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

Don’t 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

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 (don’t 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)

- Berry’s 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

- Kocker’s 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 vertically to check for eye movements

- Von Griffe’s Sign > Lid lag

- Stillvack’s Sign > Lid retraction

(Both of the above are due to over-activity of smooth muscle part of levator pelpebrae superioris muscle)

- Geoffre’s 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

H) CIRCULATION (Lower Limb)

1. INSPECTION Ask the patient to raise the leg & look for:

- Pain

- Paresis

- Paraplegia

Look for:

- Color

- Swelling

- Skin Changes (Ulcers, Abscesses, Gangrene)

- Buerger’s 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

I) BREAST

· Position the patient to 45^o

· Take consent

· Ask for privacy / proper exposure / female attendant in case of male examiners

1. INSPECTION Always look at the normal breast first

- Symmetry

- Number

- Swellings

- Skin changes

- 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

- Inspect the under surface of breast by raising with the dorsum of your hand

- Palpate the lymph nodes > don’t miss the supra-clavicular & 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

H) CIRCULATION (Lower Limb)

1. INSPECTION Ask the patient to raise the leg & look for:

- Pain

- Paresis

- Paraplegia

Look for:

- Color

- Swelling

- Skin Changes (Ulcers, Abscesses, Gangrene)

- Buerger’s 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

J) LYMPHEDEMA

1. INSPECTION Look for:

- Site

- Size

- Shape

- Extent

- Demarcation

- Color

- Other areas

- Skin Changes (Ulcers, Abscesses, Gangrene)

- Squaring of toes

2. PALPATION - Ask for tenderness

- Temperature

- Stemmer’s sign

- Lymph nodes

3. AUSCULTATION With bell for bruit

4. Do GPE to find out the causes of secondary lymphedema.

K) 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

- Trendelenberg’s test

- Tourniquet test > place 5 Tourniquets & open from above downwards

- Perthe’s 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. Harvey’s Test on superficial abdominal veins.

L) 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 lifting

M) 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 after asking for tenderness

2. PALPATION - Ask for tenderness

- Swelling > Site, size (take exact measurements in atleast two directions), shape, surface, consistency, color, tenderness, temperature, skin changes & fixity, compressibility (absent in 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

Varicocoel:

- Testis palpable separately

- “Bag of worms” feel on STANDING

Direct vs Indirect Hernia:

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

N) PAROTID SWELLING

1. INSPECTION - Site

- Size

- Shape

- Symmetry

- Surface

- Angle of jaw

- Facial nerve function

- Stenson’s Duct

- Wirson’s 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.

O) 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)

- Ape thumb deformity

- Erb’s paralysis (Policeman receiving tip deformity)

- Tinel’s 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 Froment’s 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 Froment’s 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.

- 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

- Volkmann’s 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

- Baker’s 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.

> 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 (don’t 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 & Love’s 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).