A Key to Surgical Methods!

(This is only a revision key & not a substitute for the books.) Before starting any exam, always proceed to the following points: Introduction & Greetings Take consent Ask for privacy / female attendant in case of male examiners Positioning of the patient Proper exposure Dont forget to thank the patient after completion of the exam.

A) SWELLING
S Start - History W Where - Site, lies in which structures, mobility E External Features L Lymph Nodes - Enlarged or not palpable L Liquid - Fluctuation, trans-illumination I Internal Features - Hard, tender N Noise - Thrill, bruit G General Appearance of the patient

B) ULCER
1. Site, size, shape - for exact, trace on a sterile transparent plastic 2. Base - Solid brown or grey dead tissue > dead skin
- Yellow grey wash leather slough > syphilitic ulcer - Bluish unhealthy granulation tissue > TB ulcers - Poor granulation tissue, bare underlying structures > ischemic 3. Edge - Flat gently sloping edge > venous ulcers - Square cut or punched out > trophic, syphilitic ulcer - Undermined edges > TB ulcers - Rolled edges > BCC - Everted edges > SCC

4. Depth 5. Discharge - Ask permission from examiner to remove it 6. Underlying Structures 7. Lymph nodes exam

KHIZZER KHAN

Page 1

8. Local blood supply & adjacent skin innervation 9. General physical exam of the patient

C) THYROID
1. INSPECTION Ask the patient to take a sip of water (dont ask the patient to
swallow the saliva) & then protrude the tongue out. From front & side, look for: - Movement with swallowing & tongue protrusion - Retero-sternal extent - Skin changes, prominent vessels, scar marks - Nodules > symmetry, size, shape, extent (from side) - Pemberton sign 2. PALPATION First, ask the patient for any tenderness. From front: - Palpate one side by pressing other. - Measure (in cm) the 3D size of the swellings. - Palpate trachea (3 finger method) - Berrys Sign From back, flex the neck a little to relax muscles, and then feel for: - Movement with swallowing - Retero-sternal extent - Turn the neck to one side & palpate the other side - Lymph node palpation - Kockers sign - Pinch skin to check its mobility over the swelling - Check for bone mets in spine > press gently over the spine & ask for any pain. 3. PERCUSSION From front, percuss along the clavicles (a finger above & below the clavicle with direct percussion over the bone) & then 3 fingers over the upper part of sternum & chest wall.

4. AUSCULTATION WITH BELL, listen for any bruit at the upper poles of thyroid. Examination of thyroid also includes the following: 1. HANDS Ask the patient extend hands straight forwards with fingers spread &
look for: - Tremors (place a paper if not sure) Press down the upper part of arm to check for: - Proximal myopathy Feel the pulse for: - Rate / Rhythm

2. EYES Ask the patient to follow your finger in H shape & also move it
KHIZZER KHAN Page 2

vertically to check for eye movements - Von Griffes Sign > Lid lag - Stillvacks Sign > Lid retraction (Both of the above are due to over-activity of smooth muscle part of levator pelpebrae superioris muscle) - Geoffres Sign > Loss of wrinkling while looking up - Mobius Sign > Loss of accommodation (Both of the above are due to exophthalmos) - Exophthalmos due to retero-orbital fat, edema cellular infiltration - Ophthalmoplegia due to edema & cellular infiltration of muscles & nerves, patient especially cannot look up & out - Chemosis due to impaired venous & lymphatic drainage

3. CVS SYSTEM 4. RESPIRATORY SYSTEM 5. EDEMA & SKIN CHANGES 6. GPE Look for:
- Cyanosis - Mental retardation - Voice changes

D) HEMORRHOIDS
1. Inspection While the patient is in left lateral position, look for:
- Any sinus - Skin tags - Visible fissure - Scar Marks - Visible hemorrhoids

2. Digital per Rectal Exam 3. Proctoscopy

E) CIRCULATION (Lower Limb)

1. INSPECTION Ask the patient to raise the leg & look for:
- Pain - Paresis - Paraplegia Look for: KHIZZER KHAN Page 3

- Color - Swelling - Skin Changes (Ulcers, Abscesses, Gangrene) - Buergers Angle > Compare on both sides - Capillary filling time - Venous Filling - Pressure Areas

2. PALPATION - Ask for tenderness

- Temperature - Capillary refilling - Pulses > Repeat after exercise

3. AUSCULTATION With bell 4. Check muscles & nerves for ischemia

F) BREAST
Position the patient to 45o Take consent Ask for privacy / proper exposure / female attendant in case of male examiners

1. INSPECTION Always look at the normal breast first

- Symmetry - Swellings - Skin changes - Number - Discharge - Axillae - Supra-clavicular fossae - Limb Swelling - Visible veins Ask the patient to raise the hands & then look for: - Skin changes - Swellings - Symmetry Repeat the above observations while asking the patient to firmly placing the hands against the hips. 2. PALPATION - Ask for tenderness - Feel for tenderness - Feel for any lump (with flat of fingers & not palm) - Check axillary tail KHIZZER KHAN Page 4

- Inspect the under surface of breast by raising with the dorsum of your hand - Palpate the lymph nodes > dont miss the supraclavicular & axillary lymph nodes. If you find a lump in breast, check for: - Mobility > in atleast two directions - Size - Skin fixity - Fluctuation - Trans-illumination - Slip sign > for fibro-adenoma Ask the patient to press the areolae or yourself press them from all four directions to look for: - Any discharge Ask the patient to firmly press the hands against the hips. - Check for mobility Repeat the above observations while asking the patient to extend the hands forwards to fix the serratus muscle. Ask the patient to sit & then from the back, check: - Lymph nodes - Bone tenderness

3. ABDOMEN PALPATION 4. CHEST AUSCULTATION 5. Always look for TESTICULAR ABNORMALITY in case of males.
Causes of Gynaecomastia: - Infants > Maternal Oestrogens - Adolescents > Temporary hormonal imbalance Testicular atrophy Hormone secreting testicular tumors Klinefelter Syndrome Pituitary imbalance - Middle aged > Idiopathic, Traumatic - Elderly > Drugs (Digoxin, INH, Spironolactone, Cimetidine, Oestrogens) Cirrhosis Bronchial CA Carcinoid tumors

G) LYMPHEDEMA
1. INSPECTION Look for:
- Site KHIZZER KHAN Page 5

- Size - Shape - Extent - Demarcation - Color - Other areas - Skin Changes (Ulcers, Abscesses, Gangrene) - Squaring of toes 2. PALPATION - Ask for tenderness - Temperature - Stemmers sign - Lymph nodes

3. AUSCULTATION With bell for bruit 4. Do GPE to find out the causes of secondary lymphedema.

H ) VARICOSE VEINS
1. INSPECTION While standing & from front as well as behind
- Skin changes - Hair changes - Visible veins - Edema 2. PALPATION While standing, - Ask for tenderness - Palpate the veins & Sephano-femoral junction - Edema, facial defects, texture of skin - Cough impulse Ask the patient to lie down, empty the veins by stroking movements of hands after raising them, and then look for: - Venous guttering - Feel for gap in fascia - Palpate Sephano-femoral junction - Trendelenbergs test - Tourniquet test > place 5 Tourniquets & open from above downwards- Perthes walking test > perform if the veins fail to collapse 3. PERCUSSION - Feel the percussion wave conduction

4. AUSCULTATION - Listen for bruit over prominent veins 5. GPE & Rule out all the causes by relevant systemic exam especially abdominal. 6. Harveys Test on superficial abdominal veins.
KHIZZER KHAN Page 6

I) PARA-UMBILICAL HERNIA
1. INSPECTION Look for:
- Abdominal distension - Umbilicus > Shape & location - Swellings at other hernia site Ask the patient to cough & then, to raise the head while lying down with arms on sides: - Observe the swelling. Ask the patient to reduce the swelling & then look for its re-appearance.

2. PALPATION - Ask for tenderness

- Cough impulse - Swelling > Site, size, shape, consistency (better way is to feel it while the patient raises the head) - Check for divarication of recti 3. PERCUSSION - Check the percussion note above the swelling.

4. AUSCULTATION - Listen for bowel sounds in the swelling. 5. GPE & Rule out all the causes by relevant systemic exam.
- Abdominal palpation - Bladder palpation if aged male - Auscultation of chest - Ask about heavy weight liftin

J) INGUINAL HERNIA
While patient standing, sit on the side of hernia & perform:

1. INSPECTION Look for:

- All the hernial orifices - Scar mark or any other finding - Ask about reducibility - Effect of Cough if the swelling is reduced - Look at the posterior surface of scrotum for any sinus or discharge afte asking for tenderness 2. PALPATION - Ask for tenderness - Swelling > Site, size (take exact measurements in atleast two directions), shape, surface, consistency, color, tenderness, temperature, s changes & fixity, compressibility (absent in KHIZZER KHAN Page 7

vascular tumors) Find out answers to following five questions - Are the testes separately palpable? - Can you get above the swelling? - Is Cough impulse positive? > Place one hand on the back of patient & other on the swelling - Is the swelling trans-illuminant? - Is the swelling reducible? 3. PERCUSSION - Check the percussion note above the swelling.

4. AUSCULTATION - Listen for bowel sounds in the swelling.

While patient lying on bed, stand on the right side of patient,& confirm the above findings. In addition, perform: - If reducible, ask the patient to reduce - Deep ring occlusion test > +ve if it strikes the thumb, -ve if it comes out of superficial ring Do GPE & Rule out all the causes by relevant systemic exam. - Abdominal palpation - Bladder palpation if aged male - Auscultation of chest - Ask about heavy weight lifting

Hydrocoel vs Epididymal cyst:

Hydrocoel
1. Testis not palpable separately but cord is. 2. Fluctuant, ovoid 3. Fluid thrill positive 4. Dull to percuss 5. Trans-illuminant (not hematocoel) 6. Non reducible 7. Cough impulse absent

Epididymal cyst
1. Testis palpable separately, swelling usually above & behind. 2. Fluctuant, elongated, multi-locular 3. Fluid thrill positive 4. Dull to percuss 5. Trans-illuminant 6. Non reducible 7. Cough impulse absent

KHIZZER KHAN

Page 8

Varicocoel:
- Testis palpable separately - Bag of worms feel on STANDING

Hernia: Direct vs Indirect

Direct Hernia
1. Can descend into scrotum & usually does. 2. Reduces up, then laterally, finally backwards 3. Deep ring occlusion test +ve 4. Defect not palpable 5. Direction of re-appearance along the inguinal canal & then downwards. 6. Common in children & young adults.

Indirect Hernia
1. Can but usually does not descend into scrotum. 2. Reduces up and then straight backwards. 3. Deep ring occlusion test -ve 4. Defect may be palpable above pubic tubercle 5. Direction of re-appearance straight from the superficial ring downwards. 6. Uncommon in children & young adults.

D/D of Lump in groin:

- Inguinal hernia - Femoral Hernia - Enlarged lymph nodes - Saphenovarix - Femoral artery aneurysm - Ectopic testis - Hydrocoel of cord or canal of Nuck - Lipoma of cord - Psoas bursa - Psoas abscess - Encysted Hydrocoel of cord - Hematocoel of round ligament

K) PAROTID SWELLING

KHIZZER KHAN

Page 9

1. INSPECTION - Site - Size - Shape - Symmetry - Surface - Angle of jaw - Facial nerve function - Stensons Duct - Wirsons Duct 2. PALPATION - Ask for tenderness - Temperature - Size - Shape - Surface - Consistency - Mobility - Skin fixity - Trans-illumination > usually -ve - Fluctuation - Slip sign - Bimanual palpation (with fingers of one hand in mouth & other on surface, done for salivary glands other than parotid) - Lymph nodes 3. PERCUSSION - Dull 4. Oral cavity exam - Inspect the inside for discharge while pressing outside. Palpate bimanually.

L) NERVES
1. Sciatic Nerve : - Straight leg raising test 2. Common Peroneal Nerve :
- Damage leads to Talipes equino varus deformity - Patient is unable to dorsiflex & evert the foot. - Dropped foot i.e. the patient walks without undue lifting of the foot.

3. Tibial Nerve :
- Damage leads to Talipes calcaneo vulgus deformity - Patient is unable to plantar flex & heels are with the ground. - Ask patient to plantar flex against the resistance.

4. Femoral Nerve - Ask patient to extend the knee against the resistance. 5. Median Nerve :
- Oschner Clasping test (Gun sign, pointing index) KHIZZER KHAN Page 10

- Ape thumb deformity - Erbs paralysis (Policeman receiving tip deformity) - Tinels test > tap the nerve at wrist - Sensory supply for palmer aspect of thumb, index & middle fingers, dorsal aspect of the distil phalanx, and the half of middle phalanx of the same fingers & a variable amount of radial side of the palm of the hand. - Hold the wrist fully flexed for 1-2 minutes > symptoms of nerve compression if carpal tunnel syndrome present. Injury at wrist - Wasting of the thenar eminance - Absent abduction of thumb - Absent opposition of thumb Injury at or above the cubital fossa - Wasting of the thenar eminence & forearm - Loss of flexion of thumb & index fingers - Hand held in Benediction Position, with ulnar fingers flexed & index fingers straight.

6. Ulnar Nerve
- Sensory supply for anterior & posterior surface of the little finger, ulnar side of the ring finger & skin over hypothenar eminence & similar strip of skin posteriorly. Injury at wrist Wasting of the hypothenar eminence & hollows between metacarpals - Absence of flexion of little & ring fingers - Claw hand, with little & ring fingers hyper-extended at the metacarpophalangeal joints & flexed at inter phalangeal joints. - Absence of adduction & abduction of the fingers with a positive Froments test. Injury at the level of elbow - Wasting of the intrinsic muscles - Claw hand, but with terminal inter phalangeal joints not flexed as half of flexor digitorum profundus now paralyzed. - Positive Froments test. Injury high above the elbow - All the above - The flexor carpi ulnaris also paralyzed.

7. Radial Nerve
- Sensory supply for small area of skin over the lateral half of first metacarpal & the back of first web space. Injury in the axilla - Wrist Drop i.e. Absence of extension of wrist. KHIZZER KHAN Page 11

- Loss of triceps action. Injury at the level of middle third of humerus - Wrist Drop - Sparing of brachioradialis Injury to the posterior interosseous - Hand held in radial deviation when attempting extension. - No wrist drop - An inability to maintain finger extension against forcible flexion. Injury to the superficial branch of the nerve - No motor loss.

* (While checking for motor action of the nerve, feel the muscle you are testing
to check whether or not it is contracting.) Other causes of claw hand: a) Neurological: - Spinal > Polio, Syringomyelia - Brachial plexus > compression due to trauma or malignancy - Nerves > Trauma, Neuritis b) Musculoskeletal - Volkmanns ischemic contracture - Joint diseases

P) JOINTS

1. Knee Joint
LOOK:
- Varus i.e. ( ) or vulgus i.e. )( deformity. - Skin redness, scar, lacerations - Dimple on medial side - Wasting of vastus medialis - Fixed flexion

FEEL:
- Temperature - Knee effusion > Stroke test - Bakers Cyst > Appears in full extension - Circulation > Pulses, capillary filling

MOVE:
- Active > Flexion measure in cm how much the heel stops in short of hip > Extension force the knee in bed while standing for hyper-extension - Passive > Flexion Look at patients face for any discomfort. KHIZZER KHAN Page 12

> Extension Raise off patients heels of the bed. - Lag test > Straight Leg Raising & then ask the patient to bend the knee for 20o & then straighten it > absent in lesions of quadratus femorus.

STABILITY:
- Collaterals > Varus & Valgus knee tests - Cruciate ligament > Anterior & posterior drawer tests (sit on patients foot while doing these tests to keep it still) - Pivot shift test > Do gently to prevent muscle spasm. - Patella apprehension test (dont actually dislocate the patella of the patient).

2. Hip Joint
LOOK & FEEL as above:
- In addition measure true & apparent Leg Length Discrepancy MOVE: - Modified Thomas test - Abduction, Adduction, Rotation - Referred Pain > Pastry Rolling Test

STABILITY:
- Trendelenburg test

(Do rest of the joint exam from the chapter on Musculoskeletal Examination from Bailey & Loves Short Practice of Surgery. Details of special tests mentioned in this scheme can be read from any book on surgical methods. Also prepare yourself the methods that are left).
EDITED BY :-

MUHAMMAD KHIZER HAYAT KHAN FINAL YEAR MBBS , NMC MULTAN

DATED: 13-07-2013

KHIZZER KHAN

Page 13