ABDOMINAL EXAMINATION

i) 3 things: Introduce, consent, privacy. v) Abdominal examina=on: “Ideally, I should expose the pt from
ii) Rub hands with alcohol. nipple line to mid thigh, but for the pt’s modesty, I will only
iii) Put the pt in supine posi=on, 0°. expose un=l pubic symphysis”
iv) Peripheral examina=on: • Expose adequately.
• Observe pts from the end of the bed — age, body size, • Observe from end of bed. Look for: abdominal respira=on,
ethnicity, conscious, comfortable, sallow appearance distension, umbilical (centrally located, inverted), scars (if
• Look for aIachments and connec=ons any, measure and palpate), dilated veins/ caput medusa,
• Branula with/out infusion/connec=on to normal saline visible bowel movement/ peristalsis
• O2 mask with 5L • Check for hernia (orifices intact) – ask pt to turn right/ led
• CBD with straw colour urine then cough. Look at the orifices.
• Started with hand examina=on • Light palpa=on — Kneeling and palpate 9 regions. Always
• Check for flapping tremor asterisk- (+ve in Chronic Liver look at pt’s face. Look for tenderness, rigidity
Disease) • Deep palpa=on — Kneeling and palpate 9 regions. Always
• Check hands for: warmth, pallor, palmar erythema, look at pt’s face. Look for mass. If there is any, describe as
dupuytren’s contracture, clubbing, peripheral cyanosis, lump and bump.
lekonychia, CRT • Check liver. Palpate from RIF. Then measure liver span. If
• Check arms for: bruises, taIoos, injec=on marks, scratch palpable below costal margin then mark with highlighter.
marks, yellow brown skin pigmenta=on Then percuss from above and measure. If liver enlarged,
• Face examina=on: then say it is liver because it has smooth surface etc.
- Eyes — pallor, jaundice • Check spleen. Palpate from RIF then move medially
- Nose — clear discharges towards LHC. Then ask the pt to turn sideways towards you
- Mouth — oral hygiene, oral thrush, central cyanosis, and percuss 9th, 10th, 11th ribs (Traube’s space). If spleen
hydra=on status, tonsils not enlarged, throat not enlarged, say spleen enlarge because presence of notch
injected etc.
• Check for LN enlargement (Virchow’s node) • Check kidneys. Ballot the kidney.
• Check upper chest: • Check for ascites – do shiding dullness.
- Spider naevi — if any, then try occlude the central • Do fluid thrill (if there is ascites). Ask pt to place one hand
arteriole to confirm on abdomen then flick from one side and feel any
- Gynaecomas=a vibra=ons with the other hand.
- Loss of axillary hair • Auscultate for bowel sound. Place stethoscope at ileocecal
• Check leg for edema jx (RIF). Listen for intensity and pitch.
• Listen for renal bruit. Place stethoscope above umbilicus,
2cm lateral to midline.
• Ask pt to sit. Check for renal punch (place one hand and
punch with the other hand) - between 12th ribs and lateral
border of vertebral column.

vi)I would like to complete my examina=on with: per rectal

examina=on, etc.
BREAST EXAMINATION

i) 3 things: Introduce, consent, close curtain. i) Examine the pathological breast:

ii) Rub hands with alcohol. • Palpate 6 regions.

iii) Sit the pt 45°. • If there is any mass, describe the mass — site, shape, size,
iv) Ask the pt to expose from neck to umbilicus. temperature, tenderness, margin, surface, mobility (move

v) Inspec=on from the end of bed: the mass in X shape, ask pt to tense pect. major muscle
• Ask pt to raise both hands (to exaggerate asymmetry and and repeat moving mass in X shape), rela=on to skin and

skin tethering). Look for asymmetry, scars, obvious mass, deep structures.
s k i n c h a n g e s ( s k i n d i m p l i n g , p e a u d ’o ra n g e , • Ask pt for any nipple discharge. If any, ask pt to squeeze.

hyperpigmenta=on, ulcera=on, nodules, etc), nipple ix)Ask pt to sit by the bed, then palpate axillary lymph nodes by
changes (destruc=on, depression, discoloyra=on, suppor=ng the pt’s arm and palpate using the other hand. Do

displacement, devia=on, duplica=on, discharge), etc. Ask the same for the other side. Axillary LN: anterior, central,
pt to lid her breast to look for scars under the breast. posterior, apical, and lateral.

• Ask pt to ‘cekak pinggang’ to tense the pectoralis major x) Examine for supraclavicular LN.
muscle. If there is aIachment to pectoralis major muscle, xi)Symptoms of metastases:

the mass would be more prominent. • Ask pt to lid clothes from behind. Check for bony
vi) Examine the normal breast first. Cover the other side. tenderness from behind (mets to bone).

vii)Palpa=on of normal breast: • Respiratory examina=on from back — percuss and

• Palpate 6 regions (4 quadrants, nipple and tail of breast) auscultate (lung mets).

• Ask pt for any nipple discharge. If there is, ask pt to • Abdominal examina=on for hepatomegaly (liver mets).
squeeze (never squeeze pt’s breast). xii)I would like to complete my examina=on by comple=ng the

triple assessment.
THYROID EXAMINATION

i) Sit on a chair, expose un=l supraclavicular. vi)Thyroid status:

ii) Step back and inspect. Go around the chair to look for any • Hand:

swelling. - Tremor
i) General inspec=on: - Palms moist and sweaty or dry

• Siong s=ll and composed, or looking nervous and agitated - Tachycardia or bradycardia
• Thin or fat • Eyes:

• Distribu=on of any was=ng or faIening - Exophthalmos — appearance of sclera below the

• Under-clothed or sweaty inferior limbus.

• Any aIachment - Lid retrac=on — If the upper eyelid is higher than

• Obvious swelling — site, size, skin changes, discharge, scar normal and the lower lid is in its correct posi=on.

ii) Inspect the neck: - Lid lag — When the upper lid does not keep pace with
• Ask the pa=ent to swallow. the eyeball as it follows a finger moving from above

- Observe general contours and surface of swelling downwards.

- Is the skin puckered, tethered and pulled up by - Ophthalmoplegia — check for double vision.

swallowing (advanced thyroid ca that has infiltrated - Chemosis — conjunc=va becomes thick, boggy and
the skin — anaplas=c carcinoma) crinkled and may bulge over the eyelids.

• Is the lump moves up as the tongue comes out • Arm:

• Any distended neck veins (if mass obstruct thoracic inlet) - Bagi dua jari kat pt. Suruh dia genggam and tarik

iii) Palpa=on: sekuat mungkin.

• Palpate the neck from behind. Use metacarpal and palpate - Pastu kau tarik arm pt mcm angkat tangan baby tu.

(one hand hold the opposite lobe, the other palpate). - Do chicken wing and kau tekan deltoid. Proximal
• Confirm the swelling moves with swallowing. myopathy. Tekan dari dpn pon boleh. No need ke

• Fell the lower border of the gland on swallowing. belakang.

• Do lump and bump examina=on. - Reflex. Tangan. And arm tu.

• Any cervical and supraclavicular lymphadenopathy. • Leg — for pre=bial myxoedema (in certain pts with Graves’
• Caro=d pulse (feel one by one). disease, red, blotchy, raised areas may be seen over the

• Check trachea central or not. shins, caused by deposits of myxoid =ssue within the skin).
iv) Percussion — from 2nd intercostal upwards.

v) Auscultate — at swelling for systolic bruit.

Addi3onal informa3on
Pemberton's sign:
• To evaluate venous obstruc=on in pts with goiters.
• +ve — when bilateral arm eleva=on causes facial plethora. It has been aIributed to a “cork effect” resul=ng from the thyroid
obstruc=ng the thoracic inlet, thereby increasing pressure on the venous system.
CHEST TUBE EXAMINATION
i) 3 things: introduce, consent and close curtain.
ii) Rub hands with alcohol.
iii) General inspec=on.
iv) Chest inspec=on — look at the chest tube:
• Measure the anchor length in cm

• Look at the vapour within the tube

• No=ce the dressing (soaked or not) — indicate any leaking

• Look at the surrounding skin (healthy or not)

v) Look at the underwater seal cartridge. No=ce the colour of the
fluid (Hemoserous etc)
vi) Ask pt to cough and look at the underwater seal cartridge to
assess whether it’s func=oning or not.

Addi3onal informa3on
• How to tell wether it is chest tube inser=on: • Where to put the tube — at the safe triangle (just above the rib
- Connected to underwater seal system to avoid neuromuscluar bundle):
- Fluctua=on of meniscus with respira=on - Haemothorax — angle is downward (blood goes down)
- Presence of water vapour (air in pleural cavity) — indicates - Pneumothorax — angle is upward (air moves up)
that it’s func=oning
- Presence of bubbles — air trying to escape the lung
- Colour — blood indicates haemothorax
• Ini=ally, 300 ml of water is put in first → observe tomorrow’s
value → if s=ll 300 ml, indicates it drains only air
(pneumothorax), if the volume increase, it is haemothorax.
• The length inserted in no less than 12 cm.
• For MVA pt:
- “Cervical collar in situ, probably have spinal injury”.
- Pneumothorax is mainly due to clavicle and rib fracture. • When to remove the tube:
- Paradoxical movement of chest wall during breathing → - When the drain no longer serve its purpose.
involve 2 segments (2 ribs minimum). - When lung is able to expand fully.
- Put chest tube to prevent tension pneumothorax.
- In pneumothorax — tracheal devia=on, reduce chest
movement during respira=on, hyperresonant, absent
breath sound → check oxygen satura=on.
- Open pneumothorax: injury un=l pleural space.
- How to examine MVA:
- A — intubated or not, connected to oxygen
- B — RR, respiratory effort, signs of open wound, chest
tube
- C
HERNIA EXAMINATION

Start just like abdominal examina=on:

i) General examina=on. • Palpate hernia (just like palpa=ng the lump)

ii) Check for abdomen: - Site, shape, size, tender, warm, side, margin, consistency,
• (Expansile cough impulse) Ask pt to turn his/her head to can’t get above, punctum, discharge, peristalsis

led side and cough. Do it twice if no hernia=on. - Trans-illumina=on test

• (Reducibility) If there is hernia, ask pt to manually reduce - Percussion

the hernia. - Ausculta=on

- Reducible (proceed to next step) • Palpate scrotum, testes, sperma=c cord.

- Irreducible (proceed lump and bump) • Do abdominal examina=on to know the cause of inguinal
• Occlude the deep inguinal ring [1.25cm above the mid hernia (↑ intra-abdominal pressure) — I would like to

inguinal point – between ASIS and pubic tubercle (first complete my examina=on by:
bony prominence ader pubic symphysis)]. Then, ask pt to - Digital rectal examina=on — hard fecal impac=on, BPH

stand up while occluding the deep inguinal ring. (straining during micturi=on)
• Ask pt to cough while occluding the deep inguinal ring - Abdomen examina=on

(Deep Ring Occlusion Test). Posi=ve when there is - Respiratory examina=on (chronic cough) — COPD, TB
something pushing the occluding fingers.

- Direct — through Hasselbach Triangle. Hernia will **Diagnosis should include:

come out during deep occlusion test. 1. Recurrent

- Indirect — did not pass inguinal canal so not come out 2. Reducible/irreducible
during deep occlusion test. 3. Right/led

4. Direct/indirect
5. With/without complica=ons

Indirect inguinal hernia Direct inguinal hernia

Can descend into the scrotum Does not go down into the scrotum

Reduces upwards, then laterally and backwards Reduces upwards and then straight backwards

Controlled, ader reduc=on, by pressure over the deep inguinal Not controlled ader reduc=on by pressure over the deep
ring inguinal ring

Ader reduc=on, bulge reappears in the middle of the inguinal

Ader reduc=on, bulge comes directly forwards
region and flows medially and obliquely towards the scrotum

Found in all age groups Rare in children and young adults

Script Example

My pt an elderly man is lying comfortable in supine posi=on. On inspec=on of abdomen, there is a midline laparotomy scar noted,
with two transverse scars at right and led iliac fossa. There is an obvious right inguinal swelling, no extending to scrotum. There is no

erythematous change, no skin excoria=on, no dilated veins, no punctum or discharge, no visible pulsa=on or peristalsis. Cough
impulse is posi=ve as the mass becomes obvious ader coughing. On palpa=on, mass is oval in shape 5 x 4 cm, sod and doughy, has

well-defined margin, non-tender, not warm to touch, can get below and reducible. Occlusion test is nega=ve. Genitalia examina=on is
normal. Scrotum is well-developed. Both testes are palpable, normal size. Normal sperma=c cord, no bag of worms felt. Since pt’s

swelling is completely reducible, I would like to ask pt to stand for further assessment. When pt is standing, do trans-illumina=on
test. It’s nega=ve. I would like to complete my examina=on by doing rectal examina=on, abdomen and respira=on examina=on.

How to do occlusion test?

Make sure swelling is completely reducible. Find landmark: Midway between ASIS and pubic tubercle. Occlude opening with one
finger. Ask pt to cough, if nega=ve, ask pt to stand, finger s=ll occlude the opening. Ask pt to cough again.

What is your complete provisional diagnosis?

Right recurrent completely reducible inguinal hernia with no complica=ons such as strangula=on, ischemia or incarcera=on.

How to know if it is bowel or omentum?

• Bowel — Visible peristalsis on inspec=on, gurgling sensa=on on palpa=on and when you try to reduce it, ini=ally it is hard and then

become easy, bowel sound on ausculta=on.

• Omentum — No visible peristalsis, sod and doughy on palpa=on and when you try to reduce it, it is easy ini=ally but hard at last,

no bowel sound heard.

How to manage this pt?

Since this is a recurrent disease, I would like to take complete history and assess his risk factors (occupa=on, congenital,

complica=ons of previous opera=on, abdominal mass, urinary and bowel symptoms, respiratory problems, heavy liding). Ader that, I
would like to perform complete physical examina=on. Then, do pre-op assessment, op=mize pt’s condi=on, take blood for

inves=ga=ons, do CXR, ECG, prepare pt for laparoscopic hernioplasty where we put in mesh to induce fibrosis and prevent hernia.

What are advantages of laparoscopic surgery?

Small incision, less bleeding, less incision, faster recovery, reduced dura=on of hospitaliza=on, reduced chronic pain.

What are the disadvantages?

Need highly experienced surgeon, longer opera=on =me, and risk of recurrence if surgeon is not experience enough.
Other op3on for surgery?

• Herniotomy: excision of sac ader reduc=on, usually in children because they have weak and immature ligament.
• Hernioplasty

• Herniorrhaphy: reconstruc=on by using pt’s own =ssue.

Type of open repair surgery that you know of?

• Lichtenstein: most common, flat mesh is placed on top of the defect

• Shouldice: four-layer reconstruc=on of fascia transversalis, difficult to perform

• Bassini: tension repair, edges of defect are sewn back together without any mesh

• Desarda: simpler, faster, tension-free, mesh-free

Special type of hernia that you know of?

• Sliding hernia: an organ is part of hernia sac eg. colon or urinary bladder

• Pantaloon hernia (saddle bag hernia): combined direct and indirect hernia
• Maydl’s hernia: two adjacent loops of small intes=ne are within a hernial sac with =ght neck – double lumen

• Richter’s hernia: hernia involving only one sidewall of bowel

• LiIre’s hernia: hernia involving Meckel’s diver=culum.
LUMP AND BUMP EXAMINATION
i) Inspec=on:
• Site

• Skin changes

ii) Palpa=on (from outside to inside):

• Site

• Shape
• Size

• Tenderness
• Temperature

• Margin (regular/irregular)
• Surface

• Consistency
• Mobility

• AIachment to skin (pinch skin)

• Fluctua=on test — Pressure on one side of a fluid-filled

cavity makes all the other surfaces protrude. This is

because an increase of pressure within a cavity is

transmiIed equally and at right angles to all parts of its

wall.

• Slip test — lipoma slide under your finger

• Translucency (transillumina=on) — Light passes easily

through clear fluids but does not pass through solid

=ssues.

iii) Percussion (if appropriate)

iv) Ausculta=on (if appropriate)

STOMA EXAMINATION

i) General abdominal inspec=on – moving with respira=on, scars, viii)Cough for parastomal hernia.
visible mass, visible peristalsis etc. ix)Check for shiding dullness (ascites).

ii) Site of stoma (right/led iliac fossa): x) Check for bowel sound (ausculta=on).
• RIF – ileostomy (greenish) xi)I would like to complete my examina=on with:

• LIF – colostomy (brownish) • Examina=on of perineum:

iii) Measure how many cm from umbilicus. - Presence of anus – loop colostomy / ileostomy /

iv) Content of stoma: Hartman’s procedure

• Faeculent fluid - Absence of anus – end colostomy [abdominoperineal

• Bulky feces – hint for colostomy restric=on (APR)]

v) Presence or absence of sprout: • Per rectal examina=on (if anus presence) to look for

• Sprout – hint for ileostomy palpable mass etc.

vi) If colostomy, check whether it has 1 or 2 lumen:

• 1 lumen — end colostomy (permanent)

• 2 lumen — loop colostomy (temporary)

- emergency (large bowel obstruc=on)

- defunc=oning

- bowel rest
vii)Surrounding skin (inflamma=on)

Sample script

There is stoma at ____________, measured _________________ cm from umbilicus. The content of stoma is _______________.
There is presence / absence of sprout. I think it is ileostomy/ colostomy with/without complica=ons due to ________.

Addi3onal informa3on

• An ar=ficial surgically created cutaneous opening: • Types of stoma:

- Bowel — ileostomy, colostomy - Anatomy — ileostomy, colostomy
- Urinary tract — ureterostomy - Temporary or permanent
• Indica=on: to divert the faeces - End, loop, double barrel
• Look for: • Complica=ons:
- Cough for parastomal hernia - Local — skin irrita=on, mucocutaneous separa=on,
- Loca=on retracted stoma, prolapsed stoma, parastomal hernia
- Lumen - Systemic — dehydra=on, electrolyte imbalance
- Sprout • Purpose of sprout — small bowel content flow directly to
- Presence of gas or faeces (stoma func=oning or not) stoma bag (content > acidic)
- Colour of stoma • Hartmann — sigmoid colectomy + proximal end colostomy
VASCULAR EXAMINATION (VENOUS AND ARTERIAL SYSTEM)

VENOUS SYSTEM

1. Inspec=on (while pt lying down): 5. Percussion: Ask pt to stand

• Ask pt to lid cloth (pakai macam cawat) • Percussion wave conduc=on:

• Look for either varicose vein/ ulcer (arterial/venous) i) Normally, it transmits percussion wave in antegrade

• Look for the distribu=on of varicose vein/ calf swelling/ direc=on (ke atas)
Lipodermatosclerosis ii) If the valve is incompetent, percussion is transmiIed

• Measure size of visible veins retrogradely (downward)

• Skin changes 6. Ausculta=on over the prominent varices. Look for bruits

• Check for ankle edema (machinery murmurs indicate secondary arteriovenous fistula)
2. Ask pt to stand: Check front and back of leg by asking pt to 7. I would like to complete my examina=on:

turn around • Doppler Ultrasound

3. Palpate : • Arterial Examina=on

• Palpate along the varicose vein distribu=on (feel for fascia • Abdominal Examina=on
defect or thickening of vein) • Per Rectal Examina=on

i) Long saphenous vein - medial leg

ii) Short saphenous vein - posterior leg

• Palpate for tenderness (phlebi=s), hardness (thrombosis)

• Do cough impulse (impulse/thrill indica=ng incompetent

valves at their junc=on)

• Measure from =bial tuberosity (4cm below?)

4. Ask pt to lie down:

• Ask pt to lid the leg to empty the vein. Then search for

Sapheno-Femoral Junc=on (find pubic tubercle, then 2.5

lateral and 2.5cm below). Do tourniquet test by puong

tourniquet at the area and ask pt to stand. Posi=ve is when

the release of tourniquet causing the appearance of

varicose vein. If fail, do one more =me because most of

the =me, it is due to SFJ.

• Do mul=ple Tourniquet Test:

i) 5 cm above medial malleolus

ii) 10 cm above medial malleolus

iii) 15 cm above medial malleolus

iv) Below knee (popliteal)

ARTERIAL SYSTEM

1. Inspec=on (while pt lying down): 4. Auscultate:

• Ask pt to lid the lower cloth (just like cawat) • Listen along courses of all major arteries.

• Look for either varicose vein / ulcer (arterial or venous) • Bruits — caused by turbulent flow beyond a stenosis, or an
• Skin changes — moIled, gangrene irregularity in artery wall.
↳ bluish-red lace ,
like

2. Palpa=on: 5. Ankle Brachial Systolic Index (ABSI):

• Skin temperature • F i n d systo l i c re a d i n g at b ra c h i a l p u l s e u s i n g

• CRT, bone and joint tenderness sphygmomanometer and stethoscope.

• Ankle edema • Find systolic reading at ankle pulse using

• Look for pressure area and between digits (trophic sphygmomanometer and Doppler ultrasound.

changes, gangrene, etc) • Then divide ankle to brachial systolic reading. Ra=os >1
• Peripheral pulses: indicate s=ff, calcified limb vessels.

- Femoral — mid inguinal point (halfway between

symphysis pubis and ASIS). 8. I would like to complete my examina=on by:

- Dorsalis pedis — runs from a point on the anterior • Measuring the blood pressure
surface of ankle joint, midway between malleoli, • CVS examina=on

towards the cled between 1st and 2nd metatarsal • Caro=d pulse examina=on
bones. • Neurological examina=on

- Posterior =bial — 1/3 of the way along a line between • Abdominal examina=on
=p of medial malleolus and point of the heel.

- Popliteal

3. Buergers test (angle to which the leg has to be raised before it

becomes white):

• Ask pt to lid the leg un=l the leg turns pale. Es=mate the
degree of Buergers angle.

- Ischemic limb — 15-30° eleva=on for 30-60s cause

pallor

- If <20° — severe limb ischemia

• Ask pt to sit up and dangle the foot over the bed. Posi=ve

when the leg turns red/pink.

thickened nails,
trophic changes -

scaly skin ,

brittle nail absent hair

,
 PERIPHERAL ARTERIAL DISEASE EXAMINATION PERIPHERAL VASCULAR DISEASE EXAMINATION

i) Adequate exposure — from umbilicus all the way down. i) Ask pt to stand up.
ii) General examina=on — distress, comfortable, swea=ng. ii) Check the distribu=on of varicosi=es — great saphenous

iii) Lower limb inspec=on (from outside to inside) or short saphenous.

• Skin changes — any atrophic changes, dry scaly skin, iii) Do trendelenburg or tourniquet test.
loss of hair, diabe=c nephropathy (diabe=c related
infec=on) or immunocompromised • Swelling → hemosiderin deposi=on → lipodermatosclerosis

• Subcutaneous =ssue — any infec=on or boils → ulcer

• Muscles — any twitching, atrophy, is it equally • Symmetrical or not

distributed • Any obvious deformity
• Nerve and blood vessels • Spots on skin could be immunocompromised
iv) Lower limb palpa=on • Ulcers
• Temperature • Hyperpigmented skin surrounding the wound

• Ulcer • Scab around wound indicates on going healing process

✓ Venous — more at gaiter area, arterial — in • Is it foul smelling

between the toes and pressure areas • Any necro=c base on the wound
✓ Check for — site, size, surrounding skin (any • Femoral pulse → popliteal pulse → posterior =bial (in

spreading celluli=s), edges (granula=ng, roll between =p of medial malleolus) → dorsalis pedis (half
pearly edges which is a sign of basal cell between medial and lateral malleolus)

carcinoma, ill defined or well defined, punch hole • CRT

or sloppy), base (necro=c, discharge, full of pus)

• Pulse — check from normal to abnormal area

✓ Femoral pulse — at mid-inguinal point (between

ASIS and pubic symphysis)

v) ABSI

vi) Special test — Bueger’s test

6Ps of Acute Limb Ischemia

1. Pain

2. Pallor
3. Perishingly cold

4. Paralysis
5. Paraesthesia

6. Pulseless