mqwertyuiopasdfghjklzxcvbnm

yuiopasdfghjklzxcvbnmqwerty
dfghjklzxcvbnmqwertyuiopasd
xcvbnmqwertyuiopasdfghjklzx
qwertyuiopasdfghjklzxcvbnmq
SURGERY EXAMINATIONS

Revision Notes by Brig Irfan Shukr

iopasdfghjklzxcvbnmqwertyui
MC 2784
Hamza Ali Malik

hjklzxcvbnmqwertyuiopasdfgh
bnmrtyuiopasdfghjklzxcvbnmq
iopasdfghjklzxcvbnmqwertyui
hjklzxcvbnmqwertyuiopasdfgh
bnmqwertyuiopasdfghjklzxcvb
 A Guide For Medical Students to Help in Revision

Examination of Thyroid
Before examination.

1. Introduce yourself.
2. Take consent
3. Take his shirt off to expose till nipple level.
4. Stand in front of patient, and ask following questions to determine goiter is
simple (Thyroid function normal) or toxic (increased function of the thyroid
gland)
a. Good Appetite with Weight loss
b. Heat intolerance and preference to cold.
c. Other symptoms like nervousness, insomnia, palpitations etc.
d. Menstrual irregularities.

Generally Inspect the Patient

1. Sitting still and composed (Simple goiter) / Constantly moving his fingers and
looking nervous & agitated (Toxic goiter)

Examine the Hands

1. Pulse: Increased (Toxic goiter). If patient has other features of toxic goiter but
the pulse is normal, ask the patient that is he is taking Antithyroid drugs?
2. Palms: Moist and warm (Toxic goiter)
3. Tremor: Test for a tremor by asking the patient to hold there arms in front of
them, elbows & wrist straight & separated. Thyrotoxicosis causes a fine, fast
tremor. A fine tremor may be accentuated by placing a sheet of paper over
fingers.

Examine The Eyes

1. Normal eyes
a. Upper lid halfway between pupil & superior limbus
b. Lower lid at tangent to inferior limbus.
2. Following early clinical signs may be present in toxic goiter.
a. Lid Retraction
i. Upper lid raised (At limbus)
ii. Lower lid normal
b. Lid Lag
i. When the upper lid don’t keep pace with the eye ball as it follows
a finger moving from above the downward, the patient has lid
lag.

(Note: when sclera is visible between lower eyelid and limbus it is exophthalmos)

Examine the neck

1. Ask the patient to swallow. (Goiter moves on swallowing)

2. Ask the patient to open the mouth and then to put out his tongue. (A lump that
moves up as the tongue comes out is attached to hyoid bone; throglossal cyst)
3. See Neck veins (Distended neck veins in retrosternal extension of goiter / large
goiter as it obstructs thoracic inlet)
4. Palpate the neck from front to look for size and surface. (To confirm diffuse
goiter / Multinodular goiter / Solitary thyroid nodule)
5. Check the position of trachea.
 6. Palpate the neck from behind the patient. Stand behind the patient. Place your
thumbs on the ligamentum nuchae and tilt the patient head slightly forward to
relax the anterior neck muscles. Let the palmer surface of your fingers rest on
each side of the neck. They will be resting on lateral lobes on thyroid gland. A
small lobe can be made prominent & easier to fell by pressing firmly on the
opposite side of the neck. Ask the patient to swallow while you are palpating the
gland to confirm that any swelling moves with swallowing and is actually part of
the thyroid. This maneuver also lifts up the lumps that are lying behind the
sternum into the reach of your fingers. (To confirm again diffuse goiter /
Multinodular goiter / solitary thyroid nodule; retrosternal extension)
7. Palpate the whole neck for cervical and supraclavicular lymphadenopathy
(Thyroid cancer)

Percussion:

1. Percussion over sternum gives a resonant note in normal cases. In retrosternal

goiter it gives a dull note.

Auscultation:

1. It should be done in upper pole. Presence of thrill and bruit are feature of toxic
goiter.

Check for reflexes

 Examination of Abdomen
Before starting
 Intro & consent
 Position: supine, hands by the side, legs extended for inspection & flexed for
palpation
 Exposure: nipples to mid-thigh

GPE
 Face: Dehydration, jaundice, pallor
 Hands: clubbing, koilonychias, leukonychia, pallor, palmer erythema, Dupytren`s
contracture, Flapping tremor, splinter haemorrhage|
 Pulse rate & volume, Temp, RR

Inspection: do it from foot end also as well as side

 Shape: scaphoid, flat or protuberant. Flanks full or not
 Movement of Abd wall.
 Umbilicus: normally inverted. Everted, transverse, vertical slitting
 Hair Distribution
 Pulsation or prominent veins
 Swelling, scar, striae
 Hernial orifices

Palpation
 Ask pt for any painful area. Start from non-tender area.
 Move in S shape manner
 Hand & forearm should be at level of abdomen.
Superficial Palpation: to gain pt`s confidence
Deep Palpation:
 Tenderness, guarding, or rigidity
 Palpable mass:
o Movement with respiration: Intra-peritoneal mass move while retro-
peritoneal don’t
o Carnet`s Sign: Ask pt to lift the head slightly. The abd muscle get taut &
swelling, if intra-peritoneal i.e. deep to muscles, will decrease in size. In
case of para-umbilical or epigastric hernias, feel the defect in linea alba
during this manoeuvre
o Rest of examination same as in swelling
 Special Signs:
 Appendicitis
o Pointing: pt points at McBurney`s point as max pain
o Rovsing`s: Deep palpation in left iliac fossa cause pain in right
iliac fossa
o Psoas: pt in left lateral position & hyperextended the leg at hip
joint. Pain with this signifies retrocaecal appendix.
o Obturator: Flex leg at knee & internally rotate at hip, pain with
this signifies pelvic appendix
o Rebound Tenderness: deeply palpate in Rt ileac fossa, then
withdraw the hand suddenly & completely. Pt will wince with
pain.
  Cholecystitis
Murphy`s sign: palpate at 9th costal margin & with inspiration
press the hand upward & deep. Pt will wince with pain as the inflamed
GB touches the hand.
 Perforated Peptic Ulcer: Normal liver dullness will be obliterated.
Palpation for Viscera
Liver:
Kidney: bimanually, ballottement
Spleen:
Bladder:
Aortic & Para-aortic LNs: In the midline between Xiphiod & umbilicus.

Percussion
 For Visceras
 Fluid Thrill
 shifting Dullness

Auscultation
 Bowel sounds
 Renal bruit
 hepatic bruit & friction rub
 Splenic rub
 Aortic bruit
At the end examine:

 Hernial orifices
 External Genitalia
 DRE
 Back of pt.

Relevant Questions: Acc. To the findings

How to Describe:
 My pt is … aged man with … built, (jaundiced or pale), (well hydrated) & has …
abdomen which is moving with resp. with … shape umbilicus, scar marks, visible
veins or pulsations.
 There is … (tenderness) in … region, with or without guarding & rigidity. … (No)
mass is palpable.
 There is … (visceromegaly) Fluid thrill & shifting dullness is … for ascites &
bowel sounds are … (audible)
 Hernia orifices are intact, genitalia are …, the back is … & there is …
lymphadenopathy.
 MASS ABDOMEN

Carnet test.
Intra-abdominal or extra-abdominal Ask the patient to raise the legs or head
The mass becomes less conspicuous




Reflect the
clinical
symptoms are
Decide the The commonest masses
related to which
organ/tissue of originating from that
organ/system.
origin. organ/tissue is the differential
E.g. GIT, Urinary,
diagnosis
hepato-biliary
etc.
+ Ultrasound to Specific test to confirm
confirm tissue the diagnosis
Determine the
of origin
mass shows signs
of which organ*
Diagnosis confirmed

 Liver: Present in RUQ abdomen. It moves downwards with respiration. Fingers

do not go between mass and costal cartilage. Dull on percussion.
 Kidney:
 Abdominal Trauma
Q: What is the first step in management of abdominal trauma?
A: Primary Survey.

Q: Which component of primary survey is affected by abdominal trauma?

A: Circulation.

Q: What are the classification of abdominal trauma, and its significance?

A:

Blunt Penetrating
Management Conservative, unless patient Laparotomy
remains unstable on resuscitation

Importance in Dx Clinical examination History

Q: What is investigation of choice in abdominal trauma patients?

A:
1. “FAST-Focused Abdominal Sonography for Trauma” in unstable person.
2. CT scan in stable person.

Q: What is the initial treatment?

A:
1. NPO
2. IV drip normal saline 30-drops/ minute.
3. Nasogastric intubation.
4. Foley’s catheterization
5. Analgesics
6. Antibiotics
7. Monitoring
a. Clinical features
b. Vital signs
c. Intake output.
Q: What is operative treatment of individual organs?
A:

Liver Ligation; packing

Spleen Splenectomy
Intestine Primary repair
Colon Colostomy
Stomach Primary repair
Mesentery Ligation bleeding vessel. Resection unviable small intestine.
Central hematoma Exploration
Peripheral hematoma Exploration if expanding
Pelvic hematoma Conservative
Urethra Suprapubic cystostomy
Pelvic fracture Stabilization
 Jaundiced patient
Step 1: confirm obstructive jaundice. (H/O deep jaundice, itching, high colored urine,
and pale stools).

Step 2: confirm cause stones or malignancy. (Fit the patient into having maximum of
following pointers)

Stone Malignancy
Age Middle age Elderly
Gender Female Male
Jaundice Painful Painless
Intermittent Progressive
Duration Long Short
Past h/o gall stones Yes No
Abdomen examination Palpable gallbladder
Mass abdomen

Step 3: investigate to confirm above:

LFT: In Obstructive jaundice, raised

o Bilirubin
o Conjugated bilirubin
o Alkaline phosphatase

Ultrasound abdomen (dilatation of CBD/intrahepatic biliary dilatation)

confirms obstructive jaundice

Stones Mass No stone or mass

ERCP CT Scan ERCP with

Image guided Biopsy if periampulary
FNAC/ Biopsy Lesion
CA 19-9 CA 19-9
 Management:

Obstructive jaundice effects of:

Arrange
FFP. Dose
Vitamin K
PTTK or PT, If still more 10 units /Kg
10 mg slow
Coagulopathy more than than 03 = 06 bags
IV for 05
03 second seconds (each bag
days
has 100
units)

Start Ceftriaxone If not. Give

If patient has 01 gram 12 prophylaxis IV
fever, raised TLC hourly injection brfore
Sepsis
or raised procedure
neutrophils (3rd Generation (ERCP)/Operatio
Cephaolsporin) n

Ensure Ensure
Adequate intake, Preload is
output. corrrcet.
If Urine output
Renal Failure Maintain intake Inj. Lasix 40 mg
is less
output chart. IV
Give IV Normal Inj Mannitol
Salin, if oral is less 20% IV

ensure
Adequate intake output
Give Carbohydrate.
Liver Failure Oral Glucose
IV 10% Glucose drip

Electrolyte imbalance: Hypokalemia is the most important electrolyte imbalance.

Ensure serum K is not at low level. If at low level, than add 20 mmol KCl ampule in each
1000 ml IV drip.
Management of Biliary Stone

Principle

Removel of stones from CBD Cholecystectomy

ERCP, & Endoscopic removal of Followed by Laparoscopic cholecystectomy

Stones
If not possible

Open cholecystectomy
ENDOSCOPIC REMOVEL NOT
POSSIBLE OR FAILS

Exploration of CBD & Open Cholecystectomy

Additional notes:
Indication of Exploration of CBD
 Preoperatively: Ultrasound / ERCP shows stones
 During Operation: (1) CBD Stones felt. (2) Per-operative Pre-exploratory
Cholangiography demonstrates stones.

Drainage procedures after exploration of CBD

 Choledocho-duodensotomy if CBD is dilated > 01 cm (1.5 cm)
 Sphicteroplasty if CBD is not dilated.
 SPACE OCCUPYING LESION LIVER
History & Clinical examination

HCC Metastsis Benign Hydatid cyst Inflammatory

History of Pancreas Adenoma Contact with dog, Pyogenic Liver

Hepatitis Stomach Haemangioma sheep. abscess
Cirrhosis Colorectal FNH Amoebic liver
Significant wt loss Breast abscess
& weakness Prostate
Ovaries
First investigation:

Can confirm by
CT Scan or ELISA

Confirm by
needle aspiration
& Blood CP
showing
leukocytosis and
neutrophilia
 Ultrasound

Suspicion of
Benign
malignancy

(1) Solid, (2) Complex Simple Cyst: (1) Clear

solid-fluid mass, (3) fluid, (2) Thin regular
Wall thickness wall, (3) Normal liver
irregular tissue around it.

Hydatid cyst: Multiple

small cyst

Abscess: Thick fluid

collection with septae
& liver parenchyma
around showing
reaction

Suspicion of malignancy:

 Tumor markers: CEA (Colorectal); Alpha-Fetoprotein (HCC); CA 9-19(Carcinoma

Pancreas)
 Tri-phasic CT Scan:
o Phase 1(Arterial); Phase 2 (Portal venous or Early venous); Phase
3 (Late Venous)
o Characteristic findings:
 HCC: Hyper-vascular; seen prominently in early arterial phase
 Haemangioma: Star burst
 FNH: Central Scar
 Adenoma & Mets: Hypo-vascular
  History & MRI will differentiate between adenoma &
Metastatic lesion

After ruling out HCC, Adenoma liver, and Hemangioma

 For metastasis:
 Ultrasound guided biopsy
 For primary
 Colorectal: Colonoscopy
 Gastro-duodenal: Upper GIT endoscopy
 Breast: Triple assessment
 Prostate: DRE, PSA, Ultrasound guided biopsy if hard lesion
 Pancreas: CT Scan/Endoscopy + ERCP
 Cervical Carcinoma: Pap smear.
Management

Metaststic disease Adenoma,

HCC Colo rectal mets
(Non Colo-rectal) Heamangioma

Not metastatic, if primary is Treat the Conservative

than do liver successfully metastatic disease. stop OCP
resection to excise treated without The treatment is > 4 cm, may
the carcinoma chance of local palliative) consider surgery.
Patient should be recurrence, treat
in Child A. the mets by
Remaining Liver Liver resection
should be 30% Ablation of mets
(normal), 60% by:
(Cirrhotic) Cryosurgery
RFA: Radio
Liver Tranplant if Frequency Ablation
cannot save 60% laser
cirrhotic liver & Alcohol injection
Patient meets
Milans Criterion.

EXAMINATION OF THE SWELLING

BEFORE STARTING
 INTRODUCTION AND CONSENT.
 POSITION & EXPOSURE. ACCORDING TO THE SITE THE AREA OF DRAINING
LYMPH NODES SHOULD BE EXPOSED.

INSPECTION
 SITE AND EXTENT
 SHAPE
 COLOUR
 SURFACE OVERLYING SKIN
  COUGH IMPULSE IF APPLICABLE
 MOVEMENT WITH RESPIRATION (Abdominal)
 VISIBLE PERISTALSIS/PULSATION

PALPATION
 1ST ASK FOR ANY PAIN IN THE SWELLING.
THEN:
1. 2 Ts i.e. TEMPERATURE & TENDERNESS. Check temperature with dorsum of
hand, 1st at normal skin then on the swelling.
2. INHERENT FEATURES OF SWELLING i.e.
o SIZE (in two planes)
o CONSISTENCY; SOFT (lip) FIRM (nose) HARD (forehead). Check whether
uniform or variable consistency.
o MARGINS; Regular or irregular, well defined or not.
o MOBILITY; Check in two planes.
o ATTACHMENT :
 Whether attached to overlying skin? Check by pinching of the
skin.
 If not attached to skin, tense the underlying muscle to see
whether situated below or above it. If it becomes more
prominent, it is situated superficial & vice versa.
3. “FLUID” THINGS i.e.
 FLUCTUATION; in two planes. Place index fingers on both sides of the
swelling. Keep one finger static and press the swelling with the other
finger. The fluid, if present, will strike the static finger.
 FLUID THRILL; in small swellings, place three fingers on the swelling and
tap the central one, the other two will feel the thrill. In large swellings, do
as done to check ascites.
 TRANSILLUMINATION; X-ray roll and torch placed at right angle.
 Resonance: Percuss the swelling. Solid and fluid-filled lumps sound dull
when percussed. A gas filled lump sounds hollow and resonant.
 PULSATILITY; Palpable pulse in the swelling.
 EXPANSILE: Fingers move apart.
 TRANSMITTED: Fingers move in same direction.

4. Reducibility & Compressibility:

a. Reducible: goes back on pressure & a stimulus required to reappear
b. Compressible: comes back by itself when pressure is removed
c. Cough Impulse: +ve in swellings which are in continuity with
i. Peritoneal cavity
ii. pleural cavity
iii. spinal anal & cranial cavity
5. Relations to surrounding structures
a. Skin: you cannot move skin over it.
b. Subcutaneous: skin is mobile, and the swelling moves over
contracted muscle underneath it.
c. Muscle: mobility diminished on contracting the muscle.
 d. Bone: swelling disappears, under bulk of contracted muscle

6. Check regional LNs & distal NV Status

Auscultation:
Bruit

GENERAL EXAMINATION

 History and examination provide data, which is required to answer the

following questions :
1. What is the tissue of origin? / From which tissue plane it is arising?
a. E.g is it from skin, subcutaneous tissue, muscle, or bone, in case
of a limb.
2. Any hard signs?
a. E.g. Lobulation, and slip sign in lipoma. Punctum in sebaceous
cyst.
3. Any effect on surrounding structures?
4. Proximal and distal effects of the swelling?
a. Includes distal neurovascular effect, or proximal lymph nodes.
5. Is it congenital, traumatic, and inflammatory or neoplastic?
6. What does the patient think has caused the swelling?

Relevant Questions:

 When noticed
 how noticed
 Progression
 Associated symptoms
 Any other swelling
Table: process of diagnosing a lump

Confirmation of diagnosis

FNAC

If inconclusive

Trucut biopsy

If inconclusive

Incisional / Excisional biopsy

Note: Ultrasound may help in diagnosis.

6
 HARD SIGNS

Sebaceous cyst Punctum

Lipoma Lobulations, Slip sign

Compressible Vascular

Reducible with cough impulse Hernia

Pulsatile (Expansile) Aneurysm

Thyroid swelling Moves on swallowing

Thyroglossal cyst Moves with tongue protrusion

How to describe:

 There is … cm, … shaped swelling in … region, with … overlying skin

 The swelling is … (tender or not), with … temp… consistency, … margins, mobile
or fixed & lying in … (region& superficial/deep to muscle) attached to skin or
not.
 It is … trans illuminant, … fluctuant, … pulsatile, …compressible or reducible with
… cough impulse
 Regional LNs are … & distal NV Status is …

Be prepared to answer following question in examination, if the case is of

swelling:

1. Describe your clinical findings?

2. What is your diagnosis?
3. Justify your diagnosis?
4. How will you confirm the diagnosis?
5. What is the treatment?
6. Why you want to operate?
 Examination of Inguino-Scrotal Swelling
Before Starting
Intro & Consent
Exposure: Umbilicus to Knee
Position: First Standing then Lying

Inspection:
 Make Pt Stand & Inspect from Front
 Site & Extent: Whether swelling is inguinal, inguino-scrotal or
scrotal
 Shape:
 Overlying Skin: Temp, redness, scar
 Visible Cough Impulse: Done twice. Look At normal & Then
abnormal site
Palpation:
1. From Front:
 2 T`s i.e. temp & Tenderness
 Get Above the Swelling: If Extending into the scrotum, can`t get
above the swelling. Testis can always be felt separately in adult
hernias
 Consistency
 Size
2. Look at skin of post. Aspect of scrotum, external ureteral meatus for
any structure (predisposing to hernia) & palpate spermatic cord,
penile urethra.
3. Now stand up & Go to the hernial side:
 Standing in line with pt, place one hand behind the pt to
support him & with the other hand palpate the hernia,
trying to reduce it.
 If it is reduced, do a palpable cough impulse,. Hand should
be placed roughly on superficial ring to feel the impulse.
Percussion:
Make the pt Lie on the Bed:
 If the hernia was not reduced while standing, now first ask pt to
try & reduce it.
 If it doesn’t reduce, flex the ipsilateral leg at knee & internally
rotate hip. It should reduce now.
 If still doesn’t reduce, declare it irreducible.
 Don’t perform ring occlusion test in irreducible hernia.
Check for Predisposing Conditions:
1. Auscultate Chest (Chronic Bronchitis)
2. DRE (for BPH)
3. Palpate abdomen for any mass, ascites, enlarged bladder
J
Ring Occlusion Test: (Two Finger Method)
 First localize pubic tubercle by one the two methods:
 From umbilicus go straight down, 1st bony projection felt is pubic
symphysis, just lateral to it is the tubercle.
 Ask the pt to adduct thigh against resistance. The adductor longus get
prominent& guides to its attachment i.e. pubic tubercle.
 1.25cm above midpoint of symphysis pubis & Ant. Sup. Ileac spine is
deep ring. 1.25cm above the pubic tubercle is superficial ring.
 Place your thumb on deep ring & index finger on superficial ring after
reducing hernia. Ask the pt to cough. If swelling appears, it is femoral
hernia. Now remove pressure on the superficial ring, if swelling appears
on cough, it is direct hernia. Indirect hernia can only appear if pressure
on deep ring is removed.
Zieman`s Test: A modification of above test. A 3rd finger is placed on femoral ring
(middle finger) to check for femoral hernia.
If it continues to scrotum, note the following:
 Tender or Non-tender
 Transilluminant or Not: Torch & X-ray roll should be in one line. Don’t
place on exactly post aspect of scrotum as testis comes in between.
 Testis separately palpable or not: if palpable, check tenderness,
consistency, sensation, position, weight
 Flactuation: Hold the upper pole of swelling between thumb & index
finger of one hand & apply intermittent pressure at the lower pole by
other hand.
 Palpate Epidydimis: Palpate on post aspect of testis
 Palpate Spermatic Cord: Between thumb & Index Finger at the root of
scrotum. Note tenderness & Thickness
 Swelling reducible on lying down or not (Varicose, Congenital
hydrouretor)
 Palpate Lymph Node:
Para-aortic ( Testicular Malignancy)
Inguinal
 Examine Kidneys: Renal growth gives rise to varicose
Lung: Mets, TB
Liver: Mets
Gynacomastia: Feminizing testicular tumors
Flow Chart on Browse (Page # 356)
Relevant Questions:
 Duration
 Associated Symptoms e.g Pain, Obstruction.
 Ask for predisposing factors: Cough, Smoking, LUTS (lower urinary tract
symptoms),
 Constipation, H/O weight lifting, previous surgery i.e. Appendectomy,
Herniorraphy
How to Describe:
Hernia

 There is …. cm, globular swelling in the … side inguinal region, which

is … (extension) into the sacrotum, with … overlying skin & visible
expansile cough impulse.
 It is…(tender) with.. temp & … margins & can’t get above the swelling
 It is … (reducible) , has …(palpable) expansile cough impulse & ring
occlusion test is … for … (direct/Indirect) inguinal hernia
 Auscultation of chest is…, Prostate is … (Enlarged) on DRE & there is
… palpable mass in abdomen.
Scrotal swelling

 The… (Side) scrotum is enlarged. Measuring approx. … with..

overlying skin & hangs down more as compared to … side & im
able to get above the swelling
 It is … 9tender), has … Temp, … consistency, … (Fluctuant & Trans
illuminant)
 The testis is … separately in its … position & ( non-tender) with …
consistency & … sensation
 The epididymis 7 spermatic cord are palpable … (normally)
 The para-aortic & inguinal LNs are …, there is palpable abdominal
mass & chest is … (clear)
INGUINAL HERNIA
 History and examination provide data to answer the following questions:
1. Is it hernia?
a. The swelling is reducible, and has expansile cough impulse.

2. Is it a direct or indirect inguinal hernia?

a. Deep Ring Occlusion Test:
i. If on occlusion of deep ring the hernia appears, it is indirect
inguinal hernia.

3. Is it simple or complicated?
a. Reducible
b. Irreducible
c. Obstructed
i. Patient has irreducible inguinal hernia with clinical features of
intestinal obstruction. These are pain abdomen, vomiting,
abdominal distention and absolute constipation.
d. Strangulated
i. Patient has irreducible inguinal hernia, and severe pain at hernia
site. The hernia is tender.

4. Are there any predisposing causes?

a. Chronic cough
i. Patient may be having chronic obstructive airway disease.
b. Chronic constipation
c. Chronic urinary obstructive symptoms.
i. Patient having prostatism.
 5. What problem is it giving to the patient?
a. Discomfort / pain

6. What is the clinical variety of the indirect inguinal hernia?

a. Bubonocele
i. The swelling does not go beyond pubic tubercle.
b. Funicular or incomplete.
i. The swelling goes beyond pubic tubercle, but does not reach
bottom of scrotum.
c. Complete
i. The swelling reaches up to bottom of scrotum.

7. What are the contents of the inguinal hernia?

a. Intestine
i. Bowel sounds present; Initial portion reduces with difficulty,
then the rest reduces easily.
b. Omentum
i. No bowel sounds; Initial portion is easily reducible, but last
portion reduces with difficulty.

QUESTIONS ASKED BY EXAMINER

1) What are your clinical findings?
a) Swelling inguinal region; Reducible; Expansile cough impulse present; Ring
occlusion test is positive or not.

2) What is the diagnosis?

a) E.g right inguinal hernia.

3) Is it a direct or indirect inguinal hernia? Why?

a) E.g Indirect inguinal hernia. When the deep inguinal ring is occluded, swelling
does not appear on coughing or standing. When the occluding thumb is removed,
the swelling re-appears.

4) What do you want to do?

a) Operate/ not operate.

5) Why do you want to operate/not operate?

a) Discomfort to the patient.
b) Complicated inguinal hernia.

6) When would you want to operate?

7) Which operation would you want to do? Why have you chosen this operation?
a) Lichtenstein mesh repair ;

8) What operations for inguinal hernia do you know of?

a) Bassini herniorrhaphy
b) Shouldice repair
c) Lichtenstein mesh repair
d) Prolene darning
e) Laparoscopic repair
9) Laparoscopic repair. Principle?
a) TAPP (Transabdominal Preperitoneal)
i) TAPP requires access to the peritoneal cavity with placement of a mesh
through a peritoneal incision. This mesh is placed in the preperitoneal space
covering all potential hernia sites in the inguinal region. The peritoneum is
then closed above the mesh leaving it between the preperitoneal tissues and
the abdominal wall where it becomes incorporated by fibrous tissue.

What is your diagnosis? It is an Inguinal hernia?

It is an inguino scrotal It is inguino-scrotal swelling because I cannot get above the

swelling or scrotal swelling? swelling.

Why do you say it is hernia? The swelling has expansile, cough impulse.

Why it is inguinal hernia? It is in inguinal region.

Is it direct or indirect It is direct / indirect hernia because on ring occlusion test the
hernia? swelling appears / not appears.

Where is deep ring? It is above the point between pubic tubercle, and anterior iliac
spine.

Which clinical variety of It is bubonocele / funicular / complete because the swelling is

indirect hernia it is? up to pubic tubercle / beyond pubic tubercle in to scrotum /
reaching up to base of scrotum.

Why hernia occurs? In young man due to persistent Processes Vaginalis. In old
man because of degeneration of wall, the area becomes weak.

Which factors predispose to Urinary obstruction (prostatism), chronic constipation,

hernia? chronic cough.

What is the treatment? Herniorrhaphy.

Why you want to operate? It is causing symptoms. The natural history is progressive.

Which operation? Lichenstein Mesh repair?

Why mesh repair? It has least recurrence rate?

Why mesh repair has least It is tension free.

recurrence rate?

Name other operations? Shouldice, Bassini, and Darning.

What is principle of Double breasting of deep fascia.

Shouldice repair?

What is principle of Bassini Joining conjoint tendon with inguinal ligament.

repair?

What is principle of A mash of prolene is created between conjoint tendon and

Darning? inguinal ligament.

Which is most important Fascia tranversalis.

layer in hernia?
What is difference between In herniorrhaphy local tissue is used to strengthen the
herniorrhaphy, and posterior layer. In hernioplasty foreign tissue is placed to
hernioplasty? strengthen the posterior wall.

What you will do if patient Optimize the patient by treating chronic cough, constipation,
has predisposing causes? or prostatism.

Name laparoscopic repairs? TAPP (Trans Abdominal Pre Peritoneal) and TEP (Totally
Extra Peritoneal) repairs.

TAPP (Trans Abdominal Pre TAPP requires access to the peritoneal cavity with placement
Peritoneal))? of a mesh through a peritoneal incision. This mesh is placed in
the pre peritoneal space covering all potential hernia sites in
the inguinal region. The peritoneum is then closed above the
mesh leaving it between the pre peritoneal tissues and the
abdominal wall where it becomes incorporated by fibrous
tissue.

TEP (Totally Extra In TEP the peritoneal cavity is not entered and mesh is used to
Peritoneal)? seal the hernia from outside the peritoneum. The mesh
becomes incorporated by fibrous tissue.

What is triangle of doom The apex is at deep ring. The lateral margin is gonadal vessels.
The medial margin is vas deferens. In it is major vessels.

Swelling at wound site on The diagnosis is hematoma. The treatment is open the wound,
the day of operation. evacuate hematoma, secure bleeding point.
Diagnosis and treatment?

Swelling at wound site on 4th If no signs of inflammation:

– 5th post op day. Diagnosis Diagnosis: Seroma
and treatment? Treatment: Repeatedly aspirate till dryness

If signs of inflammation are present

Diagnosis: Abscess
Treatment: Open the wound; Drain the pus; Do NOT remove
the mesh

When to remove mesh? If infection becomes persistent?

 HYDROCELE
Step 1. Confirm it is a scrotal swelling.
Feel the spermatic cord above the scrotal swelling. If it is felt the swelling is scrotal.

Step 2. Confirm it is hydrocele.

If the swelling is (1) non-tender, (2) trans illuminant by doing trans illumination
test., and (3) testis and epididymis are NOT definable, than it is a hydrocele.

Step 3. Is it primary or a secondary hydrocele?

Primary hydrocele Secondary hydrocele
It is large & tense It is small & lax
H/O
dysuria, pain (epididmorchitis)
Loss of sensation in testis (Testicular
tumor)

Step 4: Investigations.
a. Ultrasound scrotum. Confirms dx (Also tells prim or sec & cause of sec)
b. For secondary hydrocele add following investigations:
i. Epididymorchitis: (1) Urine RE & CS, (2) Blood CP.
ii. Testicular Tumor: (1) Tumor markers: Alpha FP, Beta HCG, LDH.
(2) Ultrasound abdomen for Para-aortic lymph nodes.

TREATMENT PRIMAY HYDROCELE

Aim: at the end of operation the volume of tissue on the affected side should be roughly
same as on healthy side.
Evaluation: The size and thickness of Tunica Vaginalis will decide that in order to
reduce the size to normal, you have to
Evert the sac (Operation name: Jabouley )
Evert the sac & plicate the loose Tunica Vaginalis (Lords Operation)
Excise the sac (Operation name: Excision of sac)

TREATMENT OF SECONDARY HYDROCELE

Secondary hydrocele due to

Testiular tum or
epididym orchitis
Antibiotics: Tablet Ciproxin 250 m g 8 Radical orchiectom y using inguinal
hourly approach
Change antibiotic if necessary on c?s if there i,s doubt, expose inguinal canal.
report. Apply soft clam p on the sperm atic cord
at level of deep ring. Deliver testis into
the operation w ound. Split open the
testis, like splitting open an apple. If
tum or seen do radical orchiectom y. If
norm al, close the testis halves and stitch
tunica to hold the tw o halves together.
Stage the tum or.
Furthur treatm ent depends upon stage.
the prim ary treatm ent is chem otherapy.
 Lymphoma
Q-1: Clinical differences between Hodgkin lymphoma and Non Hodgkin
lymphoma:

Hodgkin Lymphoma Non-Hodgkin Lymphoma

Suspect Involves cervical lymph node Involves an organ, a lymph

group, followed by node at uncommon site
involvement of adjacent
groups, progressing to
involve axillary or inguinal
group

Age Young Middle aged

Systemic signs Absent Present

Q-2: Histological difference between Hodgkin lymphoma and Non Hodgkin

lymphoma:

Reed-Sternberg cells are present in Hodgkin lymphoma.

Q-3: If FNAC shows lymphoma, what to do?

Needs lymph node excision, to determine type of lymphoma because treatment depends
upon histology.

Q-5: Which lymph node should be biopsied?

Cervical; in the center of group; largest; on which FNAC has not been done.

Q-6: Staging of lymphoma

Lymph node group: Named group of lymph node.

Extra lymphatic site: any organ other than spleen, thymus.

Stage-I: A single lymph node group OR a single Extra lymphatic site.

Stage-II: A single lymph node group PLUS an adjacent lymph node group OR Extra
lymphatic site ON ONE SIDE OF DIAPGRAGM.
Stage-III: Both sides of diaphragm are involved.
Stage-IV: involvement of Bone marrow.

To stage CT scan abdomen & Lung + Bone marrow biopsy is done

Q-7: Staging Laparotomy?

Includes Splenectomy, Biopsy of Liver, and Biopsy of Para-aortic lymph nodes.

 Examination of Salivary Glands
Parotid Gland
Before Starting
Intro & Consent
Exposure: Face & Neck
Position: Sitting on stool

Inspection & palpation:

1. Area of parotid: Below, behind & slightly in front of the ear lobule. It
obliterates the normal hollow below the ear lobule.
2. Check movements of jaw
3. Features of swelling:
o 5 S (Site, size, shape, surface, skin)
o Temp, tenderness, consistency, fluctuation
o Fixity to skin & masseter muscle: Ask the pt to clench his teeth for
masseter contraction & then move the swelling in both plane. If
movement decreases, it is fixed to masseter.

4. Parotid Duct ( Stenson`s): Ask the pt to clench his teeth. The duct can be
palpated just above the masseter border. Look for its thickening,
tenderness, its orifice in mouth on the buccal mucosa opp to upper 2 nd
molar tooth. Note any discharge (pus, blood) from orifice, when gland
pressed from outside.
5. Examine the gland bimanually for deep part:
Place one hand behind ramus of mandible & finger of other hand
inside the mouth in front of the tonsil. Check for tenderness, consistency 7
calculus
6. Examine Facial nerve:
7. Go to pt`s back 7 check all cervical LNs
 Submandibular Gland
 Position, exposure as above
 Features of swelling as above
 Submandibular (Wharton`s) Duct:
o Inspect the floor of mouth on both sides of the frenulum or the
orifice of SM duct. Look for any pus discharge. Giving lemon juice
to pt will cause secretions instantly
 Bimanual palpation:
o Place one finger of the hand on the floor of mouth pushing it
backward & fingers of other hand placed just medial to the inferior
margin of mandible

Relevant Questions:
o Questions of swelling
o Does swelling increases in size & get painfull during meals?

How to Describe:
 As described in swelling
 The swelling is palpable bimanually indicating its origin from … gland &
the parotid/SM duct is… thickened & there is … discharge from the duct
orifice
 The facial nerve is … (intact) & … LNs are palpable.
 Examination of The Knee Joint
BEFORE STARTING
 INTRODUCTION & CONSENT
 EXPOSURE: UPTIL INGUINAL REGION, ALWAYS EXPOSE BOTH SIDES.
 POSITION : SUPINE

INSPECTION (LOOK)
1. SWELLING; If present note whether localised or generalised.
2. MUSCLE WASTING
3. POSITION OF PATELLA, WHETHER AT SAME LEVEL ON BOTH SIDES
Extensor apparatus which is responsible for extension of knee joint consists of 4
structures
Quadriceps Femoris
Patella
Ligamentum patellar
Tibial tuberosity
 In case patient is unable to extend the knee, there should be a lesion of
Femoral nerve OR any of the above structures.
 If femoral nerve is intact, then in case of lesion of the b,c,d, the patella
will be displaced superiorly. If lesion of a, level of patella will be same.
4. SCAR MARKS, SINUSES
5. ANY VALGUS (Outward) OR VARUS (Inward), LEG DEFORMITY

PALPATION (FEEL)
1. TEMPERATURE
2. TENDERNESS ; CHECK AT THREE SETS OF POINTS
 At the level of superior attachments of collateral ligaments on the
femoral condyles.
 At level of joint line (Approx at junction of upper 2/3rd & lower 1/3rd of
patella).
 At the level of inferior attachment of collaterals on the head of fibula and
upper end of tibia.
 Check patellar tenderness; superficial surface and articular surface as
well by moving the patella sideways.
 Slide patella up and down over the femur to assess patello-femoral joint.
3. CHECK FOR EFFUSION IN JOINT ; PATELLAR TAP TEST
With left hand, push the patella inferiority, and stroke the patella down
with right hand. A characteristic tap is heard in effusion as the patella strikes the
underlying bone.
4. CHECK INGUINAL LYMPH NODES & DISTAL N.V. STATUS.

MEASUREMENTS
IF QUADRICEPS MUSCLE WASTING IS SUSPECTED ON INSPECTION, THEN
MEASURE BOTH THIGHS FROM A FIXED BONY POINT, AND COMPARE.
MOVEMENTS
FLEXION AND EXTENSION ARE MAIN MOVEMENTS AT KNEE JOINT.

 FLEXION: In supine position, heel should touch the hip. If not, measure the
distance between
heel and hip and compare with other side. If distance is equal, then flexion is
okay.
 EXTENSION: Ask the patient to lift the legs off the bed straight up in the air or
check in sitting position with legs freely hanging by bedside.
o If extension is not possible, check sensations in femoral nerve territory.
o If normal, problem is in extensor apparatus.
o If patella was displaced superiorly on inspection, you know that lesion
may be in:
 PATELLA e.g. transverse fracture of patella
 LIGAMENTUM PATELLAE i. e. complete rupture
 TIBIAL TUBEROSITY i e. avulsion fracture
 XRAYS WILL HELP TO DIFFERENTIATE BETWEEN THE ABOVE THREE.
o If patella is in normal position, lesion is suspected in quadriceps. Palpate
along the whole length of this muscle starting from below for any
obvious defect showing complete muscle rupture. Compare with normal
side.

SPECIAL TESTS
REMEMBER THREE SETS OF LIGAMENTS
1. MEDIAL AND LATERAL COLLATERALS
2. ANTERIOR AND POSTERIOR CRUCIATES
3. MEDIAL AND LATERAL MENISCI
STRESS TESTS FOR COLLATERALS
 VALGUS STRESS FOR MEDIAL COLLATERALS
 VARUS STRES FOR LATERAL COLLATERALS
o Flex the leg at knee to about 30^, place left hand on the knee and right
hand on the ankle. Keep left hand static and when the right hand pulls
the leg outward, it is valgus stress. When it pushes it inward, it is varus
stress. With left hand feel opening up of joint on the side being tested.
o Positive stress test with extended knee shows increasing severity of tear.

DRAWER TESTS FOR CRUCIATES

 ANTERIOR DRAWER FOR ANTERIOR CRUCIATE
 POSTERIOR DRAWER FOR POSTERIOR CRUCIATE
o Flex both the legs and sit yourself on the patient's feet so as to stabilize
them. Pull the tibia forwards for anterior drawer and posterior for
posterior drawer. Any excess movement of tibia more than that on
normal side is indicative of some tear.
LACHMANN'S TEST FOR ANTERIOR CRUCIATE
o This is specific for anterior cruciate. Flex the leg to about degrees. Hold the lower
anterior part of thigh with left hand and with right hand hold the upper part of
tibia from behind. Now keeping the left hand static for stabilisation, try to move
the tibia anteriorly with right hand. If excess movement is positive, test is
positive.
MCMURRAY's TEST FOR MENISCI
o 1st flex the leg at knee.
o Adduct the hip, turn the foot inwards and slowly extend the leg for LATERAL
meniscus.
o Opposite of it is for MEDIAL meniscus.
 TEST IS POSITIVE IN CASE OF ANY PAIN, LOCKING OR CLICKS DURING THIS
MANEUVER.
SLOKUM TEST
o A modification of drawer test. Place the knees in flexed position, if you externally
rotate the foot and then do anterior drawer, it will check anterior cruciate and
medial collateral. If you internally rotate the foot and do anterior drawer, it will
check anterior cruciate and lateral collateral.
PATELLAR APPREHENSION TEST
o Done in recurrent dislocation of patella. Keep patella pushed laterally while
flexing the knee from an extended position. The test is positive if patient stops
the examiner as the manoeuvre cause dislocation of patella.
NOW LAY THE PATIENT PRONE AND INSPECT POPLITEAL FOSSA THEN DO

APLEY's DISTRACTION AND GRINDING TESTS

a) DISTRACTION TESTS: For collaterals, flex the leg at right angle. Place your knee
on the back of thigh to stabilize it. With both hands pull the foot upwards. Now if
you rotate it medially, any painful feeling by the patient will be due to lateral
collateral. If you rotate it laterally, medial collateral will be checked.
b) GRINDING TEST: For menisci, flex the leg at right angle. Push the foot
downwards to engage the menisci. Now the external rotation of foot will check
medial meniscus and internal rotation will check lateral meniscus.
YOU CAN CHECK THE GAIT IN THE END BY ASKING THE PATIENT TO WALK.

RELEVANT QUESTIONS
1. ABLE TO STAND IMMEDIATELY AFTER THE INJURY.
2. SWELLING AFTER THE INJURY IMMEDIATELY (in cruciate injury)OR DELAYED
(in meniscal injury)
3. DIFFICULTY IN CLIMBING STAIRS (cruciate injury)
4. CLICKS OR CLUNGS
5. ANY HISTORY OF LOCKING (meniscal injury )

HOW TO DESCRIBE
 ON INSPECTION, THE KNEE IS ____ SWOLLEN, THERE IS ____ MUSCLE WASTING
OR LEG DEFORMITY AND PATELLA APPEARS TO BE AT ____ POSITION.
 THERE IS ____ TENDERNESS AT ____ (SITE) WITH ____ TEMPERATURE.
PATELLAR TAP TEST IS ____ THERE IS FULL RANGE OF FLEXION AND
EXTENSION OR FLEXION /EXTENSION IS LIMITED TO ____ DEGREES.
 _____ TEST IS POSITIVE SHOWING LESION OF ____ LIGAMENT, REST OF THE
LIGAMENTS ARE INTACT AND PATELLAR APPREHENSION TEST IS _____
 THE REGIONAL LYMPH NODES ARE _____ AND DISTAL N-V STATUS IS ____
 Examination of Vascular System
Before Starting
Intro & consent
Exposure: both limbs
Upper Limb: whole upper body up till nipple
Lower Limb: up till umbilicus
Position:
Sitting in upper limb
Lying supine in lower limb

Inspection:
1. Colour of limb
2. Muscle wasting
3. If an area of Gangrene describe:
a. Area involved
b. Line of demarcation formed or not (well formed in dry gangrene)
c. Area proximal to gangrene normal (dry gangrene) or showing
signs of inflammation (wet gangrene)
d. Local signs of ischemia: hair loss, shiny skin, loss of S/C fat,
brittle nails with transverse ridges
e. Any ulcer, visible veins, scar marks

Palpation
 Temp: check proximal part than distal (to compare). Compare with normal limb
 Tenderness: check in calf for DVT
 Look in hidden areas for any ulcer: inter-digital areas, back of leg, axilla
 Check Berguer`s Angle simultaneously when looking at the back of leg:
Raise both legs by placing right hand beneath both feet. Note the
angle at which sole colour gets pale. Then with other hand passively dorsiflex &
plantiflex the ankle joint. (Modified Berguer Test) which will cause calf pain to
the pt. then ,make the pt to sit & look for reappearance of pink colour in affected
limb.
 Capillary Refill: press at pulp of nail beds. Compare with other side
 Venous Refill: (Harvey`s Sign): empty a segment of superficial vein with 2
fingers. Then remove the distal one & note the speed of refilling. Compare with
other
 Crepitus: +ve in gas gangrene
 Pulses: distal to proximal or vice versa. Always compare.
o Dorsalis Pedis: place right hand on sole to keep the ankle in 90o
dorsiflexion & place fingers of left hand in the 1 st web space at mid tarsal
level.
o Post. Tibialis: Place leg in position in which ankle jerk is checked i.e. ext.
rotation at hip, flexion at knee & dorsiflexion of ankle joint. Place fingers
about 1/3rd of the way between the medial malleolus & heel.
o Popliteal: Flex leg at knee & place fingers of both hands in the lower half
of the popliteal fossa with thumbs in front. If doubtful, palpate it in prone
position with extended knee.
o Femoral: between ASIS & pubic symphysis.
 Sensations: Impaired in ischemia. “Glove & Stocking” sensory loss in DM>
  Suspected Muscle wasting: Girth of muscle from a fixed bony point.
 Examine Regional LNs.

Auscultation
 For bruit over Axillary, Carotid, Aorta, Femoral & Popliteal arteries.
 Machinery murmur in AV fistulas.
In Upper Limb: examination is same as above except following:
1. Pulses:
 Radial, Radio-radial & radio-femoral delay
 Brachial artery: medial to biceps tendon in cubital fossa
 Axillary artery: centre of axilla
 Subclavian artery: just above the middle of clavicle
 Carotid artery: just in front of sternomastoid below the angle of mandible
 Allen`s Test: (for Ulnar & Radial arteries)
o press both ulnar & radial arteries & ask the pt to open & close the
fist. The palm will turn white. Now release pressure on radial artery,
the colour of palm should return to pink. Repeat by releasing
pressure on ulnar artery. Compare the speed of colour change. It
should be equal in both.
2. Thorasic Outlet Syndrome: if u are suspecting it, then perform:
Adson`s Test: Ask the pt to take a deep breath in & hold his breath with
head turned towards effected side. The radial pulse if gets weaker, the test is
+ve. It signifies cervical rib.
Hyper Abduction Test: Abduct the affected arm above 90o while feeling
radial pulse. If it gets weaker, the test is +ve. Signifies Pect. Minor syndrome.
Costo-Clavicular Compression Test: Ask the pt to throw shoulder
downward & backward as an exaggerated military position of standing
attention. If radial pulse gets weaker, it signifies compression of sub-clavian
artery between clavicle & 1st rib.
3. Check BP on both arms

Relevant Questions:
 About pain, at rest or intermittent claudication, walking distance
 H/O chronic illness i.e. IHD, DM
 H/O smoking

How to Describe:
 On inspection, there is … discoloration of … with local signs of ischemia like …
Line of demarcation is … (well-formed/not) & area immediately proximal is …,
there is … muscle wasting, ulcer or visible veins.
 The temp of … area is …, capillary refill is … venous refill is …, peripheral pulses
are … (palpable) bilaterally & there is … LNs palpable.
 The Berguer`s angle appears to be … with +ve modified Berguer`s Test. Power is
…, sensations are … & there is … bruit audible.
 EXAMINATION OF VARICOSE VEIN
BEFORE STARTING

 INTRODUCTION AND CONSENT

 EXPOSURE: whole lower limb up to umbilicus. pt should wear underwear
 POSITION:
standing at a place where you can go all around the pt
lying

INSPECTION AND PALPATION (Pt Standing)

1. Note the site and course of varicosities. Go all around the pt.
a. LONG SEPHENOUS: passing in front of medial malleolus, ascending on
medial aspect, passing behind the knee and then reaching onto anterior
aspect of thigh, at about its mid-point and terminating into S-F junction
at about 3-4cm lateral to pubic tubercle.
b. SHORT SEPHENOUS: passing behind lateral malleolus and ascending on
the calf, terminating in S-P junction in popliteal fossa.
c. LOOK FOR ANY VARICOSITIES IN SCROTUM OR ABDOMEN

2. LOOK FOR ANY SKIN CHANGES SECONDARY TO VARICOSE VEIN

a. Eczema
b. Varicose ulcers in GATTER's area: just above the medial malleolus.
c. Lipodermatosclerosis: skin thickening + edema + fibrotic change.
d. Pigmentation scar marks

3. NOTE VISIBLE COUGH IMPULSE AT S-F JUNCTION (Morrissey's sign)

4. SCHWARTZ's SIGN: Tap a varicosity and feel for thrill at just below S-F junction.
Now place one hand on the varicosity and percuss at S-F junction. The lower
hand will now feel the thrill.
5. NOTE ANY SCAR MARKS AND VISIBLE PULSATIONS.
6. MARK THE VARICOSITIES (with pt's permission)
NOW MAKE THE PT LIE ON BED SO THAT AFFECTED LEG IS TOWARDS YOUR SIDE.

1. PALPATE THE ABDOMEN AND PELVIS FOR ANY MASSES. ALSO PALPATE THE
INGUINAL LYMPH NODES.
2. FEGAN's TEST: place the leg on your shoulder and feel on the marked side for
and defect in deep fascia which feel like circular openings with sharp margins.
 NOTE : if on raising leg, veins don't collapse, it may be an A-V fistula or
extensive ileofemoral DVT
3. SINGLE TORNIQUET TEST:
a. Empty the veins (in same position while the leg is on shoulder) and apply
a single tourniquet on the upper thigh as high as possible. Make the pt
stand & see for the varicosities refilling. If they fill on opening the
tourniquet, S-F junction is incompetent.
b. If there were small saphenous varicosities on inspection, do the test by
applying tourniquet on S-P junction.
 4. MULTIPLE TORNIQUET TEST:
(Generally not required, however can be done if S-F junction is intact)
For this make pt lie again, empty veins and apply 5 tourniquets
 3 at 5, 10, 15 cm above medial malleolus.
 1 above knee
 1 mid-thigh
Start opening from below and observe the varicosities refilling on opening of any
tourniquet.

5. MODIFIED PERTHE's TEST:

again apply tourniquet at about S-F junction and ask pt to work out. If he
develop severe pain in calf or varicosities get 15 times more prominent it
signifies DVT.

AUSCULTATION:

IF THERE IS SUSPECTED A-V FISTULA, THEN LISTEN FOR BRUIT OVER THAT
AREA.
NOTE: there are no perforators in small saphenous system.

AFTER THE EXAMINATION YOU MUST KNOW:

 WHETHER PRIMARY OR SECONDARY VARICOSE VEINS?

 LONG OR SHORT SAPHENOUS SYSTEM?

RELEVANT QUESTIONS:

 Duration
 Any predisposing cause: previous pelvic/inguinal surgery, radiation to inguinal
region, pregnancy or pelvic mass.
 What symptoms does it give to pt?
HOW TO DESCRIBE:
 There are multiple dilated, tortuous, superficial veins present in ----region. The
skin of lower leg is ------and SCHWART's sign in ------. The cough impulse is -----
and there are ------- scar marks etc.
 Tourniquet test shows ------ S-F junction and ----- valves incompetence. NO
abdominal or pelvic mass is -------.Inguinal lymph nodes are ----- and PERTHE's
test is ---- showing ----- (normal) deep veins.
Description:
 The patient has dilated tortuous elongated veins.
o (Confirms varicose veins)
 These are present on present on medial side of leg, and thigh / lateral and
posterior side of leg.
o (Confirms Long Saphenous / Short Saphenous system involved)
 There are skin changes / no skin changes (Discoloration, thickening)
o (Confirms Lipodermatosclerosis)
 There is no ulcer on medial side of lower leg / ulcer that is shallow, with
slopping edges, has granulation tissue visible in floor, base is mobile, with or
without infection and slough.
o (Confirms Varicose Ulcer)
 There is swelling present / absent in the lower leg.
o (Confirms DVT)
  On coughing there is cough impulse present / absent on the medial side of groin.
o (Confirms SFJ incompetence)
 The veins are not tender or indurated.
o (Confirms Thrombosis of vein)
 I can feel / do not feel fluid thrill on coughing when I feel swelling medial side of
groin.
o (Confirms SVJ incompetence)
 I can feel / do not feel thrill at the lower end of column of varicose vein when I
percussed the column of veins at the top.
o (Schwartz test: Confirms Incompetence Vein Valves)
 The skin is thickened and warm.
o (Confirms Lipodermatisclerosis)
 After emptying the veins on lying down I do not feel any defect in the fascia
when I palpate the veins.
o (Confirms Incompetent Perforators)
 On deep palpation I do not feel any mass abdomen
o (Confirms Secondary Varicose: Intra abdominal mass)
 The single tourniquet test:
o Is positive because after emptying the veins I applied a tourniquet just
below the SF Junction. On standing the varicose veins did not fill. When I
released the tourniquet the varicose vein filled
 (Confirms SFJ Incompetence)
o OR the test is negative because on standing the varicose veins filled and
when I released the tourniquet the varicose vein did not fill more.
 (Confirms SFJ is Competent)
 On auscultation there is no bruit on the varicose vein.
o (Confirms Secondary Varicose Vein: AV Fistula)
 The Perthes test appears to be positive because when I applied the tourniquet in
the upper leg and asked the patient to walk he experienced pain and discomfort
on walking.
o (Confirms DVT)

Questions / Answers
1. Why do you say it is varicose vein?
a. Veins are dilated, tortuous and elongated.

2. Which system is involved?

a. It involves:
i. Long saphenous system because it is present on medial side of
leg, and thigh.
ii. Short saphenous system because it involves lateral and posterior
side of leg.

3. Is it primary or secondary?
a. It is primary because
i. There is no past history of DVT, swelling of legs (DVT)
ii. On examination of abdomen there is no mass abdomen (Mass
compressing veins)
iii. The affected limb does not show gigantism, the varicose veins are not
present at abnormal sites & there is no bruit or thrill on varicose veins.

4. Why he has primary veins?

a. There is incompetent SV junction and / incompetent perforators.

5. Why do you say SF junction is incompetent?

 a. After emptying the veins I applied a tourniquet just below the SF
Junction. On standing the varicose veins did not fill. When I released the
tourniquet the varicose vein filled.

6. Why did you do multiple tourniquets test after single tourniquet test?
a. After emptying the veins I applied a tourniquet just below the SF
Junction. On standing the varicose veins filled.
b. When I released the tourniquet:
i. The varicose vein filled even more and became more prominent.
It means in addition to incompetent varicose veins, incompetent
perforators are also present.

7. How did you interpret the multiple tourniquet test?

a. After emptying the veins I applied a tourniquet just below the SF
Junction, above the knee, below the knee, middle of leg, and lower leg.
b. On standing the veins became filled between “this and this tourniquet”.
Therefore the perforator is between these two tourniquets.
c. On standing I started releasing the tourniquets from downwards
upwards. The veins filled after releasing “this (name it)” tourniquet.
There fore the incompetent perforator is present just above or at the site
of tourniquet released.

8. How do you confirm the in competencies?

Duplex Ultrasound.

9. Why you want to operate?

a. The patient feels ache and pain in legs after prolonged standing, or work.
b. The complications (Skin changes, Ulcers) are present. These are
progressive.
c. The veins are cosmetically unacceptable to the patient.

10. What operation you will do?

a. I will do (1) Flush ligation of SV junction, with ligation of all tributaries at
SV junction, (2) stripping of saphenous vein up to knee, and (3) stab
avulsion of remaining varicose veins.

11. Why you want to strip the saphenous vein up to knee?

a. To avoid damage to saphenous nerve that cause sensory loss on medial
side of lower leg and foot.

12. Why you want to do all three procedures in all cases?

a. The recurrence rate is less

13. What are complications of varicose veins?

(1) Skin changes, (2) Varicose Ulcers, (3) Hemorrhage, (4) Thrombosis.

14. What is the postoperative care?

(1) Apply crepe bandage from toes to thigh. (2) Keep leg
elevated on the pillow. (3) Mobilize the patient next day
with crepe bandage on.
 Examination of Ulcer
Before Starting
Intro & Consent
Position & Exposure: According to the site area of draining
LNs should be exposed
Inspection:
 Site & number
 Shape --- (Regular / irregular)
 Visible discharge --- (Pus / reddish / serous)
 Surrounding skin
 Margin
 Edge
 Floor

Palpation:
Ask for any pain in ulcer
then
 2 T`s ( Temp & tenderness) Check Temp of surrounding skin & compare
with normal skin
 Size (Wear a glove for proper palpation)
 Base: the portion of ulcer just beneath the floor. Check for tenderness,
induration & attachment to underlying structures
 Depth: check in mm
 Check regional LNs & distal N-V (Neuro-vascular) Status
 Note: If there is H/O DM or ischemia, additionally check
o Hidden areas for any ulcers i.e. interdigital areas, back of leg.
o Dermatoses ( Glove & stocking loss in DM)
o Sense of vibration (1st to go in DM) check with tuning fork
o Power & Deep tendon jerks (Diminished in DM)

Relevant Questions:

 When noticed
 Progression
 Character of discharge
 H/O trauma, DM ( if on lower limb) Features of ischemia
 Associated symptoms (pain)
 Any other ulcer

Shapes of ulcer
Sloping ------ Healing

Punched out ---- Syphilis, Trophic ulcer

Undermined ---- TB

Rolled Up ---- BSS

How to describe:
 There is... cm … mm deep … shaped ulcer situated in … area with …
surrounding skin. It has … margins … edge with visible … in floor.
 The base is … to underlying structures & the regional LNs are …
 There are …. Other ulcers, there is … NV deficit, power is … , deep tendon
reflexes are … & sense of vibration is …
Q-What is your diagnosis?

It is:
1. Venous ulcer because on history patient complains of mild pain in leg. The ulcer
is superficial & above medial malleolus. Its edge is sloping. The surrounding skin
shows thickening and discoloration. PLUS on standing there are varicose veins.
2. Ischemic ulcer because patient gives history of intermittent claudication / rest
pain. PLUS on examination ulcer is at pressure point of the foot. There is loss of
hair, the limb is cooler, and distal pulsations are decreased / absent as compared
to normal side.
3. Diabetic ulcer because patient gives history of diabetes mellitus. Ulcer involves
the foot and there is swelling, redness, and tenderness of foot with pus
discharge.
4. Traumatic ulcer because there is history of trauma at the ulcer site.

How will you investigate the patient?

The investigations will be for ulcer itself (1**), the disease causing the ulcer (2**) and
general condition of the patient (3**).

1 Ulcer itself Discharge for C/S If discharge present

Blood CP For leukocytosis & neutrophilia for
infection
2 For disease Varicose ulcer Duplex ultrasound to see
causing it competency of junction and
perforators
Ischemic Duplex ultrasound to evaluate blood
flow
CT angiogram / Angiography
Blood lipid profile
Diabetic Blood Sugar level
Carcinoma Biopsy of edge
Tuberculosis Biopsy for histopathology and
culture
3 For general Blood CP, Urine RE, X-ray chest PA view, ECG, LFT, RFT, Blood
condition of pt glucose, HBsAg, HCV.
How will you treat the patient?

The treatment will be of the ulcer itself (1***), the disease causing the ulcer (2***) and to
improve the general condition of the patient (3***)

1 Ulcer itself Wound toilet with normal

saline daily

Antibiotis broad spectrum If infected

till C/S report available.

Debridement If there is dead tissue / slough

Dressing with sterilized

gauze

2 Disease Venous Compression stockings

causing the
ulcer Leg elevation on sitting

Operation for varicose veins

(ligation of incompetent junction,
Stripping of vein & stab avulsions
of remaining varicosities)

Arterial Drugs:
Antiplatelet.
Lipid lowering

Vascular bypass operation if

possible on report of CT
angiogram

Diabetic Strict sugar control on insulin

Tuberculosis Anti-Tuberculosis treatment

Carcinoma Wide excision / radiation

3 For general Blood Low Hb. Transfuse blood

condition of
patient Continue / start medicines For Co-morbid diseases

Diabetes mellitus

Chronic renal failure, IHD, HTN,

COPD
 DIABETIC FOOT
The history taking, clinical examination, investigation and management of following
aspects of diabetic foot should go side by side.

Effects of Diabetes
Foot Leg Diabetes mellitis Mellitis on end Sepsis
organs or systems

Cellulitis (1) CVS (HTN,

Examine: (1) Controlled IHD, TIA, Confirm in:
Abscess, Ulcer or not controlle
Gangrene Strokes
(1) Distal (1) Sepsis if
pulses. (2) On drugs or (2) Diabetic pulse > 90/min,
Insulin Nephropathy Resp rate >
(2) Sensation
INVESTIGATION (Vibratio & (3) Diabetic 20/min, has
touch). retinopathy fever, TLC > 12
X-Ray Foot
INVESTIGATION or <4 (Any of
Discharge for C/S (3) Inguinal the two).
lymph nodes. Blood Glucose level INVESTIGATION (2)Severe
Glycosylated Hb sepsis. Above
level (1) ECG, 2-DEcho,
lipid profile, X-Ray plus organ
TREATMENT Chest for CVS. failure.
INVESTIGATION
Antibiotics (2) RFT & Hb. for (3) Septic
(Cellulitis) Doppler nephropathy. shock. If BP <
Incision & Ultrasound (3) Fundoscopy 90 mm of Hg.
Drainage (Vascular) for retinopathy
(Abscess) TREATMENT
Debridement Insulin on
(Dead tissue) sliding scale TREATMENT
Wound Toilet TREATMENT
(Wound) (1) Inj.
Treat the Augmentin 1.2
Amputation disease
(Gangrene) gram08 hourly
after test dose.
TREATMENT (2)Inj. Amikin
500 mg 12
Optimize end
hourly if renal
organ fuctions
functions are
Continue OK.
medicines for
co-morbid (3) Inj Flagyl
conditions 500 mg 8 hrly.

Questions Asked
1. Why do you say the patient has diabetic foot?
2. What is his Wegener’s grade?
3. Why knowing Wegener’s grade is important?
4. What is the distal neurovascular status of the patient?
5. Why it is important to know the distal neurovascular status of the patient?
6. How is the glycemic control of the patient?
7. How do you intent to control his blood sugar?
 8. What sub-type of diabetes does the patient have and what is its duration?
9. What investigations will you do in this patient?
10. Is there any end-organ damage, or co-morbid?
11. How will you manage this patient? Justify.
12. If amputation is required, what will be its level? Justify.
13. What is the state of sepsis?

Some Answers:
 Q-1: Wegener’s grade?
 I: skin involved.
 II: Muscles & Subcutaneous tissue involved
 III: Osteomyelitis
 IV: Patchy gangrene
 V: Gangrene of forefoot

Note: the treatment from grade III onwards is amputation.

 Q-2: Level of amputation at which level?

 At the level of amputation there should be no:
 Infection (odema, erythema, warm, tender skin)
 Good blood supply (Proximal pulses are palpable)
 Intact sensations
 Length of remaining stump is optimal for wearing
prosthesis.
 Q-3: Why called diabetic foot?
 The septic condition of foot could be attributed to effects of
diabetes. These include poor nutrition due to vaculopathy,
neuropathy, and immunosuppression.

 Q-4: What are the important components of management of diabetic foot?

 Foot management (antibiotics, wound toilet, debridement,
Incision & drainage, amputation).
 Control of sepsis (Broad spectrum IV antibiotics and surgical care
of diabetic foot)
 Treatment of associated diseases due to diabetes mellitis (IHD,
HTN, Nephropathy)
 Excellent glycemic control by Insulin
 Education of patient regarding foot care.

 Q-5: Example of sliding scale?

 Monitor blood sugar level 06 hourly and give regular insulin as
follows:
 Blood sugar level 200 mg%- Insulin Nil
 Blood sugar level 200-240 mg%- Insulin 2 Units
 Blood sugar level 240-280 mg%- Insulin 4 Units
 Blood sugar level 280-320 mg%- Insulin 6 Units
 Q-6: Why X Ray foot is important?
 Cannot differentiate between Wegener’s grade II & III without X-
Ray .
 PARENTRAL NUTRITION
STEP 1: DETERMINE THE ENERGY REQUIREMENT
In a healthy adult: 25-30 KCal/kg/day. For 60 kg the calorie requirement will
be 25x60=1500 calories. A diet of 2000 calories may be sufficient for surgery patients
with increased calorie need.
 70% of carbohydrates
 30% from fats, maximum can go up to 60%
STEP 2: DETERMINE THE PROTEIN REQUIREMENT
Nitrogen requirement is 01 gram for 150 calories. Therefore for 1500 calories the
requirement of Nitrogen will be 1500 divided by 150 = 10 grams.
To provide 01 gram of Nitrogen, 06 grams of Protein is required. Therefore daily
requirement will be 10 (grams of Nitrogen) x 6 = 60 gram of proteins.
STEP 3: DETERMINE THE FLUID REQUIREMENT
30ml/kg/day of maintenance fluids plus fluid replacement for output and insensible
losses approx. therefore the fluid requirement will be 30 x 60 = 1800 ml. Add 500 ml of
insensible loss. A 2500 ml of fluid will be sufficient in 24 hours.
STEP 4: DETERMINE ELECTROLYTE REQUIREMENTS
 Na: 1-2 mmol/day = 100 mmol/day
 K: 1 mmol/day = 50 mmol/day
 Ca: 05mmol/day
 Mg: 01 mmol/day
Give following parenteral nutrition in 24 hours

Preparation Amount Calories Na K Extra

(Cal) (mmol) (mmol)

Aminovel 10% 500 ml 50 25 Has 8 gram of Nitrogen**

bottle **1000 ml of Aminovel will have 16
(Use 02 gram of nitrogen, and meets body
Bottles = requirement.
1000 ml) Also has the required amount of Mg.
Intralipid 20% 250 ml 500 ml Give as slow infusion in 08 hours.
bottle
(Use 01
bottle)
Glucose 25% 1000 ml 1500 To metabolize glucose for 1000 ml
drip 25%, add 25 units of insulin to 1000 ml
(Use 25% Glucose drip.
1&1/2
drip)
KCl Ampule 25

THE AVAILABLE TPN PREPARATIONS**

1. 25% Dextrose 1500 ml in 24 hrs 500ml 8hrly =1500 kcal
a. Add 25 units regular insulin in 1000 mi 25% glucose drip.
2. Inj. Liposcin 20% 250 ml OD= 500Kcal (2kcal/ml)
3. Inj. Aminovel 10% 1000 ml IV OD (Each 1000ml of 5 or 10 % contains Na: 50
mmol , K: 25mmol)
4. Inj. N/Saline 250 ml OD+ 1 ampoule of KCl (38.5mmol Na, 25mmolK)
5. Inj. Multibionta: One ampoule IV OD
6. Inj. 10% Ca. Gluconate (10ml) IV one ampule daily.
7. Inj. Vitamin K IV/IM once weekly
8. Inj. Multitrace-5 Concentrate IV once OD
Note: B Braun Company sells these preparations. Nutriflex (Rs 5500) is for parenteral
nutrition & Nutricom (2500) is for enteral.
Pass central venous catheter for administration of TPN
Monitoring of the patient on TPN:
Daily:
 Vital signs
 Blood glucose level: 6 hourly
 Body weight
 Fluid balance
Twice weekly if patient in stable in ward, daily in ITC setting.
 Full Blood Count
 Urea, Creatinine and electrolytes
 LFT
 ABG
Once weekly:
 Urine and plasma osmolality
 Liver function tests
 Serum Albumin
 PT/PTTK
 Calcium, Magnesium, Zinc and phosphate
Reference: Discussed in surgical ward 3 audit meetings keeping in view the
available preparations and the practicability of the regimen to be adopted

Fluid or electrolyte imbalance

Postoperative fluid requirement:

First postoperative day: give 01-liter normal saline, and 2 liters 5% Glucose.

Potassium administration:

1. The daily dose of K is 60 mmol.

2. If K is low, give 100 mmol K per day. In very low level give 200 mmol K per day.
(40 mmol extra given)
3. Add two ampules of 25 mmol of K, in 100 ml saline filled burette. Give it slowly
in at least one and a half hour, twice daily.
4. Next day repeat serum K level. If it is low give K again.
5. Do not give K in glucose, because glucose will raise insulin level in the blood, and
will transfer the K, into the cells.
 PERIPHERAL NERVES UPPER LIMB

Step 1: Inspection of hand to determine which nerve is involved.

Median Ulnar Radial

Ask the patient to show
his hand. See the shape Ape man Claw like hand Wrist drop
of hand.

Formant test
Pointing test ask the patient to hold
ask the patient to clasp the papare between thumb Ask the patient to extend
Perform specific hands together. The index and radial side of hand the thumbagainst
finger of affected hand will without bending the resistence. he will be
Tests point thumb. He will do trick unable to do it.
manrover to pinch the
papaer and hold it

Step 2: For each nerve examine (1) Lower group of muscle, and (2) higher group of
muscle.

Median Ulnar Radial

Lower group Lower group Lower group

Thumb flexion Abduction of fingers Wrist extention

Higher group Higher group Higher group

Wrist flexion Wrist Ulnar deviation with Elbow extention
flexion

Note:
 For median and Ulnar nerve the lower group of muscles is in hand and
upper group of muscles is in forearm.
 For Radial nerve the lower group of muscles is in forearm and upper
group of muscles is in arm.
 If both group of muscles show loss of function the lesion is higher. For
medial and ulnar nerve it means forearm, and for Radial nerve it means
arm.

Step 3: Examine sensations

Examine sensation for median nerve, ulnar nerve and radial nerve on Index finger, Little
finger, and over first web dorsal surface of hand respectively.

Step 4: Combine finding from history, scar on examination, and above

examination to tell:

 The nerve injured

 The site of lesion
 Management

Principle 1. Operation is useful only when the muscles supplied by it have not
degenerated and can function if nerve supply is restored. This is confirmed by EMG
studies.

Principle 2. For motor nerve maximum time is 01 year. For sensory nerve it is 1 ½ year.

Nerve injured

Incised wound or Blunt Injury

the injury is
suggestive that Conservative management
the nerve is cut
 Physiotherapy
 Splints
 TENS (Nerve stimulation)
 Monitor progress
o Clinically
o NCS & EMG studies

Exploration of the Nerve AT 03 WEEKS EVALUATE

 Primary repair with 8  Clinically

Zero prolene.  NCS & EMG
 Nerve graft if loss of (Forms the base line
nerve > 2 cm. evaluation)
 Nerve transfer into
non-functioning
group of muscles AT 03 MONTHS EVALUATE
Note: Useful in lower
injuries. In higher injuries by  Clinically
the time the nerve grows the  NCS & EMG
muscles have lost their (Decision making evaluation)
function to recover

Improvement

No Improvement
No Improvement Conservative management

 Physiotherapy
Ulnar Paradox?  Splints
 TENS (Nerve stimulation)
Tendon transfer  Monitor progress
o Clinically
o NCS & EMG studies