‫‪|P ag e1‬‬

‫‪Summary of‬‬

‫‪CLINICAL‬‬
‫‪SURGERY‬‬

‫زﻫـﺮ‬
‫اﻟﻮاﺣﺔ‬
‫ﻓﻲ ﻋﻤﻠﻲ اﻟﺠﺮاﺣﺔ‬

‫‪ ::‬ﺍﻟﻄﺒﻌﺔ ﺍﻟﺜﺎﻧﻴﺔ ‪::‬‬

 ‫‪|P ag e2‬‬

‫ﺍﳌﻘﹶﺪ‪‬ﻣ‪‬ﺔ‬
‫ﺑﺴﻢ ﺍﷲ ﺍﻟﺮﲪﻦ ﺍﻟﺮﺣﻴﻢ‬

‫ﺍﳊﻤﺪ ﷲ ﻋﻠﻰ ﺗﻮﻓﻴﻘﻪ ﻭﺍﻣﺘﻨﺎﻧﻪ‪ ،‬ﻭ‪‬ﻋ‪‬ﻈ‪‬ﻴﻢ ﻧﻌﻤﻪ‪ ،‬ﻭﺗﺘﺎﺑﻊ ﺇﹺﺣﺴﺎﻧﻪ‪ ،‬ﻭﺃﹶﺷﻬﺪ ﺃﹶﻥ ﻻ ﺇﹺﻟﻪ ﺇﹺﻻ ﺍﷲ ﻭﺣﺪﻩ ﻻ ﺷﺮﻳﻚ ﻟﻪ‪ ،‬ﻭﺃﹶﺷﻬﺪ ﺃﹶﻥ‬
‫ﳏﻤﺪﺍﹰ ﻋﺒﺪﻩ ﻭﺭﺳﻮﻟﻪ‪ ،‬ﺍﻟﻠﻬﻢ ﺻﻞ ﻭﺳﻠﻢ ﻋﻠﻴﻪ ﻭﻋﻠﻰ ﺁﻟﻪ ﻭﺃﹶﺻﺤﺎﺑﻪ ﻭﻣﻦ ﺗﺒﻌﻬﻢ ﺑﺈﺣﺴﺎﻥ ﺇﱃ ﻳﻮﻡ ﻟﻘﺎﺋﻪ‪.‬‬

‫ﺃﻣﺎ ﺑﻌﺪ‪ :‬ﻓﺈﱐ ﺃﻗﺪﻡ ﻟﻜﻢ ﻫﺬﻩ ﺍﻟﻮﺭﻗﺎﺕ ﰲ ﻋﻤﻠﻲ ﺍﳉﺮﺍﺣﺔ‪ ،‬ﻭﻻ ﺑﺪ ﺃﻥ ﺃﺫﻛﺮ ﺃ‪‬ﺎ ﻟﻴﺴﺖ ﺗﺄﻟﻴﻔﺎﹰ‪ ،‬ﻭﻟﻜﻨﻬﺎ ﰲ ﺍﻷﺻﻞ ﺗﻔﺮﻳﻎ‬
‫ﻟﺸﺮﺍﺋﻂ ﺍﻟﻌﻤﻠﻲ ﺍﳌﺸﻬﻮﺭﺓ‪ Sharma Cassette Clinics :‬ﻣﻊ ﺯﻳﺎﺩﺍﺕ ﻣﻦ ﻛﺘﺎﰊ ﺍﻟﻌﻤﻠﻲ ﻟﻠـ ﺩ‪ .‬ﻋﻤﺮﻭ ﺍﻟﺸﺎﻳﺐ ﻭ‬
‫ﺩ‪ .‬ﻭﺍﺋﻞ ﻣﺘﻮﱄ‪.‬‬

‫ﻭﺃﺭﺟﻮﻩ ﺳﺒﺤﺎﻧﻪ ﺃﻥ ﻳﻜﻠﻞ ﻫﺬﺍ ﺍﻟﻌﻤﻞ ﺑﺎﻹﺧﻼﺹ ﻟﻮﺟﻬﻪ ﺍﻟﻜﺮﱘ‪ ،‬ﻭﺃﻥ ﻳﻨﻔﻊ ﺑﻪ‪ ،‬ﻭﻫﻮ ﺳﺒﺤﺎﻧﻪ ﻭﱄ ﺍﳍﺪﺍﻳﺔ ﻭﺍﻟﺘﻮﻓﻴﻖ‪.‬‬

‫ﻗﺎﻝ ﺍﻟﺸﺎﻋﺮ‪:‬‬
‫ﺇﺫﺍ ﻫﺒﺖ ﺭﻳﺎﺣﻚ ﻓﺎﻏﺘﻨﻤﻬﺎ ‪ ..‬ﻓﺈﻥ ﺍﳋﺎﻓﻘﺎﺕ‪ ‬ﳍﺎ ﺳﻜﻮﻥﹸ‬
‫ﻭﺇﻥ ﻭﻟﺪﺕ ﻧﻴﺎﻗﹸﻚ ﻓﺎﺣﺘﻠﺒﻬﺎ ‪ ..‬ﻓﻼ ﺗﺪﺭﻱ ﺍﻟﻔﺼﻴﻞﹸ ﳌﻦ ﻳﻜﻮﻥﹸ‬

‫ﻭﻗﺎﻝ ﺣﻜﻴﻢ ﻣﻦ ﺍﳊﻜﻤﺎﺀ‪:‬‬

‫ﳌﺎ ﻛﻨﺖ ﺣ‪‬ﺪ‪‬ﹶﺛﺎﹰ ﻛﻨﺖ ﺃﺗﺼﻮﺭ ﺃﻥ ﺍﻟﺮﻋﺪ ﻫﻮ ﺍﻟﺬﻱ ﻳﻘﺘﻞ ﺍﻟﻨﺎﺱ‬
‫ﻓﻠﻤﺎ ﻛﱪﺕ ﻋﻠﻤﺖ ﺃﻥ ﺍﻟﱪﻕ ﻫﻮ ﺍﻟﺬﻱ ﻳﻘﺘﻞ‬
‫ﻭﳍﺬﺍ ﻋﺰﻣﺖ ﻣﻦ ﺫﻟﻚ ﺍﳊﲔ ﻋﻠﻰ ﺃﻥ ﺃﹸﻗ‪‬ﻞﱠ ﻣﻦ ﺍﻹﺭﻋﺎﺩ ﻭﺃﻛﺜﺮ ﻣﻦ ﺍﻹﺑﺮﺍﻕ‬

‫ﺍﻷﺭﺑﻌﺎﺀ ‪ 17‬ﺭﺑﻴﻊ ﺍﻷﻭﻝ ‪1431‬‬

‫‪Dr.ma7moud@windowslive.com - Esnips.com/user/ma7moud - 011 755 8 750‬‬

 ‫‪|P ag e3‬‬

‫ﺗﻨﻮﻳﻪ‬

‫ﺗﻮﰲ ﺍﻷﺥ ﺍﻟﺰﻣﻴﻞ‪ :‬ﻋﻤﺮﻭ ﳑﺪﻭﺡ ﺍﳉﻨﺪﻱ‬

‫ﻳﻮﻡ ﺍﻷﺣﺪ ‪ 14‬ﺭﺑﻴﻊ ﺍﻷﻭﻝ ‪ – 1431‬ﺍﳌﻮﺍﻓﻖ ‪ 28‬ﻓﱪﺍﻳﺮ ‪ 2010‬ﻡ‬

‫ﻧﺴﺄﻝ ﺍﷲ ﺃﻥ ﻳﻐﻔﺮ ﻟﻪ ﻭﺃﻥ ﻳﺮﲪﻪ‬

‫ﻭﺃﻥ ﻳﺪﺧﻠﻪ ﺍﻟﻔﺮﺩﻭﺱ ﺍﻷﻋﻠﻰ ‪ ..‬ﻣﻊ }ﺍﻟﻨ‪‬ﺒﹺﻴ‪‬ﲔ‪ ‬ﻭ‪‬ﺍﻟﺼ‪‬ﺪ‪‬ﻳﻘ‪‬ﲔ‪ ‬ﻭ‪‬ﺍﻟﺸ‪‬ﻬ‪‬ﺪ‪‬ﺍﺀ ﻭ‪‬ﺍﻟﺼ‪‬ﺎﻟ‪‬ﺤ‪‬ﲔ‪ ‬ﻭ‪‬ﺣ‪‬ﺴ‪‬ﻦ‪ ‬ﺃﹸﻭﻟﹶﺌ‪‬ﻚ‪ ‬ﺭ‪‬ﻓ‪‬ﻴﻘﹰﺎ{‬

‫ﻭﻻ ﺗﻨﺴﻮﻩ ﻣﻦ ﺻﺎﱀ ﺩﻋﺎﺋﻜﻢ‬

‫ﻫﻮ ﻭﲨﻴﻊ ﻣﻮﺗﻰ ﺍﳌﺴﻠﻤﲔ‬
 |P ag e4

:: ‫ ﺍﻟﻔﻬﺮﺱ‬::

1. Examination of a swelling …………………………………………. 5

2. Examination of an inguino-scrotal swelling ……………... 10
3. Examination of a scrotal swelling ……………………………... 13
4. Examination of a breast lump …………………………………… 15
5. Examination of a thyroid swelling ……………………………. 18
6. Examination of an ulcer ……………………………………………. 22
7. Examination of an intra-abdominal lump ………………… 25
8. Examination of a case of peripheral vascular disease 30
9. Examination of varicose veins ………………………………….. 35
 |P ag e5

EXAMINATION OF A SWELLING

v INSPECTION:

1. Site: May be diagnostic in:

• Post-auricular & external angular dermoid.
• Thoracic meningo-cele (over the back in the mid-line).

• Simple ganglion on the dorsum of the wrist.

• Thyro-glossal cyst in the front of the neck. «««««««
• Semi-membranous bursa in the medial aspect of the popliteal fossa.
INSPECTION:
2. Number: Multiple in:
• Neuro-fibromatosis (Von Reckling housens disease) with café au lait N - 5S.
patches.
• Lipomatosis (dercum's disease). Borders.
• LNs.
Color.
3. Shape:
• Spherical. Pulsation.
• Oval.
• Kidney shaped. Expansile ...
• Irregular.
«««««««
4. Size: (longitudinal, transverse & depth in cm).
o In cm, Patient fingers or Terms (lemon-size, orange-size, …).

5. Surface:
• Smooth → Cystic swelling.
• Lobulated → Lipoma.
• Irregular → Carcinoma.
• Filiform → Papilloma.
• Cauliflower → SCC.

6. Overlying skin:
• Red, edematous & shiny → Inflammation.
• Tense & shiny with dilated veins → Sarcoma.
• Punctum → Sebaceous cyst.
• Scars, ulcers or sinuses.
• Pigmentation.

7. Borders: Well or ill defined.

8. Color:
• Red → Haemangioma.
• Black → Malignant melanoma.
 |P ag e6

9. Pulsation:1
• Aneurysm of aorta.

10. Expansile cough impulse.2

v PALPATION:

1. Temperature:
ü Back of fingers – Compare with other area of normal temperature.
«««««««
ü Local rise of temperature:
• Inflammation (cellulitis & abscess). PALPATION:
• Sarcoma.
• Vascular swellings. 2T - 4S.
Edge.
2. Tenderness:3
• Solitary neuro-fibroma. Consistency.
Trans-illumination.
3. Conform the site, shape, size & surface.
Expansile …
4. Edge: Reducibility.
• Well defined & regular → benign swelling.
• Well defined & irregular → malignant swelling. Compressibility.
• Diffuse & ill defined → inflammatory swelling (cellulitis & abscess). Pulsatility.
Thrill.
ü If:
• Yielding → cyst. Crepitus.
• Fixed → solid. Pitting …
• Slippery → lipoma.
Fixity …

«««««««

1
A movement or an ↑ in size synchronous with each heart beat.
2
A visible ↑in size of a swelling synchronous with cough.
3
Pain due to pressure exerted over the swelling.
 |P ag e7

5. Consistency:
ü Fluctuation test:4
o +ve → cystic.
o -ve → solid:
§ Soft – Firm – Hard – Bony hard.
o Variable (malignant swelling).

ü Cross fluctuation → psoas abscess.

ü Bi-polar fluctuation → hydro-cele.

ü Paget's test → for small swellings < 2 cm, tense or tender swellings.
ü Sign of indentation (moulding):
1. Sebaceous cyst.
2. Dermoid cyst.
3. Colonic mass with fecal matter.

6. Trans-illumination:5
1. Meningo-cele.
2. Hydro-cele.

§ Brillian trans-iilumination:
1. Cystic hygroma.
2. Epididymal cyst.
3. Meningo-cele with thin skin.
4. Congenital hydro-cele.
5. Ranula.

§ -ve trans-iilumination:
o Opaque fluid:
§ Hemato-cele – Pyo-cele – Chylo-cele.
o Opaque wall.

7. Expansile cough impulse (or crying):

• Expansile → hernia.
• Transmitted → varicose vein.

4
Transmission of an impulse in 2 direc ons at right angles to each other.

N.B.s:
• Pascal's law: Pressure exerted to a fluid is transmitted equally in all directions.

• Pseudo-fluctuation: A false sense of fluctuation felt in large soft swellings e.g. large lipoma.

• Cross- fluctuation: Fluctua on between 2 separate cys c swellings communica ng with each other:
1. Compound palmar ganglion (above & below the wrist).
2. Psoas abscess pointing in the thigh (above & below the inguinal ligamen).
3. Deep plunging ranula (in the floor of the mouth & sub-mentally).
5
Demonstration of transmission of light through a swelling.
 |P ag e8

8. Reducibility:
1. Hernia.
2. Meningo-cele.
3. Congenital hydro-cele.
4. 1ry Varico-cele.
5. Saphena varix.

Ø Both should be tested in swellings which are likely to be communicating with abdomen, chest or
spinal canal & cranial cavity.

9. Compressibility:
• Vascular swellings e.g. saphina varix – haemangioma.

10. Pulsatility:
• Expansile → aneurysm of aorta.
• Transmitted → over an artery.

11. Thrill.

12. Crepitus: "crackling sensation"

• Osteo-arthritis.
• Fractures.
• Surgical emphysema.

13. Pitting on pressure:

• Soft pitting → early edema.
• Soft pitting in red tender area → underlying pus.
• Non-pitting → lymphoedema.

14. Fixity to surrounding structures:

1. Skin:
ü Pinch the skin or slide it over the swelling.

2. Muscles & tendons:

ü On muscle contraction, if:
o More prominent & easier to palpate → superficial to the muscle.
o Fixed & immobile → within the muscle (intra-muscular).
o Less prominent & difficult to palpate → deep to the muscle.

3. Bone.

ü Mobile in one direction → attached to the fascia, nerve or vessels.

v PERCUSSION:

• Tympanitic → Pharyngo-cele.
• Dull → All other swellings.
 |P ag e9

v AUSCULTATION:

• Bruit6 → Vascular swellings – Aneurysm.

v FOCAL EXAMINATION:

1. Regional draining LNs: if palpable, asses:

• Consistency.
• Fixed or not.
• Discrete (separate), matted or amalgamated.

2. Liver & spleen.

3. Neighboring structures for pressure effects:

• Bone → erosion (external angular dermoid).
• Artery → distal color – skin trophic changes – pulse – temperature.
• Vein → distal edema (pitting) & dilated veins.
• Nerve → trophic changes – motor or sensory changes – deformity (as foot drop).
• Lymphatics → distal edema (non-pitting).

4. Joint above & below.

:‫ ﻣﺸﺮﻭﻉ ﺍﻟﻌﻤﺮ‬.. ‫ﺍﻟﺘﻮﺑﺔ‬

:‫ ﻗﺎﻝ ﺗﻌﺎﱃ‬.. ‫ﺗﻈﺎﻫﺮﺕ ﺩﻻﺋﻞ ﺍﻟﻜﺘﺎﺏ ﻭﺍﻟﺴﻨﺔ ﻭﺇﲨﺎﻉ ﺍﻷﻣﺔ ﻋﻠﻰ ﻭﺟﻮﺏ ﺍﻟﺘﻮﺑﺔ‬
.‫( ﺳﻮﺭﺓ ﺍﻟﻨــﻮﺭ‬31) {‫ﻮﻥﹶ‬‫ﺤ‬‫ﻔﹾﻠ‬‫ ﺗ‬‫ﻠﱠﻜﹸﻢ‬‫ﻮﻥﹶ ﻟﹶﻌ‬‫ﻨ‬‫ﻣ‬‫ﺆ‬‫ﺎ ﺍﻟﹾﻤ‬‫ﻬ‬‫ﺎ ﺃﹶﻳ‬‫ﻴﻌ‬‫ﻤ‬‫ ﺟ‬‫ﻮﺍ ﺇﹺﻟﹶﻰ ﺍﻟﻠﱠﻪ‬‫ﻮﺑ‬‫ﺗ‬‫}ﻭ‬
.‫( ﺳﻮﺭﺓ ﻫﻮﺩ‬52) {‫ﻪ‬‫ﻮﺍﹾ ﺇﹺﻟﹶﻴ‬‫ﻮﺑ‬‫ ﺗ‬‫ ﺛﹸﻢ‬‫ﻜﹸﻢ‬‫ﺑ‬‫ﻭﺍﹾ ﺭ‬‫ﺮ‬‫ﻔ‬‫ﻐ‬‫ﺘ‬‫}ﺍﺳ‬
.‫( ﺳﻮﺭﺓ ﺍﻟﺘﺤﺮﱘ‬8) {‫ﺎ‬‫ﻮﺣ‬‫ﺼ‬‫ﺔﹰ ﻧ‬‫ﺑ‬‫ﻮ‬‫ ﺗ‬‫ﻮﺍ ﺇﹺﻟﹶﻰ ﺍﻟﻠﱠﻪ‬‫ﻮﺑ‬‫ﻮﺍ ﺗ‬‫ﻨ‬‫ ﺁﻣ‬‫ﻳﻦ‬‫ﺎ ﺍﻟﱠﺬ‬‫ﻬ‬‫ﺎ ﺃﹶﻳ‬‫}ﻳ‬

6
Short, medium pitched murmur heard over the swelling with each pulse wave.
 | P a g e 10

EXAMINATION OF AN INGUINO-SCROTAL SWELLING

1. Hernias.
2. Congenital hydro-cele.
3. Varico-cele.
4. Cord swellings.

v INSPECTION:
"Standing position"
«««««««
1. Site.
• Scrotal or inguino-scrotal. INSPECTION:
2. Number: N - 5S.
• Unilateral or bilateral.
Peristalsis.
3. Shape: Position …
• Pyriform (oblong) → indirect inguinal hernia.
• Globular (hemi-spherical) → direct inguinal hernia. Expansile ...

4. Size. ««««««

5. Surface:
• Smooth → omento-cele.
• Lobulated → entero-cele7.

6. Overlying skin:
• Red, edematous & shiny → Inflammation – strangulation.
• Scars of previous surgery (if irregular & ragged → post-operative wound infection).
• Discoloration → truss for a long time.

7. Peristalsis:
• Entero-cele.

8. Position of the penis:

• Hernia pushes the penis to the opposite side.

9. Expansile cough impulse:

ü Hernia with no expansile cough impulse:

1. Omento-cele with adhesions.
2. Fatty hernia of linea alba.

3. Strangulated hernia.
4. Obstructed hernia (weak).

7
Hernia containing bowel loops.
 | P a g e 11

v PALPATION:

1. Temperature.
2. Tenderness:
• Inflammation - Strangulation.

3. Conform the site, shape, size & surface.

4. Relation to pubic tubercle:

• Above & medial → inguinal hernia. «««««««
• Below & lateral → femoral hernia.
PALPATION:
5. Relation to testis.
2T - 4S.
6. Consistency: 2 Relations.
• Soft & elastic → entero-cele.
• Firm & doughy → omento-cele. Consistency.
• Tense & tender → strangulated hernia. Expansile …
• Bag of worms → varico-cele. Reducibility.

7. Expansile cough impulse: Zieman's technique8 (3 fingers test) 2 Tests.

§ 3 fingers are put as follows:
• One on the internal ring (indirect hernia). ««««««
• The 2nd on the external ring (direct hernia).
• The 3rd on the saphenous opening (femoral hernia).
§ Ask the patient to cough & see which finger receives the impulse first.

8. Reducibility: "lying down"

• Spontaneous → direct inguinal hernia.
• Manual → indirect inguinal hernia.
Ø To facilitate reduction → flexion, adduction & medial rotation of the thigh.

9. Internal ring occlusion test:

§ Put your thumb on the internal inguinal ring (1/2 inch above the Mid-inguinal point9).
§ Ask the patient to cough:
• Hernia does not protrude → indirect inguinal hernia.
• Hernia protrudes → direct inguinal hernia.

10. External ring occlusion test (invagination test):

§ Put your little finger in the external inguinal ring.
§ Ask the patient to cough:
• Impulse at the tip of the finger → indirect inguinal hernia.
• Impulse at the side of the finger → direct inguinal hernia.

8
For palpation of hernia impulse in adults.
9
The mid-point between ASIS & symphysis pubis.
 | P a g e 12

v Significance:
1. Size of the external inguinal aring.
2. Direction of the hernia tract.
3. Direction of the expansile impulse.
4. Sphinteric strength of the conjoint tendon.

v PERCUSSION:

• Tympanitic (resonant) → Entero-cele.

• Dull → All other swellings.

v AUSCULTATION:

• peristalsis in:
o Entero-cele.

Ø Examine the opposite side:

1. Palpate the testis, epididymis & cord.

2. Inspect & palpate carefully for expansile cough impulse.

Ø Look for a possible cause:

1. Tone of abdominal wall muscles:
o Malgaigne's bulging:
Simulating direct hernia but without expansile cough impulse.

2. Scars of previous surgery:

o Appendicectomy or urethro-lithotomy → injury of ilio-inguinal nerve → paralysis of
conjoint tendon.

3. RS: TB or chronic bronchitis.

4. Ascites.

5. Urethra: strcture.

6. PR: enlarged prostate.

:‫ﻘﹸﻮﻝﹸ‬‫( ﻳ‬‫ﻠﱠﻢ‬‫ﺳ‬‫ ﻭ‬‫ﻪ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ﻠﱠﻰ ﺍﻟﻠﱠﻪ‬‫ )ﺻ‬‫ﻮﻝﹶ ﺍﻟﻠﱠﻪ‬‫ﺳ‬‫ ﺭ‬‫ﺖ‬‫ﻌ‬‫ﻤ‬‫ ﺳ‬:‫ﺓﹶ )ﺭﺿﻲ ﺍﷲ ﻋﻨﻪ( ﻗﺎﻝ‬‫ﺮ‬‫ﻳ‬‫ﺮ‬‫ﻋﻦ ﺃﹶﰊ ﻫ‬
(‫ )ﺭﻭﺍﻩ ﺍﻟﺒﺨﺎﺭﻱ‬.((‫ﺓﹰ‬‫ﺮ‬‫ ﻣ‬‫ﲔ‬‫ﻌ‬‫ﺒ‬‫ ﺳ‬‫ﻦ‬‫ ﻣ‬‫ﻡﹺ ﺃﹶﻛﹾﺜﹶﺮ‬‫ﻮ‬‫ﻲ ﺍﻟﹾﻴ‬‫ ﻓ‬‫ﻪ‬‫ ﺇﹺﻟﹶﻴ‬‫ﻮﺏ‬‫ﺃﹶﺗ‬‫ ﻭ‬‫ ﺍﻟﻠﱠﻪ‬‫ﺮ‬‫ﻔ‬‫ﻐ‬‫ﺘ‬‫ﻲ ﻟﹶﺄﹶﺳ‬‫ ﺇﹺﻧ‬‫ﺍﻟﻠﱠﻪ‬‫))ﻭ‬

:(‫ﻠﱠﻢ‬‫ﺳ‬‫ ﻭ‬‫ﻪ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ﻠﱠﻰ ﺍﻟﻠﱠﻪ‬‫ )ﺻ‬‫ﻮﻝﹸ ﺍﻟﻠﱠﻪ‬‫ﺳ‬‫ ﻗﹶﺎﻝﹶ ﺭ‬:‫ )ﺭﺿﻲ ﺍﷲ ﻋﻨﻪ( ﻗﺎﻝ‬‫ﻧﹺﻲ‬‫ﺎﺭ ﺍﳌﹸﺰ‬‫ﺴ‬‫ ﺑﻦ ﻳ‬‫ﻭﻋﻦ ﺍﻟﹾﺄﹶﻏﹶﺮ‬
(‫ )ﺭﻭﺍﻩ ﻣﺴﻠﻢ‬.((‫ﺓ‬‫ﺮ‬‫ﺎﺋﹶﺔﹶ ﻣ‬‫ﻡﹺ ﻣ‬‫ﻮ‬‫ﻲ ﺍﻟﹾﻴ‬‫ ﻓ‬‫ﻮﺏ‬‫ﻲ ﺃﹶﺗ‬‫؛ ﻓﹶﺈﹺﻧ‬‫ﻭﻩ‬‫ﻔﺮ‬‫ﻐ‬‫ﺘ‬‫ ﻭﺍﺳ‬‫ﻮﺍ ﺇﹺﻟﹶﻰ ﺍﻟﻠﱠﻪ‬‫ﻮﺑ‬‫ ﺗ‬‫ﺎﺱ‬‫ﺎ ﺍﻟﻨ‬‫ﻬ‬‫ﺎ ﺃﹶﻳ‬‫))ﻳ‬
 | P a g e 13

EXAMINATION OF A SCROTAL SWELLING

v INSPECTION:
"Standing position"

1. Site.
• Scrotal or inguino-scrotal.

2. Number:
• Unilateral or bilateral.
«««««««
3. Shape:
• Globular with central constriction→ tunica vaginalis hydro-cele. INSPECTION:

N - 5S.
4. Size.
Position …
5. Surface.
Expansile ...
6. Overlying skin:
• ↓ rugosities → hydro-cele. Relation …
• Friction ulcers → very large hydro-cele.
«««««««
• Red, edematous & shiny → Inflammation (scrotal wall cellulitis - acute
epididymo-orchitits).
• Thick, edematous, firm & non-tender → filarial lymphoedema (+ Ram's horn penis).

• Excoriation & vesicles → urinary extravasation.

• Blackening & sloughing → fournier's gangreme.

• Sinuses: (posterior → tuberculous) – (anterior → syphilitic).

7. Position of the penis:

• Pushed to the opposite side → unilateral hydro-cele.
• Buried within the scrotum → large bilateral hydro-cele.

8. Expansile cough impulse:

o In the swelling.
o Over the inguinal canals.

9. Relation to testis, epididymis & cord:

• Separate from the swelling→ encysted hydro-cele of the cord.
• Incorporated within the swelling→ hydro-cele or testicular tumor.

v PALPATION:

1. Temperature.
2. Tenderness.
• Thrombo-phlepitis.
 | P a g e 14

3. Conform the site, shape, size & surface.

4. Scrotal neck test:

• Top of the swelling can be reached → scrotal.
• Top of the swelling cannot be reached → inguino-scrotal.

5. Weight:
• Heavy → malignant testicular tumor.
• Light → hydro-cele.
«««««««
6. Consistency.
• Bi-polar fluctuation test. PALPATION:
• Pinching test:
Pinching the lax tunica between 2 fingers away from the tes s. 2T - 4S.

7. Trans-illumination. Test.
Weight.
8. Expansile cough impulse.
Consistency.
9. Reducibility. Trans-illumination.
• Congenital hydro-cele.
• 1ry varico-cele. Expansile …
Reducibility.
10. Thrill.
Thrill.
10. Palpate the testis, epididymis & cord (on both sides):
ü Normal cord structure: Palpate …
o Whipcord-like vas.
o String liker fibers of cremasteric muscle. «««««««

ü Abnormal cord structure:

o Nodular vas → TB.
o Bag of worms → varico-cele (soft & compressible multiple dilated veins).

v FOCAL & GENERAL EXAMINATION:

• Inguinal & external iliac LNs.

• Testicular tumor → para-aortic & Lt supra-calvicular LNs.
• 2ry Varicosele → renal mass (hyper-nephroma).
• Epididymo-orchitis → PR for prostatitis & enlarged seminal vesicles.

‫ﻮﻝﹸ ﺍﻟﻠﱠﻪ‬‫ﺳ‬‫ ﻗﹶﺎﻝﹶ ﺭ‬:‫( ﻗﹶﺎﻝﹶ‬‫ﻪ‬‫ﻨ‬‫ ﻋ‬‫ ﺍﻟﻠﱠﻪ‬‫ﻲ‬‫ﺿ‬‫ ﺧﺎﺩﻡﹺ ﺭﺳﻮﻝ ﺍﷲ )ﺻﻠﻰ ﺍﷲ ﻋﻠﻴﻪ ﻭﺳﻠﻢ( )ﺭ‬‫ ﺍﻷﻧﺼﺎﺭﻱ‬‫ ﺃﰊ ﲪﺰﺓ ﺃﻧﺲﹺ ﺑﻦ ﻣﺎﻟﻚ‬‫ﻦ‬‫ﻋ‬
:(‫ﻠﱠﻢ‬‫ﺳ‬‫ ﻭ‬‫ﻪ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ﻠﱠﻰ ﺍﻟﻠﱠﻪ‬‫)ﺻ‬
(‫ )ﻣﺘﻔﻖ ﻋﻠﻴﻪ‬.((‫ﺽﹺ ﻓﹶﻠﹶﺎﺓ‬‫ﻲ ﺃﹶﺭ‬‫ ﻓ‬‫ﻠﱠﻪ‬‫ ﺃﹶﺿ‬‫ﻗﹶﺪ‬‫ ﻭ‬‫ﲑﹺﻩ‬‫ﻌ‬‫ﻠﹶﻰ ﺑ‬‫ﻘﹶﻂﹶ ﻋ‬‫ ﺳ‬‫ﻛﹸﻢ‬‫ﺪ‬‫ ﺃﹶﺣ‬‫ﻦ‬‫ ﻣ‬‫ﻩ‬‫ﺪ‬‫ﺒ‬‫ ﻋ‬‫ﺔ‬‫ﺑ‬‫ﻮ‬‫ ﺑﹺﺘ‬‫ﺡ‬‫ ﺃﹶﻓﹾﺮ‬‫))ﺍﻟﻠﱠﻪ‬
 | P a g e 15

EXAMINATION OF A BREAST LUMP

v INSPECTION:

v COMPARATIVE INSPECTION OF BOTH BREASTS:

1. Sitting erect with both arms by the side.
2. Sitting erect with both arms raised above the head.
3. With the patient bending forward.

1. For the 5 Ss & mobility.

2. Compare the level of the nipples:10

"Vertical distance from the clavicle & horizontal distance from the mid-line"
A nipple at a higher level is fixed by a malignant lump.

3. While raising the arms, do not forget to inspect:

• The under surface of the breasts.
• Both axillae (for enlarged LNs & axillary breast).

4. Visible lump or bulge.

• 5 Ss.

v INSPECTION OF THE AFFECTED BREAST:

1. The nipple & areola:

• Nipple displacement:
o Towards the lump → malignant.
o Away from the lump → benign.
• Nipple deviation.

• Nipple retraction: "usually associated with ↓ size of areola"

o Since childhood → congenital.
o Recently → chronic abscess with fibrosis – carcinoma.

• Nipple discharge:
o Bright red (fresh blood) → duct papilloma – carcinoma.
o Black (blackish red) → duct papilloma with obstructed duct.
o Clear watery or greenish → fibro-adenosis.
o Milky (white) → lactating breast – galacto-cele – mammary duct ectasia – non-puerperal
galactorrhoea.
o Purulent → acute mastitis – chronic abscess with duct ectasia.

• Cracks, fissures & eczema:

o Unilateral eczema & destruction → paget's disease.
o Bilateral eczema & itching → allergic eczema.

10
Auchincloss's method: The visible signs of breast carcinoma become more prominent on raising the arms.
 | P a g e 16

2. Overlying skin:
• Red, edematous & shiny → Inflammation (acute mastitis – abscess).
• Tense & shiny with dilated veins → Sarcoma.
• Dimpling & puckering.
• Peau d'orange → Infiltrating malignant lump blocking cutaneous lymphatics.
• Ulcers & nodules.

Ø Edema of the arm → malignant infiltration of axillary LNs (lymphoedema) – axillary vein
thrombosis.

v PALPATION:
"lying down with arm abducted"
1. Palpate both breasts starting with the normal one.
2. Quadrant by quadrant.
3. By the flat of the hand & the finger tips.

1. Temperature:
2. Tenderness:

v PALPATION OF THE LUMP:

3. Site, shape, size & surface.

4. Edge. «««««««

5. Consistency. PALPATION:

6. Trans-illumination: 2T - 4S.
1. Normal breast tissue. Edge.
2. Cystic hygroma.
Consistency.
7. Nipple discharge: Trans-illumination.

Nipple discharge.
8. Fixity to surrounding structures:
1. Skin:
Fixity …
ü By pinching or sliding test.
Tethering: indirect fixity to skin due to fixity to the fibrous septa
attached to the skin (Cooper's ligament).
«««««««

2. Breast tissue.
ü By holding the breast with one hand & trying to move the mass with the other hand.

3. Muscles:
v Pectoralis major muscle & fascia:
ü Ask the patient to press hardly by her hands against her waist.

v Serratus anterior (in lower outer quadrant tumors):

ü Ask the patient to press hardly by her hands against the shoulder of the examining doctor.

4. Chest wall.
 | P a g e 17

v EXAMINATION OF LNs:

• Anterior (pectoral) group → under the anterior axillary fold.

• Posterior (sub-scapular) group → under the posterior axillary fold.

• Lateral (humeral – brachial) group → lateral wall of the axilla (against the upper end of
humerus).
• Central group → medial wall of the axilla (against the chest wall).

• Apical (delto-pectoral – infra-clavicular) group → felt bi-manually in the apex of axilla (below
the clavicle).
• Supra-clavicular group → in the base of the anterior triangle of the neck behind the middle
of the clavicle.

v SYSTEMIC EXAMINATION:

• RS: effusion & consolidation.

• Abdomen: hepatomegaly (hard nodular liver) & ascites.

• PR & PV.
• Bone: swellings & tenderness.

:‫ﰲ ﺭﻭﺍﻳﺔ ﳌﺴﻠﻢ‬

‫ﺽﹺ ﻓﹶﻠﹶﺎﺓ‬‫ ﺑﹺﺄﹶﺭ‬‫ﻪ‬‫ﻠﹶﺘ‬‫ﺍﺣ‬‫ﻠﹶﻰ ﺭ‬‫ ﻛﹶﺎﻥﹶ ﻋ‬‫ﻛﹸﻢ‬‫ﺪ‬‫ ﺃﹶﺣ‬‫ﻦ‬‫ ﻣ‬‫ﻪ‬‫ ﺇﹺﻟﹶﻴ‬‫ﻮﺏ‬‫ﺘ‬‫ ﻳ‬‫ﲔ‬‫ ﺣ‬‫ﻩ‬‫ﺪ‬‫ﺒ‬‫ ﻋ‬‫ﺔ‬‫ﺑ‬‫ﻮ‬‫ﺎ ﺑﹺﺘ‬‫ﺣ‬‫ ﻓﹶﺮ‬‫ﺪ‬‫ ﺃﹶﺷ‬‫))ﻟﹶﻠﱠﻪ‬
‫ﺎ‬‫ﻬ‬‫ﻨ‬‫ ﻣ‬‫ ﻓﹶﺄﹶﻳﹺﺲ‬‫ﻪ‬‫ﺍﺑ‬‫ﺮ‬‫ﺷ‬‫ ﻭ‬‫ﻪ‬‫ﺎﻣ‬‫ﺎ ﹶﻃﻌ‬‫ﻬ‬‫ﻠﹶﻴ‬‫ﻋ‬‫ ﻭ‬‫ﻪ‬‫ﻨ‬‫ ﻣ‬‫ﺖ‬‫ﻔﹶﻠﹶﺘ‬‫ﻓﹶﺎﻧ‬
‫ﻪ‬‫ﻠﹶﺘ‬‫ﺍﺣ‬‫ ﺭ‬‫ﻦ‬‫ ﻣ‬‫ ﺃﹶﻳﹺﺲ‬‫ ﻭﻗﹶﺪ‬،‫ﺎ‬‫ﻠﱢﻬ‬‫ﻲ ﻇ‬‫ ﻓ‬‫ﻊ‬‫ﻄﹶﺠ‬‫ﺓﹰ ﻓﹶﺎﺿ‬‫ﺮ‬‫ﺠ‬‫ﻰ ﺷ‬‫ﻓﹶﺄﹶﺗ‬
‫ﻩ‬‫ﺪ‬‫ﻨ‬‫ﺔﹰ ﻋ‬‫ﻤ‬‫ﺎ ﻗﹶﺎﺋ‬‫ ﺑﹺﻬ‬‫ﻮ‬‫ ﺇﹺﺫﹶﺍ ﻫ‬‫ﻚ‬‫ ﻛﹶﺬﹶﻟ‬‫ﻮ‬‫ﺎ ﻫ‬‫ﻨ‬‫ﻴ‬‫ﻓﹶﺒ‬
‫ﻚ‬‫ﺑ‬‫ﺎ ﺭ‬‫ﺃﹶﻧ‬‫ﻱ ﻭ‬‫ﺪ‬‫ﺒ‬‫ ﻋ‬‫ﺖ‬‫ ﺃﹶﻧ‬‫ﻢ‬‫ ﺍﻟﻠﱠﻬ‬:‫ﺡﹺ‬‫ ﺍﻟﹾﻔﹶﺮ‬‫ﺓ‬‫ﺪ‬‫ ﺷ‬‫ﻦ‬‫ ﻗﹶﺎﻝﹶ ﻣ‬‫ﺎ ﺛﹸﻢ‬‫ﻬ‬‫ﺨﻄﹶﺎﻣ‬
 ‫ﺬﹶ ﺑﹺ‬‫ﻓﹶﺄﹶﺧ‬
.((‫ﺡﹺ‬‫ ﺍﻟﹾﻔﹶﺮ‬‫ﺓ‬‫ﺪ‬‫ ﺷ‬‫ﻦ‬‫ﻄﹶﺄﹶ ﻣ‬‫ﺃﹶﺧ‬
 | P a g e 18

EXAMINATION OF A THYROID SWELLING

v INSPECTION:
"Pizillo's method": extension of the neck (may be needed).

1. Site:
• On one side of the mid-line.
• In the mid-line.
• On both sides.

2. Number. «««««««

3. Shape: INSPECTION:
• Butterfly.
• U shaped.
N - 5S.
• Oval.
Borders.
• Irregular.
Pulsation.
4. Size: (longitudinal, transverse & depth in cm).
2 Movements.
5. Surface:
• Smooth → simple goiter – single nodular goiter – 1ry toxic goiter. Pemberton's sign.
• Nodular → multi-nodular goiter – 2ry toxic goiter.
• Bosselated. «««««««
6. Overlying skin:
• Red, edematous & shiny → Inflammation.
• Scars of previous surgery → thyroidectomy.
• Sinuses → thyro-glossal fistula.
• Dilated veins → retro-sternal goiter.

7. Borders (extent): "with swallowing"

• Lateral border in relation to the sterno-mastoid muscle (deep).
• Lower border in relation to the supra-sternal notch.

8. Pulsation:
• At the upper pole of the gland over superior thyroid artery → 1ry toxic goiter.

9. Movement with deglutition:

1. Thyroid.
2. Thyro-glossal cyst.

3. Pre-tracheal LNs.
4. Sub-hyoid bursa.

5. Extrinsic carcinoma of larynx.

6. Laryngo-cele.
 | P a g e 19

10. Movement with tongue protrusion: "Mid-line swellings"

1. Thyro-glossal cyst.
2. Thyro-glossal fistula.

11. Pemberton's sign:

• Ask the patient to tilt his head to one side or raise his arms to tough his hears (for 1 minute).
o Congestion of the face & respiratory distress → thoracic outlet obstruction.

v PALPATION:
1. Standard method:
From behind after flexing the neck & tilting the head to the side of examination.

2. "Lahey's method" for palpation of the deep surface of the thyroid: «««««««
By pushing the gland to one side.
PALPATION:
3. "Crile's method" for palpation of small nodules in the thyroid:
With the thumb placed over the lobe & the patient is swallowing. 2T - 4S - B.

1. Temperature. Consistency.
• Toxic goiter. Thrill.

2. Tenderness: Carotids.
• Malignancy. Trachea.

3. Conform the site, shape, size, surface & borders. Fixity …

4. Consistency: «««««««
ry
• Soft → colloid goiter – 1 toxic goiter.
• Firm → multi-nodular goiter – 2ry toxic goiter.
• Hard → riedel's thyroiditis – calcified nodular goiter – malignancy – tense thyroids cyst.

A cyst in the thyroid feels firm "fluid under tension".

While a solid swelling (Adenoma) feels soft "highly cellular".

• Is the rest of the gland palpable? "Normally not palpable except the isthmus".
o If yes → multi-nodular goiter with dominant nodule.
o If no → single nodular goiter.

5. Thrill:
• At the upper pole of the gland over superior thyroid artery → 1ry toxic goiter.

6. Carotids:
• Well felt although displaced backwards → benign goiter.
• Weak or absent → malignant goiter (berry's sign).

7. Trachea:
• Central of deviated.
• Kocher's test for scabbard trachea → malignancy.
 | P a g e 20

8. Fixity to surrounding structures:

• Riedel's thyroiditis – malignancy.

v PERCUSSION:

• Direct on the manubrium sterni or a heavy percussion stroke:

o Resonant → normal.
o Dull → retro-sternal goiter.

v AUSCULTATION:

• Systolic bruit:
o At the upper pole of the gland over superior thyroid artery → 1ry toxic goiter.

Ø Then look for:

1. Signs of thyro-toxicosis:
v Eye signs:
1) Stellwag's sign → Staring look with infrequent blinking.
2) Von Graefe's sign → Lid lag when the patient looks down while the head is fixed.

3) Dalrymple's sign → Appearance of a rim of sclera above the cornea (lid retraction).
4) Actual bulge "exophthalmos" (naffziger's method) & appearance of a rim of sclera below the
cornea.

5) Joffroy's sign → Lack of corrugation (wrinkling) of forehead when the patient looks up while
the head is fixed.
6) Mobeius's sign → Lack of proper converge when looking to near object (due to paresis of
extra-ocular muscles from infiltration by EPS → diplopia).

ü Progressive exophthalmos:
1) Further bulging of eyeballs.
2) Conjunctival congestion & edema.
3) Corneal ulcers & diminished vision.
4) Ophthalmo-plegia.

v Fine tremors:
• Outstretched hands.
• Protruded un-supported tongue.

v Tachy-cardia & pounding pulse.

• Radial pulse.
• Sleeping pulse rate: counted early morning (around 4 am) before the pa ent wakes up
without disturbing the sleep.

v Bruit – thrill.

v Warm moist skin – pre-tibial myxoedema.

 | P a g e 21

1ry thyrotoxicosis 2ry thyrotoxicosis

• Eye signs: exophthalmos. • Eye signs: exophthalmos.
• CNS signs: tremors. • CNS signs: tremors.
• CVS signs: • CVS signs:
o Tachy-carida. o Tachy-carida.
o Cardiomegaly – CHF. o Cardiomegaly – CHF.

2. Signs of myxoedema:
v Edema of face & legs.
v Hoarseness of voice.
v Lethargy.
v Delayed relaxation of deep reflexes (ankle jerk).

3. Signs of retro-sternal goiter.

4. Horner's syndrome: can occur with:

a) Retro-sternal goiter.
b) Malignant goiter.

On the affected side:

§ Ptosis.
§ Miosis.
§ Enophthalmos.
§ Anhydrosis.
§ Absent cilio-sppinal reflex.

5. Signs of metastasis:
v RS: effusion & consolidation.
v Abdomen: hepatomegaly (hard nodular liver) & ascites.
v Bone: Hard nodules on the skull – Hard cervical LNs.
v Long bone metastasis.

:‫( ﻗﺎﻝ‬‫ﻠﱠﻢ‬‫ﺳ‬‫ ﻭ‬‫ﻪ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ﻠﱠﻰ ﺍﻟﻠﱠﻪ‬‫ ﻋﻦ ﺍﻟﻨﱯ )ﺻ‬‫ﻰ ﻋﺒﺪ ﺍﷲِ ﺑﻦ ﻗﻴﺲﹴ ﺍﻷﺷﻌﺮﻱ‬‫ﻮﺳ‬‫ ﺃﹶﺑﹺﻲ ﻣ‬‫ﻦ‬‫ﻋ‬
‫ﻦ‬‫ ﻣ‬‫ﺲ‬‫ﻤ‬‫ ﺍﻟﺸ‬‫ﻄﹾﻠﹸﻊ‬‫ﻰ ﺗ‬‫ﺘ‬‫ﻞﹺ ﺣ‬‫ﺴِﻲﺀُ ﺍﻟﻠﱠﻴ‬‫ ﻣ‬‫ﻮﺏ‬‫ﺘ‬‫ﻴ‬‫ﺎﺭﹺ ﻟ‬‫ﻬ‬‫ ﺑﹺﺎﻟﻨ‬‫ﻩ‬‫ﺪ‬‫ﻂﹸ ﻳ‬‫ﺴ‬‫ﺒ‬‫ﻳ‬‫ ﻭ‬،‫ﺎﺭﹺ‬‫ﻬ‬‫ﺴِﻲﺀُ ﺍﻟﻨ‬‫ ﻣ‬‫ﻮﺏ‬‫ﺘ‬‫ﻴ‬‫ﻞﹺ ﻟ‬‫ ﺑﹺﺎﻟﻠﱠﻴ‬‫ﻩ‬‫ﺪ‬‫ﻂﹸ ﻳ‬‫ﺴ‬‫ﺒ‬‫ﺎﻟﹶﻰ ﻳ‬‫ﻌ‬‫ ﺗ‬‫))ﺇﹺﻥﱠ ﺍﻟﻠﱠﻪ‬
(‫ )ﺭﻭﺍﻩ ﻣﺴﻠﻢ‬.((‫ﺎ‬‫ﺮﹺﺑﹺﻬ‬‫ﻐ‬‫ﻣ‬

:(‫ﻠﱠﻢ‬‫ﺳ‬‫ ﻭ‬‫ﻪ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ﻠﱠﻰ ﺍﻟﻠﱠﻪ‬‫ )ﺻ‬‫ﻮﻝﹸ ﺍﻟﻠﱠﻪ‬‫ﺳ‬‫ ﻗﹶﺎﻝﹶ ﺭ‬:‫ﺓﹶ )ﺭﺿﻲ ﺍﷲ ﻋﻨﻪ( ﻗﹶﺎﻝﹶ‬‫ﺮ‬‫ﻳ‬‫ﺮ‬‫ ﺃﹶﺑﹺﻲ ﻫ‬‫ﻦ‬‫ﻭﻋ‬
(‫ )ﺭﻭﺍﻩ ﻣﺴﻠﻢ‬.((‫ﻪ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ ﺍﻟﻠﱠﻪ‬‫ﺎﺏ‬‫ﺎ ﺗ‬‫ﺮﹺﺑﹺﻬ‬‫ﻐ‬‫ ﻣ‬‫ﻦ‬‫ ﻣ‬‫ﺲ‬‫ﻤ‬‫ ﺍﻟﺸ‬‫ﻄﹾﻠﹸﻊ‬‫ﻞﹶ ﺃﹶﻥﹾ ﺗ‬‫ ﻗﹶﺒ‬‫ﺎﺏ‬‫ ﺗ‬‫ﻦ‬‫))ﻣ‬
 | P a g e 22

EXAMINATION OF AN ULCER

v INSPECTION:

1. Site:
• On the medial aspect of the lower 1/3 of the leg → varicose ulcer.
• On the face, above a line drawn from the angle of the mouth to the lobule of the ear →
rodent ulcer (BCC).
• On the neck, over the sites of tuberculous lymph-adenopathy → tuberculous ulcer.

• On weight bearing area (the heal or the sacrum) → trophic (neuro-pathic) ulcer.
• On the dorsum of the foot & toes → ischemic (arterial) ulcer.
«««««««
2. Number: Single or multiple.
INSPECTION:
3. Size: (longitudinal & transverse in cm).
N - 3S.
4. Margin:11
• Outer > white * Central > blue * Inner > red) → healing ulcer. Margin.
• Red, inflamed & irregular → spreading ulcer.
• Fibrosed thickened & white → chronic non-healing ulcer. Edge.

5. Edge:12 Floor.
• Sloping → healing ulcer.
• Punched out → trophic, traumatic or syphilitic ulcer. «««««««
• Undermined → tuberculous ulcer.

• Raised & everted → malignant ulcer.

• Raised, rolled in & beaded → rodent ulcer (BCC).

6. Floor:13
• Granulation tissue:
o Healthy – Pale – Hypertrophic.

HEALTHY GRANULATION UNHEALTHY GRANULATION

§ Red & velvety. § Pale or bluish.
§ Finely granular surface. § Coarsely granular & raised.
§ Does not bleed easily on touch. § Bleeds easily on touch.
§ Minimal serous discharge. § Purulent discharge.
§ Painless. § Painful & tender.

11
The border or transitional zone of skin around the ulcer.
12
The mode of union between the floor & the margin of the ulcer (side wall of the ulcer).
13
The exposed surface of the ulcer.
 | P a g e 23

• Slough.14

• Discharge:
o Serous.
o Purulent.
o Bloody.

7. Surrounding skin:
• Red, edematous & shiny (cellulitis) → spreading & inflamed ulcer.
• Hypo-pigmentation → non-healing ulcer.
• Large scar → marjolin's ulcer.

• Pigmentation & eczema → varicose ulcer.

• Dilated capillaries (telangiectasia) → rodent ulcer (BCC).
• Multiple scars & puckering of the skin → tuberculous ulcer.

v PALPATION:

1. Temperature.
2. Tenderness: «««««««
• Spreading & inflamed ulcer.
PALPATION:
3. Conform the site & size.
2T - 2S.
15
4. Base:
• Induration does not extend beyond the visible margin of the ulcer → Base.
rodent ulcer (BCC).
• Induration extends beyond the visible margin of the ulcer → Fixity.
malignant ulcer.
«««««««
5. Fixity.

v FOCAL EXAMINATION:

1. Regional draining LNs:

• Hard, discrete & non-tender → malignant.
• Soft & tender → infective.
• Matted & non-tender → tuberculous.

2. Neighboring structures for pressure effects:

• Artery → weak distal pulse → ischemic ulcer.
• Vein → edema & dilated veins → varicose ulcer.

14
Necrotic soft tissue not yet separated from living tissue.
15
The tissue on which the ulcer rests.
 ‫‪| P a g e 24‬‬

‫•‬ ‫‪Nerve → trophic (arterial) ulcer:‬‬

‫‪o Map anaesthetic areas.‬‬
‫‪o Search for features of leprosy (thickened posterior tibial, ulnar & greater auricular nerves‬‬
‫‪– hypo-pigmented anaesthetic patches over the limbs, back & face – leonine face).‬‬
‫‪o Detailed neurological examination.‬‬

‫‪3. Joint above & below.‬‬

‫‪v SYSTEMIC EXAMINATION:‬‬

‫‪1. CVS: congestive HF delays ulcer healing.‬‬

‫‪2. RS: TB or secondaries.‬‬
‫‪3. Abdomen: splenomegaly in hemolytic anemia in leg ulcers.‬‬

‫ﻋ‪‬ﻦ‪ ‬ﺃﹶﺑﹺﻲ ﺳ‪‬ﻌ‪‬ﻴﺪ‪ ‬ﺳﻌﺪ ﺑﻦ ﻣﺎﻟﻚ ﺑﻦ ﺳﻨﺎﻥ‪ ‬ﺍﻟﹾﺨ‪‬ﺪ‪‬ﺭﹺﻱ‪) ‬ﺭﺿﻲ ﺍﷲ ﻋﻨﻪ( ﺃﹶﻥﱠ ﻧ‪‬ﺒﹺﻲ‪ ‬ﺍﻟﻠﱠﻪ‪) ‬ﺻ‪‬ﻠﱠﻰ ﺍﻟﻠﱠﻪ‪ ‬ﻋ‪‬ﻠﹶﻴ‪‬ﻪ‪ ‬ﻭ‪‬ﺳ‪‬ﻠﱠﻢ‪ (‬ﻗﹶﺎﻝﹶ‪:‬‬
‫))ﻛﹶﺎﻥﹶ ﻓ‪‬ﻴﻤ‪‬ﻦ‪ ‬ﻛﹶﺎﻥﹶ ﻗﹶﺒ‪‬ﻠﹶﻜﹸﻢ‪ ‬ﺭ‪‬ﺟ‪‬ﻞﹲ ﻗﹶﺘ‪‬ﻞﹶ ﺗ‪‬ﺴ‪‬ﻌ‪‬ﺔﹰ ﻭ‪‬ﺗ‪‬ﺴ‪‬ﻌ‪‬ﲔ‪ ‬ﻧ‪‬ﻔﹾﺴ‪‬ﺎ‪ ،‬ﻓﹶﺴ‪‬ﺄﹶﻝﹶ ﻋ‪‬ﻦ‪ ‬ﺃﹶﻋ‪‬ﻠﹶﻢﹺ ﺃﹶﻫ‪‬ﻞﹺ ﺍﻟﹾﺄﹶﺭ‪‬ﺽﹺ‪ ،‬ﻓﹶﺪ‪‬ﻝﱠ ﻋ‪‬ﻠﹶﻰ ﺭ‪‬ﺍﻫ‪‬ﺐﹴ‬
‫ﻓﹶﺄﹶﺗ‪‬ﺎﻩ‪ ،‬ﻓﹶﻘﹶﺎﻝﹶ‪ :‬ﺇﹺﻧ‪‬ﻪ‪ ‬ﻗﹶﺘ‪‬ﻞﹶ ﺗ‪‬ﺴ‪‬ﻌ‪‬ﺔﹰ ﻭ‪‬ﺗ‪‬ﺴ‪‬ﻌ‪‬ﲔ‪ ‬ﻧ‪‬ﻔﹾﺴ‪‬ﺎ‪ ،‬ﻓﹶﻬ‪‬ﻞﹾ ﻟﹶﻪ‪ ‬ﻣ‪‬ﻦ‪ ‬ﺗ‪‬ﻮ‪‬ﺑ‪‬ﺔ‪‬؟ ﻓﹶﻘﹶﺎﻝﹶ‪ :‬ﻟﹶﺎ‪ ،‬ﻓﹶﻘﹶﺘ‪‬ﻠﹶﻪ‪ ‬ﻓﹶﻜﹶﻤ‪‬ﻞﹶ ﺑﹺﻪ‪ ‬ﻣ‪‬ﺎﺋﹶﺔﹰ‬

‫ﺛﹸﻢ‪ ‬ﺳ‪‬ﺄﹶﻝﹶ ﻋ‪‬ﻦ‪ ‬ﺃﹶﻋ‪‬ﻠﹶﻢﹺ ﺃﹶﻫ‪‬ﻞﹺ ﺍﻟﹾﺄﹶﺭ‪‬ﺽﹺ‪ ،‬ﻓﹶﺪ‪‬ﻝﱠ ﻋ‪‬ﻠﹶﻰ ﺭ‪‬ﺟ‪‬ﻞﹴ ﻋ‪‬ﺎﻟ‪‬ﻢﹴ‬
‫ﻓﹶﻘﹶﺎﻝﹶ‪ :‬ﺇﹺﻧ‪‬ﻪ‪ ‬ﻗﹶﺘ‪‬ﻞﹶ ﻣ‪‬ﺎﺋﹶﺔﹶ ﻧ‪‬ﻔﹾﺲﹴ ﻓﹶﻬ‪‬ﻞﹾ ﻟﹶﻪ‪ ‬ﻣ‪‬ﻦ‪ ‬ﺗ‪‬ﻮ‪‬ﺑ‪‬ﺔ‪‬؟ ﻓﹶﻘﹶﺎﻝﹶ‪ :‬ﻧ‪‬ﻌ‪‬ﻢ‪ ،‬ﻭ‪‬ﻣ‪‬ﻦ‪ ‬ﻳ‪‬ﺤ‪‬ﻮﻝﹸ ﺑ‪‬ﻴ‪‬ﻨ‪‬ﻪ‪ ‬ﻭ‪‬ﺑ‪‬ﻴ‪‬ﻦ‪ ‬ﺍﻟﺘ‪‬ﻮ‪‬ﺑ‪‬ﺔ‪‬؟‬
‫ﺍﻧ‪‬ﻄﹶﻠ‪‬ﻖ‪ ‬ﺇﹺﻟﹶﻰ ﺃﹶﺭ‪‬ﺽﹺ ﻛﹶﺬﹶﺍ ﻭ‪‬ﻛﹶﺬﹶﺍ‪ ،‬ﻓﹶﺈﹺﻥﱠ ﺑﹺﻬ‪‬ﺎ ﺃﹸﻧ‪‬ﺎﺳ‪‬ﺎ ﻳ‪‬ﻌ‪‬ﺒ‪‬ﺪ‪‬ﻭﻥﹶ ﺍﻟﻠﱠﻪ‪ ‬ﺗﻌﺎﱃ ﻓﹶﺎﻋ‪‬ﺒ‪‬ﺪ‪ ‬ﺍﻟﻠﱠﻪ‪ ‬ﻣ‪‬ﻌ‪‬ﻬ‪‬ﻢ‪ ،‬ﻭ‪‬ﻟﹶﺎ ﺗ‪‬ﺮ‪‬ﺟﹺﻊ‪ ‬ﺇﹺﻟﹶﻰ ﺃﹶﺭ‪‬ﺿ‪‬ﻚ‪ ‬ﻓﹶﺈﹺﻧ‪‬ﻬ‪‬ﺎ ﺃﹶﺭ‪‬ﺽ‪ ‬ﺳ‪‬ﻮ‪‬ﺀٍ‬

‫ﻓﹶﺎﻧ‪‬ﻄﹶﻠﹶﻖ‪ ‬ﺣ‪‬ﺘ‪‬ﻰ ﺇﹺﺫﹶﺍ ﻧ‪‬ﺼ‪‬ﻒ‪ ‬ﺍﻟﻄﱠﺮﹺﻳﻖ‪ ‬ﺃﹶﺗ‪‬ﺎﻩ‪ ‬ﺍﻟﹾﻤ‪‬ﻮ‪‬ﺕ‪ ،‬ﻓﹶﺎﺧ‪‬ﺘ‪‬ﺼ‪‬ﻤ‪‬ﺖ‪ ‬ﻓ‪‬ﻴﻪ‪ ‬ﻣ‪‬ﻠﹶﺎﺋ‪‬ﻜﹶﺔﹸ ﺍﻟﺮ‪‬ﺣ‪‬ﻤ‪‬ﺔ‪ ‬ﻭ‪‬ﻣ‪‬ﻠﹶﺎﺋ‪‬ﻜﹶﺔﹸ ﺍﻟﹾﻌ‪‬ﺬﹶﺍﺏﹺ‬
‫ﻓﹶﻘﹶﺎﻟﹶﺖ‪ ‬ﻣ‪‬ﻠﹶﺎﺋ‪‬ﻜﹶﺔﹸ ﺍﻟﺮ‪‬ﺣ‪‬ﻤ‪‬ﺔ‪ :‬ﺟ‪‬ﺎﺀَ ﺗ‪‬ﺎﺋ‪‬ﺒ‪‬ﺎ ﻣ‪‬ﻘﹾﺒﹺﻠﹰﺎ ﺑﹺﻘﹶﻠﹾﺒﹺﻪ‪ ‬ﺇﹺﻟﹶﻰ ﺍﻟﻠﱠﻪ‪ ‬ﺗﻌﺎﱃ‪ ،‬ﻭ‪‬ﻗﹶﺎﻟﹶﺖ‪ ‬ﻣ‪‬ﻠﹶﺎﺋ‪‬ﻜﹶﺔﹸ ﺍﻟﹾﻌ‪‬ﺬﹶﺍﺏﹺ‪ :‬ﺇﹺﻧ‪‬ﻪ‪ ‬ﻟﹶﻢ‪ ‬ﻳ‪‬ﻌ‪‬ﻤ‪‬ﻞﹾ ﺧ‪‬ﻴ‪‬ﺮ‪‬ﺍ ﻗﹶﻂﱡ‬
‫ﻓﹶﺄﹶﺗ‪‬ﺎﻫ‪‬ﻢ‪ ‬ﻣ‪‬ﻠﹶﻚ‪ ‬ﻓ‪‬ﻲ ﺻ‪‬ﻮﺭ‪‬ﺓ‪ ‬ﺁﺩ‪‬ﻣ‪‬ﻲ‪ ‬ﻓﹶﺠ‪‬ﻌ‪‬ﻠﹸﻮﻩ‪ ‬ﺑ‪‬ﻴ‪‬ﻨ‪‬ﻬ‪‬ﻢ‪- ‬ﺃﻱ ﺣﻜﻤﺎﹰ‪-‬‬
‫ﻓﹶﻘﹶﺎﻝﹶ‪ :‬ﻗ‪‬ﻴﺴ‪‬ﻮﺍ ﻣ‪‬ﺎ ﺑ‪‬ﻴ‪‬ﻦ‪ ‬ﺍﻟﹾﺄﹶﺭ‪‬ﺿ‪‬ﻴ‪‬ﻦﹺ ﻓﹶﺈﹺﻟﹶﻰ ﺃﹶﻳ‪‬ﺘ‪‬ﻬﹺﻤ‪‬ﺎ ﻛﹶﺎﻥﹶ ﺃﹶﺩ‪‬ﻧ‪‬ﻰ ﻓﹶﻬ‪‬ﻮ‪ ‬ﻟﹶﻪ‪‬‬
‫ﻓﹶﻘﹶﺎﺳ‪‬ﻮﻩ‪ ‬ﻓﹶﻮ‪‬ﺟ‪‬ﺪ‪‬ﻭﻩ‪ ‬ﺃﹶﺩ‪‬ﻧ‪‬ﻰ ﺇﹺﻟﹶﻰ ﺍﻟﹾﺄﹶﺭ‪‬ﺽﹺ ﺍﻟﱠﺘ‪‬ﻲ ﺃﹶﺭ‪‬ﺍﺩ‪ ،‬ﻓﹶﻘﹶﺒ‪‬ﻀ‪‬ﺘ‪‬ﻪ‪ ‬ﻣ‪‬ﻠﹶﺎﺋ‪‬ﻜﹶﺔﹸ ﺍﻟﺮ‪‬ﺣ‪‬ﻤ‪‬ﺔ‪.((‬‬
‫)ﻣﺘﻔﻖ ﻋﻠﻴﻪ(‬

‫ﻭﰲ ﺭﻭﺍﻳﺔ ﰲ ﺍﻟﺼﺤﻴﺢ‪)) :‬ﻓﻜﺎﻥ ﺇﱃ ﺍﻟﻘﺮﻳﺔ ﺍﻟﺼﺎﳊﺔ ﺃﻗﺮﺏ ﺑﺸﱪ‪ ،‬ﻓﺠﻌﻞ ﻣﻦ ﺃﻫﻠﻬﺎ((‬
‫ﻭﰲ ﺭﻭﺍﻳﺔ ﰲ ﺍﻟﺼﺤﻴﺢ‪)) :‬ﻓﺄﻭﺣﻰ ﺍﷲ ﺗﻌﺎﱃ ﺇﱃ ﻫﺬﻩ ﺃﻥ ﺗﺒﺎﻋﺪﻯ‪ ،‬ﻭﺇﱃ ﻫﺬﻩ ﺃﻥ ﺗﻘﺮﰊ‪ ،‬ﻭﻗﺎﻝ‪ :‬ﻗﻴﺴﻮﺍ ﻣﺎ ﺑﻴﻨﻬﻤﺎ‪ ،‬ﻓﻮﺟﺪﻭﻩ ﺇﱃ‬
‫ﻫﺬﻩ ﺃﻗﺮﺏ ﺑﺸﱪ ﻓﻐﻔﺮ ﻟﻪ((‪.‬‬
‫ﻭﰲ ﺭﻭﺍﻳﺔ‪)) :‬ﻓﻨﺄﻯ ﺑﺼﺪﺭﻩ ﳓﻮﻫﺎ((‪.‬‬
 | P a g e 25

EXAMINATION OF AN INTRA-ABDOMINAL LUMP

v INSPECTION:

1. Sub-costal angle:
• Obtuse → chronic ↑ intral-abdominal pressure.

2. Divercation of recti (rising test):

• Chronic ↑ intral-abdominal pressure.

3. The contour: "imagine a line between xiphoid process & symphysis pubis"
• Scaphoid.
• Normal.
• Distended (uniform or assymetrical):

4. Flanks:
• Concave.
• Convex.

5. The skin over the abdomen:

• Scars of previous surgery.
• Striae.
• Localized bulge(swelling).

6. The umbilicus:
• Site: Mid-way between xiphi-sternum & symphysis pubis.
• Shape: Inverted (due to its attachment to the umbilical ligaments).

• Umbilical hernia: Expansile cough impulse.

• Discharges:
o Pus → inflammation.
o Fecal → patent vitello-intestinal duct – intestinal fistula.
o Urinary → patent urachus.
o Biliary → operative bile duct injury.

• Redness → acute haemorrhagic pancreatitis (Cullen's sign).

• Pigmentation.

• Nodules (malignant → sister Joseph Mary sign).

• Dilated veins
o Around the umbilicus with centrifugal flow → caput medusae in portal hypertension.
o Vertical femoro-axillary → IVC obstruction.

7. Supra-pubic hair:
• Male → triangular towards the umbilicus.
• Female → transverse upper border.
 | P a g e 26

8. Movements:

1) With respiration:
• Male → abdomino-thorcacic.
• Female → thoraco-abdominal.

• If immobile → generalized peritonitis – internal hemorrhage – tense Ascites.

• If there is a lump, inspect its movement with respiration.

• Lumps do not move with respiration:
o Retro-peritoneal.
o Intra-abdominal.

2) Visible peristalsis:
• In the epigastrium moving from Lt to Rt → pyloric stenosis.
• Step ladder pattern → low ileal obstruction.

3) Visible pulsations:
• In thin patients → visible pulsations of abdominal aorta.
• Aneurysm of abdominal aorta.
• A lump in umbilical or epigastric regions → transmitted pulsations from abdominal aorta →
disappear in knee-elbow position.

** Do not forget **

v While standing:

9. The scrotum:
• For testicular swelling.

Ø Epigastric lump due to secondaries in the para-aortic LNs → Rt testicular tumor.

10. Hernial orifices. "expansile cough impulse"

v From the back:

11. The spine for deformity.

12. Para-spinal area for swelling or sinus. "highly suggestive of TB"

v The upper chest:

13. The Lt supra-clavicular region:

• Enlarged Virchow's LN → malignancy of stomach, colon or testis = Troisier's sign.
 | P a g e 27

v PALPATION:
"A pillow under the head & a pillow under the knees"

1. Temperature:
• Compare the temperature over the lump with the other normal side.

2. Superficial palpation: to:

1) Gain patient's confidence.

2) Elicit:
o Tenderness.
o Temperature.
o Tone of abdominal wall muscles:
Ø Gurading → the wall muscles contract on palpation.
Ø Rigidity → sustained muscle contraction whether palpating or not.
Ø Rebound tenderness → inflammation of the parietal peritoneum due to underlying inflamed
organ.

3) Superficial abdominal swellings.

3. Deep palpation:

v Of the lump:

1. Intra or extra-abdominal: "muscle contraction" either by:

1. Ask the patient to raise the neck.
2. Ask the patient to raise the legs to 30o without bending the knees.
3. Valsalva maneuver.
o More prominent & easier to palpate → superficial to the muscle (extra-abdominal).
o Fixed & immobile → within the muscle (intra-muscular).
o Less prominent & difficult to palpate → deep to the muscle (intra-abdominal).

2. Site, shape, size & surface.

3. Margin:
o Well defined margin → neoplasm.
o Ill-defined margin → inflammatory.

4. Consistency.

5. Bimanual palpation & ballotment: If lumbar.

6. Mobility.

7. Pulsatility.
 | P a g e 28

v Of the rest of the abdomen.

1. Liver:
ü Methods:
1) Starting from the Rt iliac fossa → Rt lobe.
Starting from umbilicus → Lt lobe.
2) Bi-manual.
3) Dipping (in tense Ascites).
4) Hooking.

ü Note:
o Temperature.
o Tenderness.
o Size (in cm or Patient fingers).
o Border.
o Surface.
o Consistency.

2. Spleen: "the same comment as liver + splenic notch"

ü Methods:
1) Starting from the Rt iliac fossa.
2) Hooking.

3. Kidneys:
ü Methods:
1) Bi-manual.
2) Ballottment.

4. Gall bladder:
o At the p of the Rt 9th costal margin.
o The meeting of the Rt linea semi-lunaris with the costal margin.

5. Sigmoid colon:
o By rolling using both hands in the Lt iliac fossa.

6. Lymph Nodes:
• Mesenteric: from the Rt ASIS to the umbilicus & cross the mid-line by one inch.
• Para-aortic: midway between the umbilicus & xiphi-sternum.

7. The scrotum:
o For testicular swelling.
o For testicular sensation.

8. Hernial orifices. "expansile cough impulse"

9. The spine for deformity & tenderness.

10. The Lt supra-clavicular region:

o Enlarged Virchow's LN → malignancy of stomach, colon or testis = Troisier's sign.
 | P a g e 29

v PERCUSSION:

1) Over the lump.

2) Upper & lower borders of liver: "+ tidal percussion"

Note the liver span.

3) Spleen.
Boundaries of Traub's area:
• Lt 5th space in mid-clavicular line.
• Lt 8th rib in mid-clavicular line.
• Lt 9th rib in mid-axillary line.
• Lt 10th rib in mid- axillary line.

4) Ascites:
• Moderate (> 1 L) → shifting dullness.
• Minimal (< 1 L) → percussion at the umbilicus in knee-elbow position.
• Tense → transmitted fluid thrill.

5) Hudatid thrill.

v AUSCULTATION:

• Peristalsis: Peri-umbilical area & Rt iliac fossa.

• Friction rub: Over the liver & spleen.
• Venous hum: Over xiphi-sternum in portal hypertension.
• Bruit:
o Over a pulsatile lump.
o Over the abdominal aorta & renal arteries.

** Do not forget **
ü The renal angles:16
For renal lump:
• INSPECTION: Fullness.
• PALPATION:17 Tenderness.
• PERCUSSION: Dullness.
• AUSCULTATION: Bruit.

ü PR & PV examination.

:‫( ﻗﹶﺎﻝﹶ‬‫ﻠﱠﻢ‬‫ﺳ‬‫ ﻭ‬‫ﻪ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ﻠﱠﻰ ﺍﻟﻠﱠﻪ‬‫ )ﺻ‬‫ﺒﹺﻲ‬‫ ﺍﻟﻨ‬‫ﻦ‬‫ ﺑﻦ ﺍﳋﻄﺎﺏ )ﺭﺿﻲ ﺍﷲ ﻋﻨﻬﻤﺎ( ﻋ‬‫ﺮ‬‫ﻤ‬‫ ﺍﷲ ﺑﻦ ﻋ‬‫ ﺃﰊ ﻋﺒﺪ ﺍﻟﺮﲪﻦ ﻋﺒﺪ‬‫ﻦ‬‫ﻋ‬
(‫ ﺣﺪﻳﺚ ﺣﺴﻦ‬:‫ )ﺭﻭﺍﻩ ﺍﻟﺘﺮﻣﺬﻱ ﻭﻗﺎﻝ‬.((‫ﺮ‬‫ﻏ‬‫ﺮ‬‫ﻐ‬‫ ﻳ‬‫ﺎ ﻟﹶﻢ‬‫ ﻣ‬‫ﺪ‬‫ﺒ‬‫ﺔﹶ ﺍﻟﹾﻌ‬‫ﺑ‬‫ﻮ‬‫ﻞﹸ ﺗ‬‫ﻘﹾﺒ‬‫ﻞﱠ( ﻳ‬‫ﺟ‬‫ ﻭ‬‫ﺰ‬‫ )ﻋ‬‫))ﺇﹺﻥﱠ ﺍﻟﻠﱠﻪ‬

16
Between the last rib & lateral border of sacro-spinalis muscle.
17
Murphy's kidney punch:
Press in the renal angle with your thumb for tenderness.
 | P a g e 30

EXAMINATION OF A CASE OF PERIPHERAL VASCULAR DISEASE

v INSPECTION:

1. Evidence of chronic ischemia:

• Skin trophic changes:
o Thin tapering toes (due to loss of SC fat).
v Ischemic ulcers: (see ULCER SHEET)
o Dry thin scaly skin.
o Loss of hair. Number: single or multiple.
o Brittle nails. Site: over pressure areas (ball
of big toe – heal – tips of toes).
o Ischemic ulcers. Size & shape: variable.
o Inter-digital fungal infection.
Margin: blakish or inflamed.
o Muscle wasting.
o ↓ limb circumference "girth" (measured 3 inches above Edge: punched out.
& below the knee – 2 inches above & below the elbow). Floor: granulation tissue.
o Finally → dry gangrene with black skin.
Discharge: dry.
• Color changes: Base: indurated.
o Normal color → mild ischemia.
o Postural color changes → moderate ischemia.18
o Fixed color (gangrene) → severe ischemia (white → cyanotic → brick red → black):

§ Extent (big toe, fore foot, below knee, …).

§ Type (dry or moist "septic or aseptic").
§ Line of demarcation.19
§ Line of separation.20

2. Evidence of proximal spread of:

• Infection → edema & redness.
• Gangrene → blebs, ulcerations & skip areas.21

3. Function (motor powr):

• Movements of the limb.

18
see BURGER'S ANGLE.
19
Band of hyoeremia & anaesthesia between healthy & dead tissues (evident in dry gangrene).
20
Dead tissues start to fall off by non septic ulceration proximal to the line of demarcation.
21
Areas of blackening in the proximal limb independent from the gangrene.
 | P a g e 31

v PALPATION:

1. Temperature: "uncover the limbs for 5 minutes"

• Ischemic limb is colder than the other limb.

• It may falsely warm if:

o Infection.
o Previous sympathectomy.
o Covered with blankets.

2. Tenderness.

v FOCAL EXAMINATION:

1) Arteries:
• Volume:
o Weak → arterial stenosis.
o Absent → arterial obstruction.
• Thickeninof arterial wall → atherosclerosis.
• Compressible mass with expansile pulsations, systolic thrill & ↓ distal pulse → aneurysm.

II LOWER LIMB II
• Capillary circulation:
ü Press on the tip of the toes till blanching then release your finger & inspect for the return
of red color:
o Normally → occurs within 2 seconds.
o Delayed → denotes the degree of ischemia.
o Fixed color → dead limb.

• Dorsalis pedis artery

At the proximal end of the 1st meta-tarsal space just lateral to the tendon of extensor hallucis
longus
Against the navicular & middle cuni-form bones.

• Posterior tibial artery

Mid-way between medial malleolus & tendo-achillis keeping the foot dorsi-flexed & inverted
Against the calcenium.

Ø If both are well felt → the proximal pulses are normal.

• Popliteal artery
In the popliteal fossa in supine posi on & the knee flexed to 135o
Against the upper end of tibia or the lower end of femur.

• Femoral artery
In the line of mid-inguinal point just below the inguinal ligament in supine position with the
legs slightly abducted & externally rotated
Against the head of femur.
 | P a g e 32

II ABDOMEN II
• Abdominal aorta
To the Lt of the mid-line in the epi-gastric & umbilical areas
Against the spine.

II UPPER LIMB II
• Capillary circulation.

• Radial artery
On the flexor aspect of the wrist just lateral to the tendon of flexor carpi radialis
Against the lower end of radius.

• Brachial artery
In the lower half of the arm just medial to the biceps tendon
Against the shaft of humerus.

In the upper half of the arm just medial to the biceps border
Against the shaft of humerus.

• Axillary artery
In the axilla
Against the head of humerus.

II HEAD & NECK II

• Sub-clavian artery
In the supra-clavicular fossa in the mid-clavicular line
Against the 1st rib.

• Common carotid artery

Between the upper part of the trachea & sterno-mastoid
Against the transverse process of the 6th cervical vertebra.

• Superficial temporal artery

In front of the tragus
Against the temporal bone (zygomatic arch).

• Facial artery
At the anterior border of masseter muscle.
Against the lower border of the mandible.

2) Veins:
• Thrombo-phlebitis (Burger's disease).
• Venous skin guttering.22

22
Totally emptied veins & loss of SC fat.
 | P a g e 33

3) Sensory changes: "touch & pain"

• Compare both sides.

4) LNs.

5) Joint movements:
• Passive & active.

v AUSCULTATION:

• Along the entire course of the arteries for:

o Systolic bruit → stenosis, partial obstruction or aneurysm.
o Continuous machinery murmur → A-V fistula.

v Special tests for Peripheral Vascular Disesae (PVD):

1. Tests for lower limbs:

• Burger's test:
o In horizontal position, leg elevation causes pallor & leg lowering causes cyanosis.
o Burger's angle of circulatory insufficiency23 (the smaller the angle, the more the ischemia):
< 30o → severe ischemia.

• Harvey's venous filling time:24

o In horizontal position, the veins of leg & foot are normally filled.
o Collapsed veins → indicate poor circulation.

ü Raise the leg & empty the veins, then return the leg flat & inspect for refilling:
o Normally → occurs within 5-10 seconds.
o Delayed → denotes the degree of ischemia:
> 2 minutes → severe ischemia.

2. Tests for upper limbs:

• Reynaud's phenomenon:
o Dip in cold water → blanching (pallor).
o Take out of water → swollen & cyanosed.
o After sometime → red & engorged.

23
The angle at which the limb becomes pale on elevation – the angle of the leg with the horizontal.
24
The time taken by the affected leg to regain its normal pink color.
 | P a g e 34

3. Tests for thoracic outlet syndrome:

• Adson's test:
o Palpate the radial artery of the affected hand with the patient turning his head as much as
possible towards the affected side & taking a deep breath25 → feeble or absent pulse (+ve).

• Elevated arms stress test:

o Ask the pa ent to abduct the shoulders to 90o – maximum possible external rotation –
keeping elbows flexed at 90o – open & close the fists slowly for 3 minutes → pain, cramps,
paraethesia or reynaud's phenomenon (+ve).

• Allen's test:26
o Ask the patient to close his fist tightly & compress both radial & ulnar arteries at the wrist
using both your hands.
o Ask the patient to open & close the fist till blanching occurs.
o Ask the patient to open the fist, release the radial artery & note the time taken by the hand
to regain the normal pink color.
o Repeat again for the ulnar artery.

(‫ﻠﱠﻢ‬‫ﺳ‬‫ ﻭ‬‫ﻪ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ﻠﱠﻰ ﺍﻟﻠﱠﻪ‬‫ )ﺻ‬‫ ﺭﺳﻮﻝ ﺍﻟﻠﱠﻪ‬‫ﺖ‬‫ﺔﹶ ﺃﹶﺗ‬‫ﻨ‬‫ﻴ‬‫ﻬ‬‫ ﺟ‬‫ﻦ‬‫ﺃﹶﺓﹰ ﻣ‬‫ﺮ‬‫ﻦﹺ ﺍﳋﺰﺍﻋﻲ )ﺭﺿﻲ ﺍﷲ ﻋﻨﻪ( ﺃﹶﻥﱠ ﺍﻣ‬‫ﻴ‬‫ﻦﹺ ﺍﳊﹸﺼ‬‫ﺍﻥﹶ ﺑ‬‫ﺮ‬‫ﻤ‬‫ﻴﺪ ﻋ‬‫ﺠ‬‫ﻋﻦ ﺃﰊ ﻧ‬
‫ﻠﹶﻲ‬‫ ﻋ‬‫ﻪ‬‫ﻤ‬‫ﺍ ﻓﹶﺄﹶﻗ‬‫ﺪ‬‫ ﺣ‬‫ﺖ‬‫ﺒ‬‫ ﺃﹶﺻ‬‫ﺎ ﺭﺳﻮﻝ ﺍﻟﻠﱠﻪ‬‫ ﻳ‬:‫ ﻓﹶﻘﹶﺎﻟﹶﺖ‬،‫ﻰ‬‫ﻧ‬‫ ﺍﻟﺰ‬‫ﻦ‬‫ﻠﹶﻰ ﻣ‬‫ﺒ‬‫ ﺣ‬‫ﻲ‬‫ﻫ‬‫ﻭ‬
((‫ﻨﹺﻲ‬‫ ﻓﹶﺄﹾﺗ‬‫ﺖ‬‫ﻌ‬‫ﺿ‬‫ ﻓﹶﺈﹺﺫﹶﺍ ﻭ‬،‫ﺎ‬‫ﻬ‬‫ ﺇﹺﻟﹶﻴ‬‫ﺴِﻦ‬‫ ))ﺃﹶﺣ‬:‫ﺎ ﻓﹶﻘﹶﺎﻝﹶ‬‫ﻬ‬‫ﻴ‬‫ﻟ‬‫( ﻭ‬‫ﻠﱠﻢ‬‫ﺳ‬‫ ﻭ‬‫ﻪ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ﻠﱠﻰ ﺍﻟﻠﱠﻪ‬‫ )ﺻ‬‫ ﺍﻟﻠﱠﻪ‬‫ﺒﹺﻲ‬‫ﺎ ﻧ‬‫ﻋ‬‫ﻓﹶﺪ‬
.‫ﺎ‬‫ﻬ‬‫ﻠﹶﻴ‬‫ﻠﱠﻰ ﻋ‬‫ ﺻ‬‫ ﺛﹸﻢ‬،‫ﺖ‬‫ﺟﹺﻤ‬‫ﺎ ﻓﹶﺮ‬‫ ﺑﹺﻬ‬‫ﺮ‬‫ ﺃﹶﻣ‬‫ ﺛﹸﻢ‬،‫ﺎ‬‫ﻬ‬‫ﺎﺑ‬‫ﺛﻴ‬ ‫ﺎ‬‫ﻬ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ﺕ‬‫ﺪ‬‫ ﻓﹶﺸ‬،(‫ﻠﱠﻢ‬‫ﺳ‬‫ ﻭ‬‫ﻪ‬‫ﻠﹶﻴ‬‫ ﻋ‬‫ﻠﱠﻰ ﺍﻟﻠﱠﻪ‬‫ )ﺻ‬‫ ﺍﻟﻠﱠﻪ‬‫ﺒﹺﻲ‬‫ﺎ ﻧ‬‫ ﺑﹺﻬ‬‫ﺮ‬‫ﻞﹶ ﻓﹶﺄﹶﻣ‬‫ﻓﹶﻔﹶﻌ‬

:‫؟ ﻓﹶﻘﹶﺎﻝﹶ‬‫ﺖ‬‫ﻧ‬‫ ﺯ‬‫ﻗﹶﺪ‬‫ ﻭ‬‫ﺎ ﺭﺳﻮﻝ ﺍﻟﻠﱠﻪ‬‫ﺎ ﻳ‬‫ﻬ‬‫ﻠﹶﻴ‬‫ﻠﱢﻲ ﻋ‬‫ﺼ‬‫ ﺗ‬:‫ﺮ‬‫ﻤ‬‫ ﻋ‬‫ﻓﹶﻘﹶﺎﻝﹶ ﻟﹶﻪ‬
‫ﻢ‬‫ﻬ‬‫ﺘ‬‫ﻌ‬‫ﺳ‬‫ ﻟﹶﻮ‬‫ﺔ‬‫ﻳﻨ‬‫ﺪ‬‫ﻞﹺ ﺍﻟﹾﻤ‬‫ ﺃﹶﻫ‬‫ﻦ‬‫ ﻣ‬‫ﲔ‬‫ﻌ‬‫ﺒ‬‫ ﺳ‬‫ﻦ‬‫ﻴ‬‫ ﺑ‬‫ﺖ‬‫ ﻗﹸﺴِﻤ‬‫ﺔﹰ ﻟﹶﻮ‬‫ﺑ‬‫ﻮ‬‫ ﺗ‬‫ﺖ‬‫ﺎﺑ‬‫ ﺗ‬‫))ﻟﹶﻘﹶﺪ‬
.((!‫ )ﻋﺰ ﻭﺟﻞ(؟‬‫ﻠﱠﻪ‬‫ﺎ ﻟ‬‫ﻔﹾﺴِﻬ‬‫ ﺑﹺﻨ‬‫ﺕ‬‫ﺎﺩ‬‫ ﺃﹶﻥﹾ ﺟ‬‫ﻦ‬‫ﻞﹶ ﻣ‬‫ﺔﹰ ﺃﹶﻓﹾﻀ‬‫ﺑ‬‫ﻮ‬‫ ﺗ‬‫ﺕ‬‫ﺪ‬‫ﺟ‬‫ﻞﹾ ﻭ‬‫ﻫ‬‫ﻭ‬
(‫)ﺭﻭﺍﻩ ﻣﺴﻠﻢ‬

25 st
Contracts the scalenus anterior (accessory muscle of respira on) which elevates the 1 rib & compresses the
sub-clavian artery at the thoracic outlet.
26
which artery is the dominantblood supply of the hand?
 | P a g e 35

EXAMINATION OF VARICOSE VEINS

v INSPECTION:

1. Inspection of the veins:

• Unilateral or bilateral.

• Systems affected:
o The long saphenous vein:
From the front of the medial malleolus upwards along the antero-medial aspect of the
leg, knee & thigh to end at the saphenous opening.

o The short saphenous vein:

Over the posterior aspect of the calf to converge & end at the center of the popliteal
fossa.

o Irregular distribution:
2ry varicose veins.

• Shape:
o Telangiectasia (< 2 mm).
o Reticular veins (2-3 mm).
o Tubular veins (>3 mm).
o Serpentine veins.

o Saccular:
§ Blow-outs.
§ Saphina varix (incompetent sapheno-femoral valve).

• Dilated veins over the lower abdomen above the inguinal ligament converging to the
saphenous opening:
o Superficial circumflex iliac.
o Superficial inferior epigastric.
o Superficial external pudendal.

• Collapsibility:
o By raising the leg to 60o.

• Morrissey's test:
o Holding the leg elevated to 30o or more.
o Cough impulse at the saphenous opening & retro-grade venous wave while the leg is
raised → incompetent sapheno-femoral valve.
 | P a g e 36

2. Inspection of the ankle & foot:

• Ankle (venous) flare.27
• Brown pigmentation.
• Dermatitis (redness & itching).
• Eczema.
• Varicose ulcer over the medial aspect of the lower 1/3 of the leg.
• Talipes equines deformity.
• Local gigantism in congenital A-V fistula.
• Flat foot.28

v PALPATION:

1. Temperature:
ü Local rise of temperature:
• Superficial thrombo-phlebitis.

2. Tenderness.

3. Fegan's method:
• While the patient is standing, mark the sites of blow outs.
• While the patient is lying down with the leg elevated, palpate along the marks.
o Pits29 → indicate the sites of incompetent perforators (blow outs).

4. 2 fingers test: "along the entire course of the veins"

• While the patient is standing, evacuate a segment of the vein by 2 fingers.
o Any dilata on of the vein between the 2 fingers → incompetent perforator.

5. Impulse on cough over the saphenous opening:

• Incompetent sapheno-femoral valve.

6. Thrill over the saphenous opening (Cruvilhier's sign).

7. Schwartz's (tap) test.

8. Chevrier sign:
• The reverse of Schwartz's test.

9. Edema.

27
Dilated intra-dermal venules around the medial malleolus.
It appears before venous ulceration.
28
Ask the patient to stand on a rigid flat surface & inspect the arch of the foot.
29
A circular defect in deep fascia with sharp edges.
 | P a g e 37

v Special tests for incompetent perforators:

1. Brodie-trendelenburg test:30
• The patient lies down & elevates his leg to empty the veins by massage.
• Close the sapheno-femoral junc on (4 cm below & lateral to the pubic tubercle) by your
thumb.
• Allow the pa ent to stand & observe for 30 seconds.
• Remove your thumb.

o -ve with maintained pressure → competent perforators.

o +ve with release of pressure → incompetent sapheno-femoral valve.

o +ve * -ve → the reverse.

o +ve * +ve → both are incompetent.

2. Multiple tourniquet test: "3"

• The patient lies down & elevates his leg to empty the veins by massage.
• 3 tourniquets are applied:
1) Just below the saphenous opening (in the upper 1/3 of the thigh).
2) Just above the knee.
3) Just below the knee.

o The segment of the vein that has incompetent perforator will be filled with blood.

3. Pratt's test.31

v Examination of the deep veins:

1. Patency of the deep veins:

• Modified perthe's test:
• While the patient is standing, a tourniquet is applied just below the saphenous opening.
• Let the patient to walk in situ for few minutes:

o If varicosities ↑ → in-complete re-canalization of the deep system.

o If varicosities ↓ → patent deep system.

2. Active deep vein thrombosis:

• Tender calf swelling.
• Tenderness along the course of the veins.
• Homan's sign.
• Mose's sign.

30
For incompetent sapheno-femoral valve.
31
To locate incompetent perforators accurately.
 ‫‪| P a g e 38‬‬

‫‪v FOCAL & GENERAL EXAMINATION:‬‬

‫•‬ ‫‪Enlarged inguinal LNs → infected ulcer, DVT or superficial thrombo-phlebitis.‬‬

‫•‬ ‫‪The opposite leg: varicose veins.‬‬

‫•‬ ‫‪Abdomin: lump.‬‬

‫•‬ ‫‪Scrotum: varcio-cele.‬‬
‫•‬ ‫‪Proctoscopy: haemorrhoids.‬‬

‫ﻋﻦ ﺍﺑﻦ ﻋﺒﺎﺱﹴ )ﺭﺿﻲ ﺍﷲ ﻋﻨﻬﻤﺎ( ﺃﹶﻥﱠ ﺭ‪‬ﺳ‪‬ﻮﻝﹶ ﺍﻟﻠﱠﻪ‪) ‬ﺻ‪‬ﻠﱠﻰ ﺍﻟﻠﱠﻪ‪ ‬ﻋ‪‬ﻠﹶﻴ‪‬ﻪ‪ ‬ﻭ‪‬ﺳ‪‬ﻠﱠﻢ‪ (‬ﻗﹶﺎﻝﹶ‪:‬‬
‫))ﻟﹶﻮ‪ ‬ﺃﹶﻥﱠ ﻟ‪‬ﺎﺑ‪‬ﻦﹺ ﺁﺩ‪‬ﻡ‪ ‬ﻭ‪‬ﺍﺩ‪‬ﻳ‪‬ﺎ ﻣ‪‬ﻦ‪ ‬ﺫﹶﻫ‪‬ﺐﹴ ﺃﹶﺣ‪‬ﺐ‪ ‬ﺃﹶﻥﹾ ﻳ‪‬ﻜﹸﻮﻥﹶ ﻟﹶﻪ‪ ‬ﻭ‪‬ﺍﺩ‪‬ﻳ‪‬ﺎﻥ‪ ،‬ﻭ‪‬ﻟﹶﻦ‪ ‬ﻳ‪‬ﻤ‪‬ﻠﹶﺄﹶ ﻓﹶﺎﻩ‪ ‬ﺇﹺﻟﱠﺎ ﺍﻟﺘ‪‬ﺮ‪‬ﺍﺏ‪ ،‬ﻭ‪‬ﻳ‪‬ﺘ‪‬ﻮﺏ‪ ‬ﺍﻟﻠﱠﻪ‪ ‬ﻋ‪‬ﻠﹶﻰ ﻣ‪‬ﻦ‪ ‬ﺗ‪‬ﺎﺏ‪.((‬‬
‫)ﻣﺘﻔﻖ ﻋﻠﻴﻪ(‬

‫ﻭﻋ‪‬ﻦ‪ ‬ﺃﹶﺑﹺﻲ ﻫ‪‬ﺮ‪‬ﻳ‪‬ﺮ‪‬ﺓﹶ )ﺭ‪‬ﺿ‪‬ﻲ‪ ‬ﺍﻟﻠﱠﻪ‪ ‬ﻋ‪‬ﻨ‪‬ﻪ‪ (‬ﺃﹶﻥﱠ ﺭ‪‬ﺳ‪‬ﻮﻝﹶ ﺍﻟﻠﱠﻪ‪) ‬ﺻ‪‬ﻠﱠﻰ ﺍﻟﻠﱠﻪ‪ ‬ﻋ‪‬ﻠﹶﻴ‪‬ﻪ‪ ‬ﻭ‪‬ﺳ‪‬ﻠﱠﻢ‪ (‬ﻗﹶﺎﻝﹶ‪:‬‬
‫))ﻳ‪‬ﻀ‪‬ﺤ‪‬ﻚ‪ ‬ﺍﻟﻠﱠﻪ‪) ‬ﺳﺒﺤﺎﻧﻪ ﻭﺗﻌﺎﱃ( ﺇﹺﻟﹶﻰ ﺭ‪‬ﺟ‪‬ﻠﹶﻴ‪‬ﻦﹺ ﻳ‪‬ﻘﹾﺘ‪‬ﻞﹸ ﺃﹶﺣ‪‬ﺪ‪‬ﻫ‪‬ﻤ‪‬ﺎ ﺍﻟﹾﺂﺧ‪‬ﺮ‪ ‬ﻳ‪‬ﺪ‪‬ﺧ‪‬ﻠﹶﺎﻥ‪ ‬ﺍﻟﹾﺠ‪‬ﻨ‪‬ﺔﹶ‬
‫ﻳ‪‬ﻘﹶﺎﺗ‪‬ﻞﹸ ﻫ‪‬ﺬﹶﺍ ﻓ‪‬ﻲ ﺳ‪‬ﺒﹺﻴﻞﹺ ﺍﻟﻠﱠﻪ‪ ‬ﻓﹶﻴ‪‬ﻘﹾﺘ‪‬ﻞﹸ‬
‫ﺛﹸﻢ‪ ‬ﻳ‪‬ﺘ‪‬ﻮﺏ‪ ‬ﺍﻟﻠﱠﻪ‪ ‬ﻋ‪‬ﻠﹶﻰ ﺍﻟﹾﻘﹶﺎﺗ‪‬ﻞﹺ ﻓﹶﻴ‪‬ﺴ‪‬ﻠ‪‬ﻢ ﻓﹶﻴ‪‬ﺴ‪‬ﺘ‪‬ﺸ‪‬ﻬ‪‬ﺪ‪.((‬‬
‫)ﻣﺘﻔﻖ ﻋﻠﻴﻪ(‬