degree to loose the deep fascia 3. check artery course when pt. in prone position

*palpable and normal = +2 *palpable and weak = +1 *not palpable = 0

Measure Ankle : Brachial pressure index

It’s a ratio of systolic B.P in ankle to systolic B.P in Brachial . Normally : 1.0-1.3 There is vascular disease if its less or more than normal

Listen along artery course especially if its weak *

*You have to auscultate groin + thigh

: in the medial ctor canal addu*listen over aspect of the middle third of the thigh

Measure B.P in both arms to exclude significant subclavian or innominate artery disease

*Bruits are cause by turbulent flow beyond a stenosis or an irregularity in artery wall "by bell and don’t press too hard over superficial artery. Bruits may change in volume and character if there are change in blood flow

3.Auscultation

Examination Of Venous Circulation

Pt. should be standing erect on a low stool in a warm room

You have to examine patient from all sites "in front , lateral, Behind" *visible , dilated and tortuous veins varicose veins : a. large and prominent b. minute and intradermal " cause blue

1.Inspection

patch" intradermal veins called : spider veins or venous stars slightly larger intermediate veins called: reticular veins

large prominent distended veins in the medial side of the lower calf called blow outs small dilated venules beneath the lateral and/or medial malleolus of limb with severe venous HTN is called ankle flare or a corona phlebectactica. distended veins crossing the groins and extending up over abdominal wall are collateral veins and indicate deep venous obstruction. cross-pubic collateral veins may be visible if one iliac system is obstructed. *Blue-tinged bulge in groin disappears when lying down saphena varix

2.ankle edema

3. skin pigmentation and ulceration 4. color 5.tenderness and subcutaneous induration called "lipodermatosclerosis" 6.eczema 7. Ulcer

1.Palpate great saphenous vein : from dorsal venous arch pass anterior to the medial malleolus enter medial side of the leg before passing medial epicondyle of femur entering thigh and start to merge to anterior aspect of the thigh then enter fascia lata

2. palpate short saphenous vein : lateral aspect of the foot inferior and posterior to lateral malleolus runs along posterior aspect of the leg pass between heads of gastrocnemius muscle.

2.palpation

3.palpate saphena-femoral junction : 2.5 cm below and lateral to the pubic tubercle 4.palpate sapheno-popliteal junction which variable termination in popliteal fossa.

2. ask pt. to cough while dilated veins are palpated to see if there is impulse thrill "cough impulse" indicate incompetent valve between deep veins and superficial one so back flow is turbulent

3.palpate skin for tenderness and induration "lipodermoatosclerosis"

4.palpate medial side of calf muscles for deficit in deep fascia which may sie of incompetent calf communicating "perforating" veins.

Normally : long and short saphenous vein transmit a percussion wave in an orthograde direction whether the valve competent or not

Percuss the dilated veins for wave conduction

*if wave more down ward "retrograde" while pt. is standing its incompetent valve

3.percussion

Listen over any large clusters of veins especially if they remain distended when pt. lies down and limb elevated .

A Mechinery mumur over such veins aterio-venous fistula

4. Auscultation

1.elevate the leg of pt. while he lying down on the bed and empty the veins

2. tie the tourniquet tube on the saoheno-femoral junction and ask the pt. to stand for 10-15 sec.

*if the sapheno-femoral junction is incompetent the veins above the tourniquet

5.Torniquet Tests

will dilate and veins below it will be collapsed after removal of it veins below it rapidly fill.

If Not 3. Apply it below the knee "on calf perforating" *Trendelenburg test : apply your fingers instead of tourniquet *if varicose veins fail to collapse on elevation suspect :venous HTN caused by proximal vein obstruction or presence of aterio-venous fistula

*To confirm it do "Perths walking test" : place tourniquet below knee ask the pt. to stand repeatedly on tiptoe and relax.

In normal limb this exercise will empty the superfacial veins bu sucking the blood in the surface of varicosities into deep veins through competent perforating veins and pump it through popliteal vein to heart.

Failure to achieve empting indicates : A .deep vein obstruction or b .reflux through incompetent valves in the deep or communicating veins.

*Doppler flow detector

6. General Examination

nerves testMuscles and

1.Light Touch : by using wisp of cotton wool "while pt looks away"

1.sensation

2.superfacial pain : use fresh neurological pin 3. Temp. : touch pt. with cold metallic object 4.vibration : by tuning fork 5.propioception "joint position sensation" 6. points discrimination

Ask pt. to relax then roll the leg from side to side see if there is any resistance to movement

2. Muscle Tone

1.hip extension and flexion abduction and adduction

2. knee extension and flexion abduction and adduction 3. ankle dorsiflexion and ankle planter flexion 4.great toe extension "dorsiflexion" 5.ankle eversion 6. ankle inversion

3. Muscle power

1.Deep Reflux: A.elecit knee jerk by tap quadriceps tendon below patella while hanging pt. leg with other hand B .Ankle jerk : tapping while foot dorsi-flexed and knee flexed and leg slightly laterally rotated it should jerk toward its planter reflex

2.Superfacial Reflex : Planter response : pt. lying down leg extended , by blunt point run from lateral aspect of foot start at heel moving toward the big toe . should move downward normally

4.reflexes

Measure the diameter of each leg

Male external genitalia examination

Introduce yourself / check the patient's name / Gain consent / Ensure privacy / Explain what you are going to

do.

Have a warm, well-lit room with a movable light source .

Apply alcohol gel and put on gloves .

Ask the patient to stand and expose the area from his lower abdomen to the top of his thighs .

Inspection

1) look in turn at the groin , skin creases , perineum

and scrotal symmetry ,and also skin of scrotum for

redness , swellings or ulcers .

2) note hair distribution

Patients who shave their pubic hair may have

dermatitis or folliculitis.

3) look at the shaft of penis and check the position of

the urethral opening .

To exclude hypospadias

Palpation

1) palpate the shaft of penis for fibrous capsule or

abnormal curvature

A hard plaque of peyronie's may occur on the

shaft .

2) retract the prepuce and inspect the glans for red

patches or vesicles

( always draw the foreskin forward after

examination to void paraphimosis )

Phimosis ,adhesions, inflammation or swelling

may occur on the foreskin or glans .

3) Check for any obvious discharge suggestive of urethritis.

4) palpate the scrotum gently using both hands

- check that both testes are present .

If they are NOT , examine the inguinal canal and

perineum , checking for ectopic testes .

5) place the fingers of both your hands behind

testes to immobilize it and use your index finger

and thumb to palpate the body of the testes .

-feel the anterior and medial border with your

thumb and lateral border with your index finger .

-check postion , size and consistency of the

testes , note any nodule or irregularities ,

compare between the size of both testes .

6) palpate spermatic cord with your right hand by

gently pulling the testes downward and place your

finger behind the neck of the scrotum .

7) decide whether a swelling arises in the scrotum

or from inguinal canal .

8) Examine at the base of the scrotum for any skin

abnormalities (e.g. pigmented areas, ulcers,

vesicles etc.)

Don’t forget to do transillumination test

And examine the hernia orifices and surrounding

lymph nodes

If you can feel above the swelling , it originates

from the scrotum , if you can't , the swelling

usually originates in the inguinal region .

To examine prostate -perform a rectal examination .

-palpate the prostate anteriorly through the

rectal wall.

- Note any tenderness and assess the

consistency .

-feel for any nodule

Sources :

Macleod's – page 236/237

Great video : http://www.youtube.com/watch?v=jMHsbgsJ-1g

http://gemp-

rsc.health.wits.ac.za/resources/pdf/EXAMINATION_OF_THE_MALE_EXTERNAL_GENITALIA

Female external genitalia examination

Introduce yourself / check the patient's name / Gain consent / Ensure privacy / Explain what you are going to

do

Prepare for examination:

Position the patient with help of a chaperone on to the couch (supine, flexed hips and knees with heels

together, thighs abducted).

Cover the patient's abdomen with a sheet.

Position lighting to give a clear view of external genitalia.

Put on disposable gloves.

Inspection

1) perineum for any deficiency associated with childbirth

2) hair distribution and cliteromegaly

3) skin abnormalities

- Rashes-ulcerations-swellings-lesion

4) look for discharge

-bloody

-purulent

5) Tell pt. to bear down: look for prolapse (cystocele, rectocele).

6) Tell pt. to cough (stess incontinence).

Palpation :

-Separate labia with forefinger and thumb, examine clitoris.

- Palpate Bartholin's glands [posterior of labia major] (palpable = Bartholin cyst/ abcess).

THE FEMALE EXTERNAL GENITALIA Most complaints about the external genitalia are referred to gynaecologists and are described in

detail in their textbooks, but there are three common conditions that quite often appear in a general

surgical clinic.

Bartholin cyst

When the duct of a gland is distended by obstruction or infection, it forms a cystic

swelling in the posterior part of the labium majus.The site betrays the diagnosis

Urethral caruncle This is a bright-red, polypoid granuloma that arises from the mucosa of the urethral orifice in postmenopausal women. It is

very tender and causes painful micturition, dyspareunia and occasional

bleeding.The differential diagnosis is urethral prolapse,which is purple in colour and not so tender

Carcinoma of the vulva Carcinoma of the vulva usually takes the form of achronic ulcer with an everted edge.

The patient complains of pain, a purulent or bloody discharge and sometimes of a lump in the

labia. Very small carcinomata can metastasize early and present with enlargement of the inguinal

glands. The primary ulcer can be small and hidden in the folds of the labia.There will usually be evidence of pre-malignant

changes in the surrounding skin (vulval intraepithelial neoplasia) sources : Browse pages – 357/358 Macleods – 223

Stoma examination

Classification

1- Temporary or permanent

2- End, Loop, double barrel

3- Ileostomy or colostomy

Ileostomy Colostomy

Site Right side Left side

Shape Spouted Flush

Color Red Pink

Content Small bowel content Stool

Output High output 9>500cc), continuous Low output, intermittent

More - Skin irritation - Fluid & electrolyte disturbances - Renal failure

- gas

Complication of stoma

- Early

a- Ischemia

b- Retraction

- Late

a- Bleeding

b- Leakage

c- Skin irritation, infection

d- Bowel prolapsed

e- Diversion colitis

f- Obstruction

1- Stricture (mostly)

2- Stool

3- Stenosis

g- Psychological effect

Indication of stoma

- Input

a- Feeding (percutaneous gastrostomy)

b- Lavage (appendicostomy)

- Output

a- Diversion: to protect distal anastomoses

b- Decompression

c- Exteriorization: permenant stoma, urinary diversion

Site of stoma:

- At least 5 cm from umbilicus

- Away from scars or skin creases

- Away from bony prominences, clothing,

- Easily accessible to patient

- Must be within rectus sheath

Stoma examination

- Inspection

a- Stoma

1- Location

2- Type

3- Sputed of flesh

4- Color of mucosa

5- Output of content, blood and mucus, sign of infection

6- Number of openings

7- Content of stoma bag

8- Prolapsed, retraction, necrotic tissues, discharge, wound breakdown

b- Skin around the stoma

1- Scars, irritation, blood, skin changes

2- Ask to cough (parastomal hernia)

c- Inspect the whole abdomen

- Palpation

a- 1st palpate the whole abdomen

b- Skin around the stoma, ask to cough (henia?)

c- Put finger inside the stoma

d- Do a DRE

- Percussion & Auscultation of the abdomen

Incisions

1. Kocher: Biliary or hepatic

procedures. May

be extended across to a left subcostal

incision

to give useful access to the stomach

and

pancreas.

2. Midline : General access. Usually

skirts the

umbilicus. Quick and bloodless.

3. McBurney :Appendicectomy.

Muscle layers

are split, rather than cut.

4. Battle :Appendicectomy. No longer

used

because it produces an ugly scar and

sometimes

incisional hernia. Often seen in older

patients

therefore.

5. Lanz :Appendicectomy. A better

cosmetic

result than McBurney

6. Paramedian : General access. Left

or right

according to requirements.

7. Transverse : General access.

Almost always

used in infants, and often in adults.

8. Rutherford Morison Access to

sigmoid colon

and pelvis, particularly if the midline

is very

scarred from previous surgery.

9. suprapubic: caserian section Access

to

bladder, uterus, Fallopian tubes and

ovaries.

Good cosmetic result but gives no

access outside the pelvis

Drains-Surgical

Drains: is a tube used to remove pus , blood or fluid from the wound.

Types of surgical drain :

1- Open drains : including corrugated rubber or plastic sheet which drain fluid in to a gauze pad or in to stoma bag ( high risk of infection ) .

2- Closed drains : formed by tube drain in to bag or bottle (low risk of infection ), this type can be divide in to : a- active drain: maintained under suction (which may be low or high pressure).

b- Passive drains: have no suction and work according to the differential pressure between body cavities and the exterior.

USE OF DRAINS:

Drains are used both prophylactically and therapeutically.

The most common use is prophylactic after surgery to prevent the accumulation of fluid (eg, blood, pus) or air. In any surgery in which a dead

space (eg, a cavity) is created, the body has a natural tendency to fill this space with fluid or air.

Complication of the Drains:

-poor drain placement

-infection

- discomfort (Pain)

-inefficient drainage ( by obstruction or the diameter of drian to small to remove viscous fluid)

-breakdown of anastomotic site.

-erosion into hollow organ

-premature removal (accumulation of fluid)

-Decreased mobility ( cause DVT / increase hospital stay)

***In all drain when we need to examine it we should remember five things:

1- Site of drain (abdominal , chest, nose….. ect) 2- Type of drain ( open or closed) 3- If it is active or passive 4- Content and the amount

a- Serous Fluid: is typically pale yellow and transparent b- Pus : typically white-yellow c- Blood

5- If it is work or not ( functioning or nonfunctioning )

A- Open drain: 1- Penrose drain: used to removes fluid from a wound area

*Advantages

a. Help obliterate dead space

b. Soft / malleable – less painful

* Disadvantages

c. Very irritating

d. Allow bacterial ingress

e. Cannot be connected to suction

f. Gravity dependent

2- Corrugate: Multi channel drainage system for efficient drainage during operation .

3- Gauze : just for suction

b- closed drain:

lateral border passive drain under water seal , inserted in chest tube:-1

of pectorals major, a horizontal line inferior to the axilla, the anterior border

More [12]of latissimus dorsi and a horizontal line superior to the nipple.

5th intercostal space slightly specifically, the tube is inserted into the

. anterior to the mid axillary line When a chest tube is inserted for whatever reason, maintaining patency is critical to avoid complications.

Manual manipulation, often called milking, stripping, fan folding, or tapping,

of chest tubes is commonly performed to clear chest tube obstructions. (it

placed over the rib to prevent vessels and nerve injry.

Indications:

Pneumothorax: accumulation of air or gas in the pleural space.

Pleural effusion: accumulation of fluid in the pleural space

Empyema: a pyogenic infection of the pleural space

Hemothorax: accumulation of blood in the pleural space

Hydrothorax: accumulation of serous fluid in the pleural space

Postoperative: for example, thoracotomy, oesophagectomy, cardiac surgery

Complication of chest tube:

Major insertion complications include: hemorrhage, infection, and

reexpansion pulmonary edema. Injury to the liver, spleen or diaphragm is possible if the

tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta and heart can

also occur.[6]

Minor complications include: a subcutaneous hematoma or seroma, anxiety, shortness

of breath (dyspnea), and cough (after removing large volume of fluid). In most cases,

the chest tube related pain goes away after the chest tube is removed, however, chronic

pain related to chest tube induced scarring of the intercostal space is not uncommon.

The most frequent complication associated with chest tubes is chest tube clogging, which is commonly caused by thrombus formation inside the chest tube, and can cause major subsequent complications

2-Nasogastric tube : insertion of a plastic tube (nasogastric tube or NG tube) through the nose, past the throat, and down into the stomach.

Complication: Minor complications include nose bleeds, sinusitis, and a sore throat.

Sometimes more significant complications occur including erosion of the nose where

the tube is anchored, esophageal perforation, pulmonary aspiration, a collapsed lung,

or intracranial placement of the tube.

If the NG tube's output appears to be excessive, consider the possibility that it may have

been placed in the duodenum.

is a flexible tube that is often passed through : Foleys catheter-3

.bladder and into the urethra the

The tube of a Foley catheter has two separated channels, running

ends, and down its length. One lumen is open at both

to drain out into a collection bag. The other lumen has urine allows

at the tip; the oonball a valve on the outside end and connects to a

when it lies inside the bladder, water balloon is inflated with sterile

in order to stop it from slipping out. Foley catheters are commonly

.natural rubber or silicone rubber made from

Indication:

On comatose patients

On some incontinent patients

On patients whose prostate is enlarged to the point that urine flow from the bladder is cut off.

The catheter is kept in until the problem is resolved.

On patients with acute urinary retention.

Following urethral surgeries

Following ureterectomy

On patients with kidney disease whose urine output must be constantly and accurately

measured

Before and after cesarean sections

Before and after hysterectomies

On patients who had genital injury

Post-operative evaluation

1- * Ask the patient profile *Ask the patient about the surgery *Look if there are any operative notes

*Name, Age *Type, Date *Anesthesia, Findings, Drains, Closure, …etc

2- General status of the patient ; *Ask about: *Vital signs:

(Fever, Constipation, Diarrhea, Pain, Nausea, Vomiting, SOB, Confusion, Oliguria, Anuria, Collapse). (HR, BP, RR, Temp.)

3- History 1-New or unexpected pain especially; a.In legs or chest (ThromboEmbolism). b.Increasing pain at the site of the wound. 2-Breathing (SOB, Cough, Hemoptysis). 3-Eating (Appetite, Nausea, Vomiting, Hematemesis). 4-Bowel (Passage of flatus, Motions, Bleeding per rectum, Melena). 5-Urination.

4- Physical examination *Vital signs *Ex.

*(HR, BP, RR, Temp., Wt, Ht) 1-Chest (Check for signs of infection, collapse & edema). 2-Wound(Check for presence of discharge, granulation tissue, for developing localized tenderness around it). 3-Bowel sounds(After abdominal surgery). Legs(Check for localized tenderness over soleal muscles). 4-Mental status(GCS).

5- Fluid balance *Ex. Fluid charts. *Check for input (oral, Iv,…) & output (NGT, Urine, Drains, Insensible loss). *NORMALLY, Is the patient in (+)ive or (-)ive balance.

6- Drugs Check for unnecessary drugs that can be stopped or any drugs that need to be added

7- Dressings Look for their colour if there is any (pus, blood, ..), and see if a new dressind id required

*NOTES::

What is a wound infection?

A wound infection is when bacteria enter a break in the skin.

What increases my risk for a wound infection?

Diseases such as diabetes, cancer, or liver, kidney or lung conditions slow healing.

Foreign objects such as glass or metal can get stuck in the wound and delay healing.

Poor blood supply to the wound increases your risk for infection. Blood flow may be decreased by high blood pressure, and blocked or narrowed blood vessels. The risk also increases if patient smoke, or have blood vessel problems or a heart condition.

Repeated trauma to a healing wound may increase risk for an infection, and delay healing.

A weak immune system caused by radiation, poor nutrition, or certain medicines increases your risk for an infection.

What are the signs and symptoms of a wound infection?

Redness or excessive swelling in the wound area Throbbing pain or tenderness in the wound area Red streaks in the skin around the wound or progressing away from the wound Pus or watery discharge collected beneath the skin or draining from the wound Tender lumps or swelling in your armpit, groin or neck Foul odor from the wound Generalized chills or fever

8- Drains & Tubes *Position of IV line, Drains and their types. *Presence of urine catheter. *Are the all draining well? *Can any of them be removed? *Have they became infected?

9- Investigations Ask for any tests which may be necessary (CBC, LFT, KFT, Serum Ca. and tumour markers, etc)

How is a wound infection diagnosed:

Blood tests may be done to check for infection.

X-rays may be done to look for broken bones, other injuries, or objects stuck in the skin.

A CT or MRI scan may be used to take pictures of the bones and tissues in wound area. They may be done to look for infection or other problems such as a foreign object in your wound.

A wound culture is a test of fluid or tissue used to find the

Wound infection treatment;

Wound cleaning The wound may be rinsed with sterile water. Germ-killing solutions may also be used. Objects, dirt, or dead tissue from the wound will be removed with debridement (surgical cleaning). Wet bandages may be placed inside the wound and left to dry. Other wet or dry dressings may also be used.

Antibiotics help fight or prevent an infection caused by bacteria.

NSAIDs help decrease swelling and pain or fever.

http://www.ncbi.nlm.nih.gov/pmc/articles/P

MC1360405/

http://emedicine.medscape.com/article/188

988-treatment

this checklist is for abdominal examination from Prof. Kamal BaniHani notes !

Introduce yourself

Gain consent

explain procedure and ensure good exposure(nipples to midthigh)

Inspect :

-from the foot :

1-abdominal contour (scaphoid,flat,distended)

2-umbilicus (inverted\everted-central)

3-movement with respiration

4-symmetry of the abdomen

-from the right side of the patient :

1-any skin lesion(warts,molds,erythema,scars,stria)

2-hair distribution

3-dilated veins (caput medusa,peripheral veins dilation)

4-look at epigastric region(any pulsations,bulges..)

5-comment on peristalsis (normally not present if present think of obstruction)

6-grey turner\cullen’s signs

7-inspect for hernia’s(with cough) (groin,umbilicus,epigastric,scars)

palpate:

b4 u start make sure your hands are warm

1-superficial palpation:for:

a-superficial masses

b-superficial tenderness

c-muscle tone

2-deep palpation :

a-deep masses

b-deep tenderness

3-organomegaly

liver,spleen,kidneys

-normally, the lower edge of the liver is palpable.

-in liver if palpable describe- Size, Edge , Surface, Tenderness and Consistency.

-differences between kidney and spleen : “

-spleen moves with respiration,it has notch,spleen isn’t ballotable,we can go above kidney if enlarged

Examine hernia’s : put your hand on orifices and epigastric region,umbilicus and ask the pt. to cough

looking for palpable cough impulse

*** if you find a mass during the examination proceed to abdominal lump exam!

Percuss:

to determine liver span : 2nd intercostals space tympanic till it changes to dull then percuss till it changes

to tympanic

Examination of ascites(shifting dullness,transmitted thrill)

Auscultate :

1-bowel sounds

2-renal artery bruit

Never forget

1- Digital rectal exam

2-examination of hernia’s

Introduce yourself

• Wash hands

• Chaperone

• Standing up

• Undressed from waist down

• Look for any visible lumps

• Any scars, overlying skin changes.

• The lump extends into the scrotum

• Observation of the groin area

Examine as a mass (site,skin,size,shape,…)

The most important things:

1. Can you get above it?

2. Reducibility test

3. Expansile Cough Impulse;

4. Three finger test Zieman’s technique

5. Ring occlusion test

Also Asses

• Intra or extra abdominal Tension

• Composition

• Percussion and auscultation; Bowel Sounds

• Always examine both groins

• Transillumination

3-external genitalia