Surgery

Physical
Examination
Yazan Addasi

Qussai Shaaban

Aseel Al- Daajah

Abdallah Bani-Melhem

Ahmad Matarneh

Farah Al-Haj

Oweis Khrais

Nisreen Bassam

Batool Sabri

Al-Anoud Odwan

Hamzeh Shourbaji

Mahmoud Shraideh

Maryam Nidal

Rawan Badran

INDEX

1- Examination of a lump

2- Abdominal lump

3- Neck examination

4- Thyroid examination

16

5- Breast examination

18

6- Ulcer examination

20

7- Lower limb examination

28

8- Male external genitalia examination

36

9- Female external genitalia examination

38

10- Stoma examination

40

11- Incisions

42

12- Surgical drains

43

13- Post operative evaluation

49

14- Abdominal exam checklist (Prof. Kamal)

52

Examination of a lump
Introduce your self
Wash your hands
ensure privacy
Take permission
Examine the lump
1- Number
2- Position
3- Color and texture
4- Temperature
5- Tenderness
6- Shape
7- Size
8- Surface
9- Edge
10- Composition (consistence/fluctuation/fluid
thrill/translucency/resonance/pulsatility/compressibility/bruits)
11- Reducibility
12- Relations to surrounding structures
State of regional lymph glands
Local circulation
Nerve supply

1- Number : - multiple neurofibromatosis/ multiple lipomatosis

2- Position:
*use a tape-measure to describe the distance from a bony point
*some lumps has special sites :
-past auricular dermoid behind ear
-thoracic meningiocele in the back midline
-external angular dermoid lateral of eye brow
3- Colour and texture
(smooth and shiny VS thick and rough)
Colour : -capillary hemangioma > red
-malignant melanoma > black
Texture: -papilloma > filiform
-SCC > cauliflower
Skin : -shiny skin with prominent veins > sarcoma
- Punctum > sebaceous cyst
- Red edematous > inflammation / infection
- Previous scar > recarrant
- Peaudorange > malignant
4- Temperature:
*by dorsal surface of your fingers
Hot >> abscess / cellulitis / sarcoma / vascular
5- Tenderness :
*feel the non tender part fist *watch patient's face
+ >> inflammation / neurofibroma
6- Shape:
*3D (sphere hemisphere pear shaped kidney shaped )
*circle is not 3D .. don't use it !!

7- Surface:
(smooth irregular nodular lobular )
8- Size :
*(length- height-depth) if symmetrical
*use diagram if asymmetrical
9- Edge:
-defined regular > benign
-defined irregular > malignant
-indistinct > inflammatory
-slipping edge >> lipoma
10- Composition:
-solid > cells
-cystic> urine- serum synovial fluid extravascular blood
-gas
-intravascular blood

Consistence (hard/rubbery/spongy/soft)
Fluctuation
*feeling at least 2 other areas while pressing on a third
*test done twice "in 2 directions"
*fluid bulge in every other direction / solid doesn't but may bulge in one direction
and this is not considered fluctuation

Fluid thrill
*tapping one side of the lump and feeling the transmitted vibration
*hand in midway if the lump is large

Translucency
*use the point light in dark place
(+) if water/serum/lymph/plasma/highly refractile fat
(-) if blood

Resonance
-dull if solid or fluid / resonant if gas

Pulsatility
*put finger to see if pulsatile
*if pulsatile put 2 fingers one from each hand
-if pushed apart >> expansile pulsation (aneurysm / vascular tumor)
-if pushed upward in the same direction >> transmitted pulsation from nearby artery

Compressibility
*lump disappear with compressing then reforms spontaneously when removing
hand (differ from reducibility)
>> venous vascular malformations

Bruits
-vascular lumps > systolic bruit
-containing bowel > bowel sounds

11- Reducibility :
*compress then ask to cough
-cough impulse >> hernia / some vascular lumps
12- Relations to surrounding structures :
*move the skin above it
*tense the muscle and see if reduced lump mobility so the lump is within or deep to
contracting muscle

lymph nodes
-limbs and trunk > axillary and inguinal LN
-head and neck > cervical LN
-intra-abdominal > pre para aortic LN

Local circulation
Nerve supply

Abdominal lump
Introduce yourself
Identify the patient name and take consent
wash your hands
Ensure privacy and warm
Appearance of patient
Inspection
1-site
2-size
3-shape
4-surroundings
5-surface
6-edges
7-transillumination
Palpation
1-temperature
2-tenderness
3-consistency
4-mobility
5-pulsatile
6-fluctuation
7-reducibility and compressibility
Examine regional lymph nodes

Percussion: dull vs resonance

Auscultation: bruits

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

*Surroundings: remote surrounds then local
*Surface: -smooth vs rough vs indurated -scars -skin
*Edges: -well defined (neoplasm) -poorly defined (inflammatory)
*Temperature: feel with back of fingers
*Consistency: soft vs firm vs hard

Mobility :

*Pulsatile: assess with 2 fingers;

-transmitted pulse = when fingers move in the same direction
-expansile = when fingers move away

Neck examination
Dear colleagues , according to our syllabus we are supposed to own the skills of physical
examination of the neck including :

Cervical lymph nodes.. .1

Thyroid examination. .2
Cystic hygroma. .3
Examination of other neck masses.

.4

Carotid artery pulsations and carotid body tumor

.5

Position of trachea. .6

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

Neck examination :

- introduce yourself.
-gain consent & corporation.
-check privacy.
-make sure that the room is warm.
1- inspection : patients neck should hold his head erect & mid-line , with symmetrical muscles
with no swelling or masses.

- observe the carotid artery for visible pulsations.

2- asses the neck active range of motion : by having the patient :
Touch his chin to his chest.

Turn his head to the right and left.

Tip his head to his right and left shoulders.

Tilt his head backward.

- all of these movements should be smooth and painless.

3- assess the spinal accessory nerve : apply resistance to the patients shoulders as he shrugs
them , the shoulder muscles should be symmetrical & overcome your resistance.

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

- note the contraction of the opposite SCM every time , the contraction of both muscles should
be equally strong.

5- palpate for the cervical lymph nodes :

pre-auricular , posterior-auricular , occipital , sub-mental , sub-mandibular , tonsillar ,
superficial cervical , deep cervical chain , posterior cervical , supra clavicular.

- note the size , shape , consistency, movability and tenderness of the nodes.
-be sure to compare one side to another.
If you detect swelling or tenderness ; search for a possible cause.

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

6- identify the trachea by localizing the sternal notch and sliding your fingers to each side of it ;
Trachea should be mid-line and symmetrical.
7-stand in front of the patient , by the fingers of your left hand , push the thyroid gland to the
right , then insert the fingers of your right hand between trachea and SCM muscle, then ask the
patient to extend his neck & swallow ; you should feel the thyroid move up & down as he
swallows.
- palpate the thyroid gland from behind ; place the fingers of both hands on the patents neck
with your index just below the cricoid , palpate the both lobes and isthmus.
- instruct the patient to sip & swallow during the examination; look for size , shape and
consistency.
-auscultate for bruits = blowing sound caused by turbulent blood flow.
If you detect any thyroid abnormality ; go through specific thyroid examination..

8- observe carotid artery for visible pulsation

- gently palpate the carotid artery using your index and middle fingers.
-remember to palpate each carotid artery separately in order not block blood flow to the brain.
-DO NOT press hard on carotid sinus which located higher in the neck to avoid vagal stimulation
which slows the heart rate.
-auscultate for bruits which are normally absent.
9-with the patient in the supine position and his head is elevated 30 degrees and by the aid of
light source , jugular vein distention become visible.
-check jugular vein pulsations which are normally not prominent and decrease with inspiration.
While you are examining the neck generally, if you find a swelling (lump) ; you have to go
through lump examination which is discussed in details in the lump sheet ; here we will go
thrugh special consideration about neck lump .....

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

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

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

-posterior triangle is bounded by posterior border of SCM anteriorly , anterior edge of trapezius
muscle and clavicle.
- to define the triangles it is necessary to get the patient to tense the neck muscles.
** the SCM muscle is made to contract by putting your hand under the patients chin and
asking them to nod their head against the resistance of your hand. This tightens both SCMs.
**the trapezius muscle is made to contract by asking the patient to shrug their shoulders
against resistance.

RELATIONS TO MUSCLES
feel the lumps in the neck with the muscles relaxed then again with them contracted. If the
lump is deep to a muscle , it will become impalpable when the muscle contracts.

RELATION TO THE TRACHEA

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

RELATIN TO THE HYOID BONE

Ask the patient to open their mouth, when the jaw is still, ask them to protrude their tongue, if
the swelling in the neck moves when the tongue protrudes , it must be fixed to the hyoid bone.
- go through examination of the lump ( size , shape , surface, skin around , etc....)

Cystic hygroma

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

Examination : you examine the lump as any lump in the neck following the detailed lump
examination in the lump sheet , here is the findings:

- found commonly around the base of the neck , usually in the posterior triangle , but they can
be very big an occupy the whole of the subcutaneous tissue of one side of the neck.
-temp. And tenderness ; they are not hot or tender , and the overlying skin is normal.

-shape : lobulated and flattened.

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

Composition : soft and dull to percussion.

Brilliant translucence
Large cyst>>fluid thrill
Can be compressed.
Can NOT be reduced.

- relations : cystic hygromata develop in the subcutaneous tissue. Thus they are superficial to
the neck muscles and close to skin but rarely fixed to it. however it is essential to perform a
thorough examination to oropharynx, as a cyst in the posterior triangle may extend deeply
beneath the SCM muscle into the retropharyngeal space.

-local tissue is normal.

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

Carotid body tumor

- site : upper part of the anterior triangle.

-not tender or hot and overlying skin is normal.
-shape : early : spherical , as it grows it becomes irregular.

Composition : solid and hard

**called potato tumors because of consistence an shape
** sometimes pulsate.
**can be compressed.

Relations : the lump is deep to the cervical fascia and beneath the anterior edge of SCM muscle.
**the common carotid artery can be felt below the mass , and the external carotid artery may
pass over its superficial surface. Without this this relationship to the arteries; the tumor is
indistinguishable from an enlarged lymph node.
**because of their intimate relationship with the carotid arteries , these tumors can be moved
from side to side but not up and down.

Thyroid examination

Introduce yourself
Check the patients name
Ensure privacy /warm room
Gain consent/Explain what
you are going to do
Notice the patient voice
General inspection

Look at the hand

Examine the eyes

Say if it is normal or there is hoarseness(malignancy>>

invasion to the recurrent laryngeal nerve)
-Nervousness/anxiety/lethargy/tiredness/weakness
-muscle wasting/general weakness
-Under-clothed and sweaty/wearing large number of
jumpers but still cold
-loss of hair especially the outer two thirds of the
eyebrows.
-feel the pulse: tachycardia(>90)>>thyrotoxicosis(and may
be the pulse be irregular if there are extrasystoles or atrial
fibrillation.
Bradycardia(40-60)>>myxoedema
-sweaty hand?
-fine tremor(ask the patient to hold his/her arm and
separate his/her fingers >>>put a paper on both hands)
-Lid retraction and lid lag: caused by over-activity of the
involuntary part of the levator palpebrae superioris muscle
the upper eyelid is higher than
normal and the lower lid is in its correct position,
the patient has lid retraction
When the upper lid does not keep pace with the
eyeball as it follows a finger moving from above
downwards, the patient has lid lag.
-Exophthalmos: caused by increase in retro-orbital fat, oedema
and cellular infiltration Sclera becomes visible below the lower
edge of the iris (the inferior limbus).
-Ophthalmoplegia :caused by weakness of the ocular
muscles(usually superior and lateral rectus and inferior oblique
muscles)
-chemosis: is a swelling of the conjunctiva caused by the
obstruction of the normal venous and lymphatic drainage of the
conjunctiva by the increased retro-orbital pressure.(red eye)

Inspect the neck

-Ask the patient to drink water: Thyroid gland attached to

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

Palpate the neck from the

front

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

/distended vein/
- to confirm your visual impression of its size, shape and surface,
and to find out if it is tender.

Check the position of the trachea by feeling with the tip of two
fingers in the suprasternal notch. The trachea should be exactly
central at this point.

Palpate the neck from behind

the patient

Percussion
Auscultation
Thank the patient

-place your thumbs on the ligamentum nuchae and tilt the

patients head slightly forwards to relax the anterior neck
muscles.
- A small lobe can be made prominent and easier to feel by
pressing firmly on the opposite side of the neck.
-tenderness/ temperature /site/shape(spherical ,irregular)
/size/surface(smooth, nodular) /Edge (clearly defined, indistinct)
/consistence (soft, spongy, hard)/ skin attachment
- Palpate the whole of the neck for any cervical
and supraclavicular lymphadenopathy.
- to define the lower extent of a swelling that extends below the
suprasternal notch by percussing along the clavicles and over the
sternum and upper chest wall.
Listen over the swelling. Thyrotoxic and vascular
glands and lumps may have a systolic bruit.

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

and

not in the examination station

I advice you to look at the tables present in Browse also because they are short and important and will not take time
Lets start...
In the history after you start with the patient profile and the chief complaint and the history of presenting illness, you
should consider and ask about these things
1- consider the age of the patient
2- ask about the menstrual pattern: menarche, menstruation ( regularity, duration, quantity of bleeding)
number of children and breastfeeding
Menopause
Relation of the lump appearance or the pain to the menstrual cycle (changes during the

cycl

e)
3- ask about medications: contraceptives and hormonal therapy ( post menopausal oestrogen )
4- ask about the family history
Examination
- exposure: fully undressed to the waist
- position: the patient lying down on the examination couch and the upper body raised 45 to the legs
There is 3 positions for the hands:

I. beside the patient

II. above the head
III. on the hip bone
As you inspect you ask the patient to put her hands above her head so the skin tethering and puckering and the asy
mmetry becomes more obvious
When the patients put their hands to the hips the pectoralis muscle becomes contracted and tense
Sometimes the patient report that there is a specific position the lump appears in it, then you have to examine it
-Inspection: I will talk about examining the breast in general but if you find a lump you should examine it like any l
ump in any other place and I will write some special notes I read in Browse

Size:
symmetry: if there is minimal difference then this is normal but if there is significant diffe
rence with recent onset it is usually pathological
skin: look for any puckering ( indicates cancer ), oedema ( peaud' orange by obstruction o
f skin lymphatics by cancer ), discoloration, nodules, ulcer
nipples and aereolae: color normally changes with age
darkening during pregnancy, aereola normally corrugated ( montgonery tubercles)
see if the nipple inverted ? slit appearance ? ( duct ectasia)
any fluid leak ? Eczema?

duplication: accessory nipple ( along the mammary line from axilla to groin) , ectopic bre
ast tissue in the anterior axillary fold
look at the axilla, arm, neck, supraclavicular fossa for grossly enlarged lymph nodes or di
stended veins or lymphoedema

- Palpation:
Palpation is done with the flat of the fingers not the flat of the hands because the fingers are more sensitive
Begin always with the normal side and Do not forget the axillary tail
If you find a lump examine it like any other place ( site, size, shape, consistence, edge, tenderness, color,

tem

perature, surface,...)
Relations to the skin: we have 2 terms:
Fixation: cannot be moved without moving skin
Tethering: deeply situated and distorting the ligament of cooper and pulls the skin inwards but remains seperate fro
m the skin ( its like that the lump is tied to the skin by a piece of string, it can move freely and independently of the s
kin within the limits determined by the length of the string but pulls the skin when moved beyond these limits )
Relations to the muscles
nipple:
If there is inversion try to evert it by gently squeezing its base or ask the patient to do so
It is normal if the nipple is easily everted
Unilateral inversion is more significant than bilateral
Discharge: gently press the aereola around the base of the nipple and observe whether any fluid comes from one
or many duct orifices
Character of discharge should be noted
examine the lymph drainage in the axilla and supraclavicular fossa
examine the neck
do general exam ( to check for metastases in the cancer cases )

Ulcer exam
Introduce yourself
Gain consent
Ensure privacy and wear gloves
Ask the patient to lie down
-Inspect :
1. Number
2.Site
3.Size
4.Shape
5.Edges
6.Depth
7.Floor
8.Discharge
9.Skin around it
-Palpate:
1.Base
2.Tenderness
3.Temp.
4.Adhesion to other structures
5.crepitus
-Assess movement of related joints
-Palpate regional lymph nodes
-assess arterial status
a-capillary refill
b-pulses
c-temperature
-assess venous status
-assess nervous status and muscle tone
a-light touch
b-pin prick
c-vibration
d-proprioception
-test the mobility of the near joints
-Cover the pt. and say thank you

LOCAL examination
On inspection you should include the following :
1-number of ulcers (single or multiple)
2-size of the ulcer in two dimension
3-site : exact anatomical location of the ulcer:
-right or left leg
-dorsal or plantar
-medial or lateral
-proximal or distal
many ulcers have a characteristic site where they occur :
a-venous ulcer: in the lower medial third of the leg above the medial malleolus
b-arterial ulcer (ischemic ulcer ) :dorsum of the foot and toes

c-neuropathic ulcer: pressure areas (ischemia with no sensation) usually called trophic ulcer
d-rodent ulcer :can be found in the face above the line joining the mouth to the ear lobule
(nose )

4-shape : regular, irregular, circular, oval

5- margin and edge:
-margin is the skin border around the ulcer, its the line demarcating the ulcer from the
surrounding skin
-edge is the place where the floor joins the margin of the ulcer (the junction between the
healthy and diseased tissue ) takes characteristic forms with the underlying disease :
a-Sloping edge healing ulcer
b-Punched edge trophic ulcer

c-Undermined edge tuberculous ulcer

d-Everted edge malignant ulcer
e-Raised edge rodent ulcer

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

6-floor of the ulcer : is the exposed surface of the ulcer note the following :
1-granulation tissue: red in color (mainly near the edges)
. 2-dead tissue: necrotic, dark in color.
3-discharge: -type:
serous. Sanguineous. Serosanguinous. Purulent discharge (pus): green (klebsilla), yellow
(staph.aureus)
*a healthy ulcer shows healthy granulation tissue ,no slough and small amount of serous
discharge
7-surrounding skin :if the ulcer is infected the surrounding skin will be red ,hot and edematous
**dark pigmentation and eczema skin is typical of varicose ulcer
**multiple scars and puckering of skin around the neck are suggestive of tuberculous ulcer
**Hypopigmentation non-healing ulcer
** Large scar Marjolins ulcer (ulcer in large scar (burn)

palpation:
1-surrounding skin for temperature(with the dorsum of the hand) and tenderness
-tenderness suggest inflammation
2-over the edge and floor of the ulcer :
-Soft: healing ulcer
-Firm: non-healing ulcer
- Hard: malignant ulcer
3-over the granulation tissue and note whether it bleeds or not
*Healthy granulation tissue may show pinpoint hemorrhagic spots, while malignant ulcer may
bleed profusely
4-the base :the tissue at which the ulcer rests.
-palpate to know the consistency and to know the underlying structure (muscle or fasciaetc)
5- test the adhesion to the structures in the base of the ulcer
FOCAL examination
*examination of regional lymph nodes depends on the site of the ulcer
-e.g. popliteal , femoral and inguinal lymph node if in the lower limb
-Hard, discrete, non-tender malignant ulcer
-Soft, tender infective
-Non-tender, matted(tangled in mass like) tuberculous ulcer

*in arterial feel the pulses related on both sides to rule out vascular disease and measure the
capillary refill time, also check the temperature on the surrounding skin :
1-dorsal pedis :lateral to extensor hallucis longus between 1st and 2nd metatarsals on navicular
bone
2-posterior tibial : 2cm below and posterior to the medial malleolus between flexor digitoru
longus and flexor hallucis longus
3-popliteal :posterior to knee joint deep in the popliteal fossa not easily palpable, if its then
think of popliteal aneurysm
4-femoral : 1cm below the inguinal ligament between vein and nerve (VAN)

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

Then test the sensation in this skin surrounding the ulcer by sharp pin to have an idea about the
sensations
if the sensations are diminished particularly in weight bearing area ulcer (trophic) you have to
do detailed neurological exam.

INVESTIGATIONS:
1-fasting B.S. and random B.S.
2-urine analysis
3-CBC
4-plain X-ray
5- swap for culture.
6-Biobsy for malignancy. It is taken from the edge of the ulcer.
7-arterio and angiogram.

Differential diagnosis :
1-ischemic ulcer
2-venous ulcer
3-traumatic ulcer
4-neoplastic (BCC, SCC)
5-trophic (neuropathic)
5-infectious(tb)

COMPLICATIONS OF ULCERS:
1-keloid: hypertrophic persistence scar
2-hypertrophic scar
3-hyper- or hypo pigmentation
4- chronic benign ulcer SCC

Diabetic ulcer exam :

Introduce yourself
gain consent
explain exam
ensure good exposure
--Inspect
Colour pallor / cyanosis /erythema
Skin dry / eczema / shiny / hair loss / haemosidrin staining
Ulcers inspect between toes & behind legs
Deformities in the joints Charcots joints
--Palpate
Temperature across the two legs cool / hot
Pulses dorsalis pedis / posterior tibial\popliteal
Capillary refill normal = < 2 seconds
Soft touch sensation use cotton assess lower limb dermatomes (compare L/R)
Pain sensation(sharp and dull) assess lower limb dermatomes (compare L/R)

Vibration sensation
1. Ask patient to close their eyes
2. Tap a 128hz tuning fork
3. Place onto patients sternum & confirm patient can feel it buzzing
4. Ask patient to tell you when they can feel it on their foot & to tell you when it stops buzzing
5. Place onto the distal phalanx of the great toe
6. If sensation is impaired, continue to assess more proximally e.g. proximal phalanx etc
Monofilaments:
1. Ask the patient to close their eyes & inform you when they feel their foot being touched
2. Place the monofilament on 5 areas across each sole
3. Press firmly so that the filament bends
4. Hold the monofilament against the skin for 1-2 seconds

Proprioception
1. Hold distal phalanx of the great toe by its sides
2. Demonstrate movement of the toe upwards & downwards to the patient (whilst they
watch)
3. Then ask patient to close their eyes & state if you are moving the toe up or down
4. If the patient is unable to correctly identify direction of movement, move to a more proximal
joint

Ankle jerk reflex

1. Dorsiflex the foot
2. Tap tendon hammer over the achilles tendon

3. Observe the calf muscle (posterior leg) for contraction normal reflex
Ankle jerk reflex may be absent in advanced peripheral neuropathy
-assess the gait : make the patient walk in front of you to observe the symmetry and gait

References:
Check the Indian guy video
also see this video for diabetic ulcer exam: http://www.youtube.com/watch?v=p20gAwHNKgU
and refer to browse 4th edition-page 32

Lower Limbs examination

Introduce yourself
Take Consent
Check Privacy
Make sure that room is warm

Examination of Arterial
circulation

1.inspection

1.color :
*purple-blue skin : excessive
deoxygenation of the blood in skin
capillaries. But blue fades to white
within few sec when pt. lies down
*Blue streaks around white
patches : ischemic leg. When
cyanosed become fixed its an
irreversible ischemia
*Blue/Black : gangrene "start in
toes"
2.Skin changes
*scar/striea
*rashes/hypo or hyper pigmentation
*bruising
*superficial veins
*scaling
*callosities "raised" : piece of skin become
thickened as a result of repeated contact and
friction
Corn "depressed.
Hyperkeratosis
3. Toes :
*polydactyly : supernumerary toes
*oligodactyly : less than 5 toes

*amputation : describe the site

*note nail thickening
4. Lumps and swelling
5. muscle wasting "pulps of toes"
6.pressure area : "ulcer"
bottom , back , lateral aspect of heel
ball of the foot
skin over malleoli : venous ulcer "most in
medial malleolus
base of 5th metatarsal head
tips of toes : arterial ulcer
between toes
Describe ulcer
Pressure necrosis : thickening of skin
purple or blue
discoloration
blistering
ulcer , black patches
gangrene
7. Hair distribution

ischemia
8.vascular angle "Burger's angle": angle to
which the leg has to be raised before become
white.
*Normally: toes stay pink even when raise it
to 90 degree
*Ischemia : raise it 15 or 30 degree for 3060 sec cause pallor
*severe ischemia : if angle < 20 degree
9. Capillary filling time : ask pt. to sit and dangle
his leg after elevating ""
*normally : remain healthy pink
*ischemic : from whit "after elevating"
pink purple
*15-30 sec. its a severe ischemia

2.Palpation

10.Venous filling : in a warm room :

*normally : dilated filled with blood veins
*ischemic : Collapse and sink veins below the
skin surface look like "blue-gutter. Called
"guttering of the veins"
1.Temperature :
* you have to expose both limbs for 5 min. to
allow the skin temp. to adjust to the temp. of
the surrounding air.
*assess temp. by backs of the fingers
*assess whole limbs
compare distal vs. proximal
compare Rt. Vs. Lt.
2.Capillary refilling : press on the tip of a nail or
the pulp of the toe for 2 sec then observe then
observe the the time taken for blenched area to
turn pink after u have stopped pressing
."normally 2 sec"
3.feel all pulses :
A. Femoral pulse : mid-inguinal point "in groin
region halfway between symphysis pubis and
SIS
B. Dorsalis Pedis : lateral to flexor hallucis
longus "mid-way between malleoli towards cleft
between first and sec. metatarsals bone.
C.Posterior tibial artery : 1/3 of way between
medial malleolus and tip of heel , easier to feel
2.5cm higher up just behind medial malleolus
D. Popliteal pulse :
1. Most convenient by extend pt. knee your
thump in tibial tuberosity and tips of your
fingers behind knee
2. Flexing the knee 135 degree to loose the
deep fascia
3. check artery course when pt. in prone
position

3.Auscultation

*palpable and normal = +2

*palpable and weak = +1
*not palpable = 0
Measure Ankle : Brachial pressure index
Its a ratio of systolic B.P in ankle to systolic B.P
in Brachial .
Normally : 1.0-1.3
There is vascular disease if its less or more than
normal
*Listen along artery course especially if its weak
*You have to auscultate groin + thigh
*listen over adductor canal : in the medial
aspect of the middle third of the thigh
Measure B.P in both arms to exclude significant
subclavian or innominate artery disease
*Bruits are cause by turbulent flow beyond a
stenosis or an irregularity in artery wall "by bell
and dont press too hard over superficial artery.
Bruits may change in volume and character if
there are change in blood flow

Examination Of Venous
Circulation

1.Inspection

Pt. should be standing erect on a low stool in

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

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

2.palpation

2.ankle edema
3. skin pigmentation and ulceration
4. color
5.tenderness and subcutaneous induration
called "lipodermatosclerosis"
6.eczema 7. Ulcer
1.Palpate great saphenous vein : from dorsal
venous arch pass anterior to the medial
malleolus enter medial side of the leg before
passing medial epicondyle of femur entering
thigh and start to merge to anterior aspect
of the thigh then enter fascia lata
2. palpate short saphenous vein : lateral
aspect of the foot inferior and posterior to
lateral malleolus runs along posterior aspect
of the leg pass between heads of
gastrocnemius muscle.

3.percussion

4. Auscultation

5.Torniquet
Tests

3.palpate saphena-femoral junction : 2.5 cm

below and lateral to the pubic tubercle
4.palpate sapheno-popliteal junction which
variable termination in popliteal fossa.
2. ask pt. to cough while dilated veins are
palpated to see if there is impulse thrill
"cough impulse" indicate incompetent valve
between deep veins and superficial one so
back flow is turbulent
3.palpate skin for tenderness and induration
"lipodermoatosclerosis"
4.palpate medial side of calf muscles for
deficit in deep fascia which may sie of
incompetent calf communicating
"perforating" veins.
Normally : long and short saphenous vein
transmit a percussion wave in an orthograde
direction whether the valve competent or
not
Percuss the dilated veins for wave
conduction
*if wave more down ward "retrograde"
while pt. is standing its incompetent valve
Listen over any large clusters of veins
especially if they remain distended when pt.
lies down and limb elevated .
A Mechinery mumur over such veins
aterio-venous fistula
1.elevate the leg of pt. while he lying down
on the bed and empty the veins
2. tie the tourniquet tube on the saohenofemoral junction and ask the pt. to stand for
10-15 sec.
*if the sapheno-femoral junction is
incompetent the veins above the tourniquet

will dilate and veins below it will be

collapsed after removal of it veins below it
rapidly fill.
If Not
3. Apply it below the knee "on calf
perforating"
*Trendelenburg test : apply your fingers
instead of tourniquet
*if varicose veins fail to collapse on
elevation suspect :venous HTN caused by
proximal vein obstruction or presence of
aterio-venous fistula
*To confirm it do "Perths walking test" :
place tourniquet below knee ask the pt. to
stand repeatedly on tiptoe and relax.
In normal limb this exercise will empty the
superfacial veins bu sucking the blood in the
surface of varicosities into deep veins
through competent perforating veins and
pump it through popliteal vein to heart.
Failure to achieve empting indicates :
A .deep vein obstruction
or
b .reflux through incompetent valves in the
deep or communicating veins.
*Doppler flow detector

6. General
Examination
Muscles and nerves test

1.sensation

1.Light Touch : by using wisp of cotton wool

"while pt looks away"

2. Muscle
Tone
3. Muscle
power

4.reflexes

2.superfacial pain : use fresh neurological

pin
3. Temp. : touch pt. with cold metallic object
4.vibration : by tuning fork
5.propioception "joint position sensation"
6. points discrimination
Ask pt. to relax then roll the leg from side to
side see if there is any resistance to
movement
1.hip extension and flexion abduction and
adduction
2. knee extension and flexion abduction and
adduction
3. ankle dorsiflexion and ankle planter
flexion
4.great toe extension "dorsiflexion"
5.ankle eversion
6. ankle inversion
1.Deep Reflux:
A.elecit knee jerk by tap quadriceps tendon
below patella while hanging pt. leg with
other hand
B .Ankle jerk : tapping while foot dorsi-flexed
and knee flexed and leg slightly laterally
rotated it should jerk toward its planter
reflex
2.Superfacial Reflex :
Planter response : pt. lying
down leg extended , by blunt point run from
lateral aspect of foot start at heel moving
toward the big toe . should move downward
normally

Measure the diameter of

each leg

Male external genitalia examination

Introduce yourself / check the patient's name / Gain consent / Ensure privacy / Explain what you are going to
do.
Have a warm, well-lit room with a movable light source .
Apply alcohol gel and put on gloves .
Ask the patient to stand and expose the area from his lower abdomen to the top of his thighs .

Inspection
1) look in turn at the groin , skin creases , perineum
and scrotal symmetry ,and also skin of scrotum for
redness , swellings or ulcers .

Patients who shave their pubic hair may have

dermatitis or folliculitis.

2) note hair distribution

3) look at the shaft of penis and check the position of
the urethral opening .

To exclude hypospadias

Palpation

A hard plaque of peyronie's may occur on the

shaft .

1) palpate the shaft of penis for fibrous capsule or

abnormal curvature
2) retract the prepuce and inspect the glans for red
patches or vesicles

Phimosis ,adhesions, inflammation or swelling

may occur on the foreskin or glans .

( always draw the foreskin forward after

examination to void paraphimosis )
3) Check for any obvious discharge

suggestive of urethritis.

4) palpate the scrotum gently using both hands

- check that both testes are present .

If they are NOT , examine the inguinal canal and

perineum , checking for ectopic testes .

5) place the fingers of both your hands behind

testes to immobilize it and use your index finger
and thumb to palpate the body of the testes .

-check postion , size and consistency of the

testes , note any nodule or irregularities ,
compare between the size of both testes .

-feel the anterior and medial border with your

thumb and lateral border with your index finger .

6) palpate spermatic cord with your right hand by

gently pulling the testes downward and place your
finger behind the neck of the scrotum .
7) decide whether a swelling arises in the scrotum
or from inguinal canal .

If you can feel above the swelling , it originates

from the scrotum , if you can't , the swelling
usually originates in the inguinal region .

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

abnormalities (e.g. pigmented areas, ulcers,
vesicles etc.)
Dont forget to do transillumination test
And examine the hernia orifices and surrounding
lymph nodes
To examine prostate

-perform a rectal examination .

-palpate the prostate anteriorly through the
rectal wall.
- Note any tenderness and assess the
consistency .
-feel for any nodule

Sources :
Macleod's page 236/237
Great video : http://www.youtube.com/watch?v=jMHsbgsJ-1g
http://gemprsc.health.wits.ac.za/resources/pdf/EXAMINATION_OF_THE_MALE_EXTERNAL_GENITALIA

Female external genitalia examination

Introduce yourself / check the patient's name / Gain consent / Ensure privacy / Explain what you are going to
do
Prepare for examination:

Position the patient with help of a chaperone on to the couch (supine, flexed hips and knees with heels
together, thighs abducted).

Cover the patient's abdomen with a sheet.

Position lighting to give a clear view of external genitalia.

Put on disposable gloves.

Inspection
1) perineum for any deficiency associated with childbirth
2) hair distribution and cliteromegaly
3) skin abnormalities
- Rashes-ulcerations-swellings-lesion
4) look for discharge
-bloody
-purulent
5) Tell pt. to bear down: look for prolapse (cystocele, rectocele).
6) Tell pt. to cough (stess incontinence).
Palpation :
-Separate labia with forefinger and thumb, examine clitoris.
- Palpate Bartholin's glands [posterior of labia major] (palpable =
Bartholin cyst/ abcess).

THE FEMALE EXTERNAL GENITALIA

Most complaints about the external genitalia are referred to gynaecologists and are described in
detail in their textbooks, but there are three common conditions that quite often appear in a general
surgical clinic.

Bartholin cyst
When the duct of a gland is distended by obstruction or infection, it forms a cystic
swelling in the posterior part of the labium majus.The site betrays the diagnosis

Urethral caruncle
This is a bright-red, polypoid granuloma that arises from the mucosa of the urethral orifice in postmenopausal women. It is
very tender and causes painful micturition, dyspareunia and occasional
bleeding.The differential diagnosis is urethral prolapse,which is purple in colour and not so tender

Carcinoma of the vulva

Carcinoma of the vulva usually takes the form of achronic ulcer with an everted edge.
The patient complains of pain, a purulent or bloody discharge and sometimes of a lump in the
labia. Very small carcinomata can metastasize early and present with enlargement of the inguinal
glands. The primary ulcer can be small and hidden in the folds of the labia.There will usually be evidence of pre-malignant
changes in the surrounding skin (vulval intraepithelial neoplasia)

sources :
Browse pages 357/358
Macleods 223

Stoma examination
Classification
1- Temporary or permanent
2- End, Loop, double barrel
3- Ileostomy or colostomy

Site
Shape
Color
Content
Output
More

Ileostomy

Colostomy

Right side
Spouted
Red
Small bowel content
High output 9>500cc), continuous
- Skin irritation
- Fluid & electrolyte disturbances
- Renal failure

Left side
Flush
Pink
Stool
Low output, intermittent
- gas

Complication of stoma
-

Early
abLate
abcdef-

Ischemia
Retraction

Bleeding
Leakage
Skin irritation, infection
Bowel prolapsed
Diversion colitis
Obstruction
1- Stricture (mostly)
2- Stool
3- Stenosis
g- Psychological effect

Indication of stoma
-

Input
a- Feeding (percutaneous gastrostomy)
b- Lavage (appendicostomy)
Output

a- Diversion: to protect distal anastomoses

b- Decompression
c- Exteriorization: permenant stoma, urinary diversion

Site of stoma:
-

At least 5 cm from umbilicus

Away from scars or skin creases
Away from bony prominences, clothing,
Easily accessible to patient
Must be within rectus sheath

Stoma examination
-

Inspection
a- Stoma
1- Location
2- Type
3- Sputed of flesh
4- Color of mucosa
5- Output of content, blood and mucus, sign of infection
6- Number of openings
7- Content of stoma bag
8- Prolapsed, retraction, necrotic tissues, discharge, wound breakdown
b- Skin around the stoma
1- Scars, irritation, blood, skin changes
2- Ask to cough (parastomal hernia)
c- Inspect the whole abdomen
Palpation
a- 1st palpate the whole abdomen
b- Skin around the stoma, ask to cough (henia?)
c- Put finger inside the stoma
d- Do a DRE
Percussion & Auscultation of the abdomen

1. Kocher: Biliary or hepatic

procedures. May
be extended across to a left subcostal
incision
to give useful access to the stomach
and
pancreas.
2. Midline : General access. Usually
skirts the
umbilicus. Quick and bloodless.
3. McBurney :Appendicectomy.
Muscle layers
are split, rather than cut.
4. Battle :Appendicectomy. No longer
used
because it produces an ugly scar and
sometimes
incisional hernia. Often seen in older
patients
therefore.
5. Lanz :Appendicectomy. A better
cosmetic
result than McBurney
6. Paramedian : General access. Left
or right
according to requirements.
7. Transverse : General access.
Almost always
used in infants, and often in adults.
8. Rutherford Morison Access to
sigmoid colon
and pelvis, particularly if the midline
is very
scarred from previous surgery.
9. suprapubic: caserian section Access
to
bladder, uterus, Fallopian tubes and
ovaries.
Good cosmetic result but gives no
access outside the pelvis

Incisions

Surgical-Drains
Drains: is a tube used to remove pus , blood or fluid from the wound.
Types of surgical drain :
1- Open drains : including corrugated rubber or plastic sheet which drain
fluid in to a gauze pad or in to stoma bag ( high risk of infection ) .
2- Closed drains : formed by tube drain in to bag or bottle (low risk of
infection ), this type can be divide in to :
a- active drain: maintained under suction (which may be low or high
pressure).
b- Passive drains: have no suction and work according to the
differential pressure between body cavities and the exterior.

USE OF DRAINS:
Drains are used both prophylactically and therapeutically.
The most common use is prophylactic after surgery to prevent the
accumulation of fluid (eg, blood, pus) or air. In any surgery in which a dead
space (eg, a cavity) is created, the body has a natural tendency to fill this
space with fluid or air.

Complication of the Drains:

-poor drain placement
-infection
- discomfort (Pain)
-inefficient drainage ( by obstruction or the diameter of drian to small to
remove viscous fluid)
-breakdown of anastomotic site.

-erosion into hollow organ

-premature removal (accumulation of fluid)
-Decreased mobility ( cause DVT / increase hospital stay)

***In all drain when we need to examine it we should remember five things:
Site of drain (abdominal , chest, nose.. ect)
Type of drain ( open or closed)
If it is active or passive
Content and the amount
a- Serous Fluid: is typically pale yellow and transparent
b- Pus : typically white-yellow
c- Blood
5- If it is work or not ( functioning or nonfunctioning )
1234-

A- Open drain:
1- Penrose drain: used to removes fluid from a wound area
*Advantages
a. Help obliterate dead space
b. Soft / malleable less painful
* Disadvantages
c. Very irritating
d. Allow bacterial ingress
e. Cannot be connected to suction
f. Gravity dependent

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

3- Gauze : just for suction

b- closed drain:
1-chest tube: passive drain under water seal , inserted in lateral border
of pectorals major, a horizontal line inferior to the axilla, the anterior border
of latissimus dorsi and a horizontal line superior to the nipple.[12] More
specifically, the tube is inserted into the 5th intercostal space slightly
When a chest tube is inserted for anterior to the mid axillary line .
whatever reason, maintaining patency is critical to avoid complications.
Manual manipulation, often called milking, stripping, fan folding, or tapping,
of chest tubes is commonly performed to clear chest tube obstructions. (it
placed over the rib to prevent vessels and nerve injry.

Indications:

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

Pleural effusion: accumulation of fluid in the pleural space
Empyema: a pyogenic infection of the pleural space
Hemothorax: accumulation of blood in the pleural space
Hydrothorax: accumulation of serous fluid in the pleural space
Postoperative: for example, thoracotomy, oesophagectomy, cardiac surgery

Complication of chest tube:

Major insertion complications include: hemorrhage, infection, and
reexpansion pulmonary edema. Injury to the liver, spleen or diaphragm is possible if the
tube is placed inferior to the pleural cavity. Injuries to the thoracic aorta and heart can
also occur.[6]
Minor complications include: a subcutaneous hematoma or seroma, anxiety, shortness
of breath (dyspnea), and cough (after removing large volume of fluid). In most cases,
the chest tube related pain goes away after the chest tube is removed, however, chronic
pain related to chest tube induced scarring of the intercostal space is not uncommon.
The most frequent complication associated with chest tubes is chest tube clogging,
which is commonly caused by thrombus formation inside the chest tube, and can cause
major subsequent complications

2-Nasogastric tube : insertion of a plastic tube (nasogastric tube or NG tube) through

the nose, past the throat, and down into the stomach.

Complication: Minor complications include nose bleeds, sinusitis, and a sore throat.
Sometimes more significant complications occur including erosion of the nose where
the tube is anchored, esophageal perforation, pulmonary aspiration, a collapsed lung,
or intracranial placement of the tube.
If the NG tube's output appears to be excessive, consider the possibility that it may have
been placed in the duodenum.

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

the urethra and into the bladder.
The tube of a Foley catheter has two separated channels, running
down its length. One lumen is open at both ends, and
allows urine to drain out into a collection bag. The other lumen has
a valve on the outside end and connects to a balloon at the tip; the
balloon is inflated with sterile water when it lies inside the bladder,
in order to stop it from slipping out. Foley catheters are commonly
made from silicone rubber or natural rubber.

Indication:

On comatose patients

On some incontinent patients

On patients whose prostate is enlarged to the point that urine flow from the bladder is cut off.
The catheter is kept in until the problem is resolved.

On patients with acute urinary retention.

Following urethral surgeries

Following ureterectomy

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

Before and after cesarean sections

Before and after hysterectomies

On patients who had genital injury

Post-operative evaluation
1- * Ask the patient profile
*Ask the patient about the surgery
*Look if there are any operative notes
2- General status of the patient ;
*Ask about:

*Name, Age
*Type, Date
*Anesthesia, Findings, Drains, Closure, etc
(Fever, Constipation, Diarrhea, Pain, Nausea,
Vomiting, SOB, Confusion, Oliguria, Anuria, Collapse).
(HR, BP, RR, Temp.)

*Vital signs:
3- History

1-New or unexpected pain especially;

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

4- Physical examination
*Vital signs
*Ex.

5- Fluid balance

*(HR, BP, RR, Temp., Wt, Ht)

1-Chest (Check for signs of infection, collapse &
edema).
2-Wound(Check for presence of discharge,
granulation tissue, for developing localized
tenderness around it).
3-Bowel sounds(After abdominal surgery).
Legs(Check for localized tenderness over soleal
muscles).
4-Mental status(GCS).
*Ex. Fluid charts.
*Check for input (oral, Iv,) & output (NGT, Urine,
Drains, Insensible loss).
*NORMALLY, Is the patient in (+)ive or (-)ive balance.

6- Drugs
7- Dressings

Check for unnecessary drugs that can be stopped or

any drugs that need to be added
Look for their colour if there is any (pus, blood, ..),
and see if a new dressind id required

8- Drains & Tubes

*Position of IV line, Drains and their types.

*Presence of urine catheter.
*Are the all draining well?
*Can any of them be removed?

9- Investigations

*Have they became infected?

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

*NOTES::
What is a wound infection?
A wound infection is when bacteria enter a break in the skin.
What increases my risk for a wound infection?

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

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

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

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

A weak immune system caused by radiation, poor nutrition, or certain medicines

increases your risk for an infection.

What are the signs and symptoms of a wound infection?

Redness or excessive swelling in the wound area

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

How is a wound infection diagnosed:

Blood tests may be done to check for infection.

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

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

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

Wound infection treatment;

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

Antibiotics help fight or prevent an infection caused by bacteria.

NSAIDs help decrease swelling and pain or fever.

http://www.ncbi.nlm.nih.gov/pmc/articles/P
MC1360405/
http://emedicine.medscape.com/article/188
988-treatment

this checklist is for abdominal examination from Prof. Kamal BaniHani notes !
Introduce yourself
Gain consent
explain procedure and ensure good exposure(nipples to midthigh)
Inspect :
-from the foot :
1-abdominal contour (scaphoid,flat,distended)
2-umbilicus (inverted\everted-central)
3-movement with respiration
4-symmetry of the abdomen
-from the right side of the patient :
1-any skin lesion(warts,molds,erythema,scars,stria)
2-hair distribution
3-dilated veins (caput medusa,peripheral veins dilation)
4-look at epigastric region(any pulsations,bulges..)
5-comment on peristalsis (normally not present if present think of obstruction)
6-grey turner\cullens signs
7-inspect for hernias(with cough) (groin,umbilicus,epigastric,scars)
palpate:
b4 u start make sure your hands are warm

1-superficial palpation:for:
a-superficial masses
b-superficial tenderness
c-muscle tone

2-deep palpation :
a-deep masses
b-deep tenderness
3-organomegaly
liver,spleen,kidneys
-normally, the lower edge of the liver is palpable.
-in liver if palpable describe- Size, Edge , Surface, Tenderness and Consistency.
-differences between kidney and spleen :

-spleen moves with respiration,it has notch,spleen isnt ballotable,we can go above kidney if enlarged

Examine hernias : put your hand on orifices and epigastric region,umbilicus and ask the pt. to cough
looking for palpable cough impulse

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

Percuss:
to determine liver span : 2nd intercostals space tympanic till it changes to dull then percuss till it changes
to tympanic
Examination of ascites(shifting dullness,transmitted thrill)
Auscultate :
1-bowel sounds
2-renal artery bruit
Never forget
1- Digital rectal exam
2-examination of hernias
Introduce yourself
Wash hands
Chaperone
Standing up
Undressed from waist down
Look for any visible lumps
Any scars, overlying skin changes.
The lump extends into the scrotum
Observation of the groin area
Examine as a mass (site,skin,size,shape,)
The most important things:
1. Can you get above it?
2. Reducibility test
3. Expansile Cough Impulse;
4. Three finger test Ziemans technique
5. Ring occlusion test
Also Asses
Intra or extra abdominal Tension
Composition
Percussion and auscultation; Bowel Sounds
Always examine both groins
Transillumination

3-external genitalia