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A Key to Surgical Methods !

(This is only a revision key & not a substitute for the books.)
Before starting any exam, always proceed to the following points:
· Introduction & Greetings
· Take consent
· Ask for privacy / female attendant in case of male examiners
· Positioning of the patient
· Proper exposure
Don’t forget to thank the patient after completion of the exam.


A) SWELLING
S Start - History
W Where - Site, lies in which structures, mobility
E External Features
L Lymph Nodes - Enlarged or not palpable
L Liquid - Fluctuation, trans-illumination
I Internal Features - Hard, tender
N Noise - Thrill, bruit
G General Appearance of the patient

B) ULCER

1. Site, size, shape - for exact, trace on a sterile transparent plastic
2. Base - Solid brown or grey dead tissue > dead skin
- Yellow grey wash leather slough > syphilitic ulcer
- Bluish unhealthy granulation tissue > TB ulcers
- Poor granulation tissue, bare underlying structures > ischemic
3. Edge - Flat gently sloping edge > venous ulcers
- Square cut or punched out > trophic, syphilitic ulcer
- Undermined edges > TB ulcers
- Rolled edges > BCC
- Everted edges > SCC
4. Depth
5. Discharge - Ask permission from examiner to remove it
6. Underlying Structures
7. Lymph nodes exam
8. Local blood supply & adjacent skin innervation
9. General physical exam of the patient



C) THYROID
1. INSPECTION Ask the patient to take a sip of water (don’t ask the patient to swallow the saliva) & then protrude the tongue out. From front & side, look for:
- Movement with swallowing & tongue protrusion
- Retero-sternal extent
- Skin changes, prominent vessels, scar marks
- Nodules > symmetry, size, shape, extent (from side)
- Pemberton sign
2. PALPATION First, ask the patient for any tenderness. From front:
- Palpate one side by pressing other.
- Measure (in cm) the 3D size of the swellings.
- Palpate trachea (3 finger method)
- Berry’s Sign
From back, flex the neck a little to relax muscles, and then feel for:
- Movement with swallowing
- Retero-sternal extent
- Turn the neck to one side & palpate the other side
- Lymph node palpation
- Kocker’s sign
- Pinch skin to check its mobility over the swelling
- Check for bone mets in spine > press gently over the spine & ask for any pain.
3. PERCUSSION From front, percuss along the clavicles (a finger above & below the clavicle with direct percussion over the bone) & then 3 fingers over the upper part of sternum & chest wall.
4. AUSCULTATION WITH BELL, listen for any bruit at the upper poles of thyroid.
Examination of thyroid also includes the following:
1. HANDS Ask the patient extend hands straight forwards with fingers spread & look for:
- Tremors (place a paper if not sure)
Press down the upper part of arm to check for:
- Proximal myopathy
Feel the pulse for:
- Rate / Rhythm
2. EYES Ask the patient to follow your finger in “H” shape & also move it vertically to check for eye movements
- Von Griffe’s Sign > Lid lag
- Stillvack’s Sign > Lid retraction
(Both of the above are due to over-activity of smooth muscle part of levator pelpebrae superioris muscle)
- Geoffre’s Sign > Loss of wrinkling while looking up
- Mobius Sign > Loss of accommodation
(Both of the above are due to exophthalmos)
- Exophthalmos due to retero-orbital fat, edema, cellular infiltration
- Ophthalmoplegia due to edema & cellular infiltration of muscles & nerves, patient especially cannot look up & out
- Chemosis due to impaired venous & lymphatic drainage
3. CVS SYSTEM
4. RESPIRATORY SYSTEM
5. EDEMA & SKIN CHANGES
6. GPE Look for:
- Cyanosis
- Mental retardation
- Voice changes

D) HEMORRHOIDS
1. Inspection While the patient is in left lateral position, look for:
- Any sinus
- Skin tags
- Visible fissure
- Scar Marks
- Visible hemorrhoids
2. Digital Per Rectal Exam
3. Proctoscopy



H) CIRCULATION (Lower Limb)
1. INSPECTION Ask the patient to raise the leg & look for:
- Pain
- Paresis
- Paraplegia
Look for:
- Color
- Swelling
- Skin Changes (Ulcers, Abscesses, Gangrene)
- Buerger’s Angle > Compare on both sides
- Capillary filling time
- Venous Filling
- Pressure Areas
2. PALPATION - Ask for tenderness
- Temperature
- Capillary refilling
- Pulses > Repeat after exercise
3. AUSCULTATION With bell
4. Check muscles & nerves for ischemia



I) BREAST
· Position the patient to 45o
· Take consent
· Ask for privacy / proper exposure / female attendant in case of male examiners
1. INSPECTION Always look at the normal breast first
- Symmetry
- Number
- Swellings
- Skin changes
- Discharge
- Axillae
- Supra-clavicular fossae
- Limb Swelling
- Visible veins
Ask the patient to raise the hands & then look for:
- Skin changes
- Swellings
- Symmetry
Repeat the above observations while asking the patient to firmly placing the hands against the hips.
2. PALPATION - Ask for tenderness
- Feel for tenderness
- Feel for any lump (with flat of fingers & not palm)
- Check axillary tail
- Inspect the under surface of breast by raising with the dorsum of your hand
- Palpate the lymph nodes > don’t miss the supra-clavicular & axillary lymph nodes.
If you find a lump in breast, check for:
- Mobility > in atleast two directions
- Size
- Skin fixity
- Fluctuation
- Trans-illumination
- Slip sign > for fibro-adenoma
Ask the patient to press the areolae or yourself press them from all four directions to look for:
- Any discharge
Ask the patient to firmly press the hands against the hips.
- Check for mobility
Repeat the above observations while asking the patient to extend the hands forwards to fix the serratus muscle.
Ask the patient to sit & then from the back, check:
- Lymph nodes
- Bone tenderness
3. ABDOMEN PALPATION
4. CHEST AUSCULTATION
5. Always look for TESTICULAR ABNORMALITY in case of males.
Causes of Gynaecomastia:
- Infants > Maternal Oestrogens
- Adolescents > Temporary hormonal imbalance
Testicular atrophy
Hormone secreting testicular tumors
Klinefelter Syndrome
Pituitary imbalance
- Middle aged > Idiopathic, Traumatic
- Elderly > Drugs (Digoxin, INH, Spironolactone, Cimetidine, Oestrogens)
Cirrhosis
Bronchial CA
Carcinoid tumors


H) CIRCULATION (Lower Limb)
1. INSPECTION Ask the patient to raise the leg & look for:
- Pain
- Paresis
- Paraplegia
Look for:
- Color
- Swelling
- Skin Changes (Ulcers, Abscesses, Gangrene)
- Buerger’s Angle > Compare on both sides
- Capillary filling time
- Venous Filling
- Pressure Areas
2. PALPATION - Ask for tenderness
- Temperature
- Capillary refilling
- Pulses > Repeat after exercise
3. AUSCULTATION With bell
4. Check muscles & nerves for ischemia


J) LYMPHEDEMA
1. INSPECTION Look for:
- Site
- Size
- Shape
- Extent
- Demarcation
- Color
- Other areas
- Skin Changes (Ulcers, Abscesses, Gangrene)
- Squaring of toes
2. PALPATION - Ask for tenderness
- Temperature
- Stemmer’s sign
- Lymph nodes
3. AUSCULTATION With bell for bruit
4. Do GPE to find out the causes of secondary lymphedema.

K) VARICOSE VEINS
1. INSPECTION While standing & from front as well as behind
- Skin changes
- Hair changes
- Visible veins
- Edema
2. PALPATION While standing,
- Ask for tenderness
- Palpate the veins & Sephano-femoral junction
- Edema, facial defects, texture of skin
- Cough impulse
Ask the patient to lie down, empty the veins by stroking movements of hands after raising them, and then look for:
- Venous guttering
- Feel for gap in fascia
- Palpate Sephano-femoral junction
- Trendelenberg’s test
- Tourniquet test > place 5 Tourniquets & open from above downwards
- Perthe’s walking test > perform if the veins fail to collapse
3. PERCUSSION - Feel the percussion wave conduction
4. AUSCULTATION - Listen for bruit over prominent veins
5. GPE & Rule out all the causes by relevant systemic exam especially abdominal.
6. Harvey’s Test on superficial abdominal veins.

L) PARA-UMBILICAL HERNIA

1. INSPECTION Look for:
- Abdominal distension
- Umbilicus > Shape & location
- Swellings at other hernia site
Ask the patient to cough & then, to raise the head while lying down with arms on sides:
- Observe the swelling.
Ask the patient to reduce the swelling & then look for its re-appearance.
2. PALPATION - Ask for tenderness
- Cough impulse
- Swelling > Site, size, shape, consistency (better way is to feel it while the patient raises the head)
- Check for divarication of recti
3. PERCUSSION - Check the percussion note above the swelling.
4. AUSCULTATION - Listen for bowel sounds in the swelling.
5. GPE & Rule out all the causes by relevant systemic exam.
- Abdominal palpation
- Bladder palpation if aged male
- Auscultation of chest
- Ask about heavy weight lifting



M) INGUINAL HERNIA
While patient standing, sit on the side of hernia & perform:
1. INSPECTION Look for:
- All the hernial orifices
- Scar mark or any other finding
- Ask about reducibility
- Effect of Cough if the swelling is reduced
- Look at the posterior surface of scrotum for any sinus or discharge after asking for tenderness
2. PALPATION - Ask for tenderness
- Swelling > Site, size (take exact measurements in atleast two directions), shape, surface, consistency, color, tenderness, temperature, skin changes & fixity, compressibility (absent in vascular tumors)
Find out answers to following five questions
- Are the testes separately palpable?
- Can you get above the swelling?
- Is Cough impulse positive? > Place one hand on the back of patient & other on the swelling
- Is the swelling trans-illuminant?
- Is the swelling reducible?
3. PERCUSSION - Check the percussion note above the swelling.
4. AUSCULTATION - Listen for bowel sounds in the swelling.
While patient lying on bed, stand on the right side of patient, & confirm the above findings. In addition, perform:
- If reducible, ask the patient to reduce
- Deep ring occlusion test > +ve if it strikes the thumb,
-ve if it comes out of superficial ring
Do GPE & Rule out all the causes by relevant systemic exam.
- Abdominal palpation
- Bladder palpation if aged male
- Auscultation of chest
- Ask about heavy weight lifting




Hydrocoel vs Epididymal cyst:
Hydrocoel
1. Testis not palpable separately but cord is.
2. Fluctuant, ovoid
3. Fluid thrill positive
4. Dull to percuss
5. Trans-illuminant (not hematocoel)
6. Non reducible
7. Cough impulse absent
Epididymal cyst
1. Testis palpable separately, swelling usually above & behind.
2. Fluctuant, elongated, multi-locular
3. Fluid thrill positive
4. Dull to percuss
5. Trans-illuminant
6. Non reducible
7. Cough impulse absent

Varicocoel:
- Testis palpable separately
- “Bag of worms” feel on STANDING
Direct vs Indirect Hernia:
Direct Hernia
1. Can descend into scrotum & usually does.
2. Reduces up, then laterally, finally backwards
3. Deep ring occlusion test +ve
4. Defect not palpable
5. Direction of re-appearance along the inguinal canal & then downwards.
6. Common in children & young adults.
Indirect Hernia
1. Can but usually does not descend into scrotum.
2. Reduces up and then straight backwards.
3. Deep ring occlusion test -ve
4. Defect may be palpable above pubic tubercle
5. Direction of re-appearance straight from the superficial ring downwards.
6. Uncommon in children & young adults.

D/D of Lump in groin:
- Inguinal hernia
- Femoral Hernia
- Enlarged lymph nodes
- Saphenovarix
- Femoral artery aneurysm
- Ectopic testis
- Hydrocoel of cord or canal of Nuck
- Lipoma of cord
- Psoas bursa
- Psoas abscess
- Encysted Hydrocoel of cord
- Hematocoel of round ligament
N) PAROTID SWELLING

1. INSPECTION - Site
- Size
- Shape
- Symmetry
- Surface
- Angle of jaw
- Facial nerve function
- Stenson’s Duct
- Wirson’s Duct
2. PALPATION - Ask for tenderness
- Temperature
- Size
- Shape
- Surface
- Consistency
- Mobility
- Skin fixity
- Trans-illumination > usually -ve
- Fluctuation
- Slip sign
- Bimanual palpation (with fingers of one hand in mouth & other on surface, done for salivary glands other than parotid)
- Lymph nodes
3. PERCUSSION - Dull
4. Oral cavity exam - Inspect the inside for discharge while pressing outside.
- Palpate bimanually.



O) NERVES
1. Sciatic Nerve - Straight leg raising test
2. Common Peroneal Nerve - Damage leads to Talipes equino varus deformity
- Patient is unable to dorsiflex & evert the foot.
- Dropped foot i.e. the patient walks without undue lifting of the foot.
3. Tibial Nerve - Damage leads to Talipes calcaneo vulgus deformity
- Patient is unable to plantar flex & heels are with the ground.
- Ask patient to plantar flex against the resistance.
4. Femoral Nerve - Ask patient to extend the knee against the resistance.
5. Median Nerve - Oschner Clasping test (Gun sign, pointing index)
- Ape thumb deformity
- Erb’s paralysis (Policeman receiving tip deformity)
- Tinel’s test > tap the nerve at wrist
- Sensory supply for palmer aspect of thumb, index & middle fingers, dorsal aspect of the distil phalanx, and the half of middle phalanx of the same fingers & a variable amount of radial side of the palm of the hand.
- Hold the wrist fully flexed for 1-2 minutes > symptoms of nerve compression if carpal tunnel syndrome present.
Injury at wrist
- Wasting of the thenar eminance
- Absent abduction of thumb
- Absent opposition of thumb
Injury at or above the cubital fossa
- Wasting of the thenar eminence & forearm
- Loss of flexion of thumb & index fingers
- Hand held in Benediction Position, with ulnar fingers flexed & index fingers straight.
6. Ulnar Nerve - Sensory supply for anterior & posterior surface of the little finger, ulnar side of the ring finger & skin over hypothenar eminence & similar strip of skin posteriorly.
Injury at wrist
- Wasting of the hypothenar eminence & hollows between metacarpals
- Absence of flexion of little & ring fingers
Claw hand, with little & ring fingers hyper-extended at the metacarpophalangeal joints & flexed at inter phalangeal joints.
- Absence of adduction & abduction of the fingers with a positive Froment’s test.
Injury at the level of elbow
- Wasting of the intrinsic muscles
Claw hand, but with terminal inter phalangeal joints not flexed as half of flexor digitorum profundus now paralyzed.
- Positive Froment’s test.
Injury high above the elbow
- All the above
- The flexor carpi ulnaris also paralyzed.
7. Radial Nerve - Sensory supply for small area of skin over the lateral half of first metacarpal & the back of first web space.
Injury in the axilla
- Wrist Drop i.e. Absence of extension of wrist.
- Loss of triceps action.
Injury at the level of middle third of humerus
- Wrist Drop
- Sparing of brachioradialis
Injury to the posterior interosseous
- Hand held in radial deviation when attempting extension.
- No wrist drop
- An inability to maintain finger extension against forcible flexion.
Injury to the superficial branch of the nerve
- No motor loss.
(While checking for motor action of the nerve, feel the muscle you are testing to check whether or not it is contracting.)
Other causes of claw hand:
a) Neurological:
- Spinal > Polio, Syringomyelia
- Brachial plexus > compression due to trauma or malignancy
- Nerves > Trauma, Neuritis
b) Musculoskeletal
- Volkmann’s ischemic contracture
- Joint diseases


P) JOINTS
1. Knee Joint
· LOOK:
- Varus i.e. ( ) or vulgus i.e. )( deformity.
- Skin redness, scar, lacerations
- Dimple on medial side
- Wasting of vastus medialis
- Fixed flexion
· FEEL:
- Temperature
- Knee effusion > Stroke test
- Baker’s Cyst > Appears in full extension
- Circulation > Pulses, capillary filling
· MOVE:
- Active > Flexion – measure in cm how much the heel stops in short of hip
> Extension – force the knee in bed while standing for hyper-extension
- Passive > Flexion – Look at patients face for any discomfort.
> Extension – Raise off patients heels of the bed.
- Lag test > Straight Leg Raising & then ask the patient to bend the knee for 20o & then straighten it > absent in lesions of quadratus femorus.
· STABILITY:
- Collaterals > Varus & Valgus knee tests
- Cruciate ligament > Anterior & posterior drawer tests (sit on patients foot while doing these tests to keep it still)
- Pivot shift test > Do gently to prevent muscle spasm.
- Patella apprehension test (don’t actually dislocate the patella of the patient).
2. Hip Joint
· LOOK & FEEL as above:
- In addition measure true & apparent Leg Length Discrepancy
· MOVE:
- Modified Thomas test
- Abduction, Adduction, Rotation
- Referred Pain > Pastry Rolling Test
· STABILITY:
- Trendelenburg test

(Do rest of the joint exam from the chapter on “Musculoskeletal Examination” from “Bailey & Love’s Short Practice of Surgery”. Details of special tests mentioned in this scheme can be read from any book on surgical methods. Also prepare yourself the methods that are left).



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