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Superficial Lesions

Inspection

Palpation

!
Draining L.N.s
Neuro-Muscular Bundle

Percussion
Auscultation

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Differences between Lipoma and Sebaceous cyst

Lipoma

Sebaceous cyst

History
Site

Subcutaneous
Subfascial
Intermuscular
Submucous
Parosteal
Extradural
Intra-articular

Scalp
Face
Neck
Scrotum
Anywhere except palm and
sole of the foot which are
devoid of sebaceous gland

Very slow

Slowly growing

Benign tumor

Retention cyst
Caused by blockage of a
sebaceous gland duct

Solitary
Multiple lipomatosis
Diffuse lipomatous deposits

Solitary or multiple

Onset
Course
Duration
Relation to other symptom
Possible Cause

Constitutional symptoms

Examination

Inspection
Number

Site
Shape
Size
Surface
Skin and color

Small
Sometimes large
Lobulated
A punctum may be seen

Special signs

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Palpation
Relations to the surroundings
Mobility
Relation to skin

Not attached to skin

Relation to other
deep structures

Attached to skin at one point


which is the site of the duct
Mobile

Other swellings
Temperature
Tenderness

No

Edge

Well defined slippery

Well defined

Soft
Pseudofluctuation
Due to mobility of the tumor
in its bed

cystic

Reducibility
Solid, fluid or gas
Consistence
Fluctuation
Draining L.N.s
Neuro-Vascular Bundle

For other skin lesions please see more on:


http://alasmar.info/2016/06/22/terms-of-surgical-importance-used-to-describe-skin-pathology/
Examination of an Ulcer on:
http://alasmar.info/2016/06/17/examination-of-an-ulcer/
Examination of the Scalp on:
http://alasmar.info/2016/06/17/scalp/
Examination of Oral Cavity on:
http://alasmar.info/2016/06/17/mouth/
All of them follows the same principles

Home page is: www.alasmar.org

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Thyroid Examination
Local examination

Inspection

Palpation

Position

Patient: Neck extended


Doctor: In front of the
patient

Patient: Slightly flexed


Doctor: Front then behind

Exposure

All head till clavicle

All head till clavicle

Comment on
Description

lump (as any swelling)


Scar of previous operation
(Healing or Complication)

lump (as any swelling)

Sternomastoid

muscle contraction

Tilt the patient's head to the same


side
Pinch the muscle
Ask him to swallow

Skin

Ask patient to swallow

Ask patient to swallow

Carotid artery

Trachea

Manubrium

Normal site
Equal volume
Displacement
Weak pulse
'Berry's sign'
Move up and down

Is lower edge seen?

While standing the patient put


fingers on gland and ask him to
swallow will feel the gland and the
larynx go up
Put fingers to stop descent of the
gland while the larynx goes down
!

Is lower edge felt?

Neck L.N.s
Neuro-Muscular Bundle

Percussion

Resonant or dull?

Auscultation

Upper pole of the gland


To hear systolic bruit if gland is highly vascular as in toxic goiter

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

General examination for thyroid status


Hands
1. Increased sweating
2. Palmer erythema
3. Pulse and water hummer pulse (Tachycardia, AF, Any arrhythmia except HB and Sleeping
pulse >90 bpm)
4. Fine tremors (by a sheet of paper on out stretched hands with palms facing downwards)
5. Thyroid acropachy
6. Onycholysis
7.

Areas of vitilligo

Eyes (stabilize the head)


1. Lid retraction (front - Dalrymple's sign)
2. Lack of forehead wrinkling on looking upwards without moving the head (front - Joffroy's
sign)
3. Lid lag (front - Von Graefe's sign)
4. Defective convergence (front - Moebius's sign)
5. Ophthalmoplegia (front)
6. Exophthalmos (back)
7.

Loss of hair of outer third of eyebrows

Other systemic manifestations


1. Pretibial myxoedema
2. Proximal myopathy
3. Signs of heart failure
4. Gynecomastia

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Thyroid investigations
Essential
Serum: TSH (T3 and T4 if abnormal); thyroid autoantibodies
FNAC of palpable discrete swellings; ultrasound guidance may reduce the 'Thy1' rate
Optional
Corrected serum calcium
Serum calcitonin (CEA may used as an alternative screening test for medullary cancer)
Imaging: Chest radiograph, Ultrasound, CT and MRI (for known cancer, some reoperation and some retrosternal goitres)
Isotope scan (if discrete swelling and toxicity coexist)
Thyroid operations
Indications for operation in thyroid swelling
Neoplasia: FNAC positive + Clinical suspicion, including: Age, Male sex, Hard texture, Fixity, Recurrent laryngeal nerve palsy and
Lymphadenopathy
Recurrent cyst, Toxic adenoma, Pressure symptoms, Cosmesis and Patient wishes
Choice of therapy of thyrotoxicosis
Diffuse toxic goiter

>45 years: radioiodine


<45 years: surgery for large goiter and anti-thyroid drugs or
radioiodine for small goiter

Toxic nodular goiter

Surgery

Toxic nodule

>45 years: radioiodine


<45 years: surgery

Recurrent thyrotoxicosis after surgery

Radioiodine
Anti-thyroid drugs for women intending to have children
Surgery has a little place

Failure of previous treatment with anti-thyroid drugs or


radioiodine

Surgery
Thyroid ablation with I123

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Neck examination
As thyroid examination + examination of any lump +
Lymph nodes examination (up-and-down technique)
1. Palpate from the chin backwards to below the ears (submental submandibular parotid
glands pre-auricular)
2. Move your hand behind the ears (post-auricular) and palpate DOWN the anterior border of
sternomastoid to the clavicle (anterior triangle including jugulodigastric)
3. Move laterally along the clavicle (supraclavicular - infraclavicular) then UP the posterior
border of sternomastoid (posterior triangle)
4. Finish by palpating back of the scalp (occipital nodes)
+ Face and scalp examination + area above the umbilicus (breast examination in females) + ENT
examination searching for primary site of infection or neoplasia
+ Abdominal examination (hapatomegaly and splenomegaly) and the rest of lymphoreticular system (other
groups of lymph nodes)

DD. A Single lump in the neck

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Facial nerve palsy


Inspection
1. General: Loss of facial expressions
2. Eyelids: on blinking, the affected side closes after the normal eyelid (Bell's
sign the eyeballs moves vertically upwards when the eye is closed)
3. Eyes: widened palpebral fissures
4. Nasolabial folds: flattened on the affected side
5. Mouth: the affected side droops and moves less when talking

Palpation
1. Occipitofrontalis: ""
2. Orbicularis oculi: ""
3. Orbicularis oris: ""
4. Buccinators: ""

Complete examination
1. Test taste (chorda tempani)
2. Test hearing (hyperacusis N. to stapedius)
3. Cause (history - scar)

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Parotid Gland
Inspection
Number
Site

Parotid region

Shape

Parotid shape if diffuse parotid enlargement

Size
Surface
Skin and color

Scar, fistula

Special signs

Relation to chewing food

Palpation
Relations to the surroundings:
Mobility
Relation to skin

Freely mobile, Tethered or Fixed

Relation to muscles

Masseter " " and Sternomastoid

Relation to nerves

Facial nerve examination

Relation to artery

Superficial temporal artery pulse

Ear

Elevation of ear lobule

Other swellings

Cervical lymph nodes

Temperature
Tenderness
Edge
Reducibility

Solid, fluid or gas


Consistence
Fluctuation

Open the mouth to assess


Ability to open
What happen to the lump?
Parotid lump usually diminish in size due to tension of parotid facsia
Dryness of the mouth
Swellings of submandibular glands and its duct (bimanual examination)
Parotid duct
Deep part of the parotid gland

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Differential diagnosis of salivary glands presentations


Swellings in parotid region
True Parotid enlargement
Extra-parotid enlargement
Lymph nodes

Lymphadenopathy

Skin and subcutaneous tissue

Sebaceous cysts
Lipomas

Muscle

Masseter hypertrophy

Bone

Mandibular and maxillary tumors


e.g. adamantinoma of the mandible

Artery

Superficial temporal artery aneurysm

Nerve

Neurofibroma

Causes of swelling of a salivary gland


Acute infection: Viral (e.g. mumps) and Bacterial (e.g. staphylococcus)
Duct obstruction
Sialectasis (chronic infection)
Tumor: Benign or Malignant
Sarcoidosis
Sjogren's syndrome

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Breast examination
Examination
Exposure: All of the top half of the trunk, Compare both breasts and Start with the
normal side (MUST ASK FOR A CHAPERONE)

Inspection
Position (Patient sitting 90 then raise arms above her head then hands on her hip)
Breast
Size, Symmetry, Contour, 6 areas (4 quadrants, Tail and Inframammary surface)
Skin
Dimpling, Puckering, Peau d'orange, Cancer encrust, Discoloration, Nodule and
Ulceration or SCAR
Nipple and areolae
Destruction, Depression (retraction or inversion), Discoloration, Displacement,
Deviation, Discharge and Duplication
e.g. Duct ectasia, Carcinoma, Paget's disease and Eczema
Axillae and arms
Supraclavicular fossae

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Palpation
Position (Patient sitting 45)
By Flat of fingers, Bimanual examination and Ask the patient to find the lump if you
did not find it
Breast '6 areas' (4 quadrants, Tail and Inframammary surface)
Lump
Number
Site
Shape
Size
Surface
Skin and color
Special signs
Relations to the surroundings
Mobility
Relation to skin

Freely mobile
Tethered
Fixed

Relation to muscles

Hands by sides
Hands press in sides

Relation to chest wall


Other swellings
Temperature
Tenderness
Edge
Reducibility
Solid, fluid or gas
Consistence
Fluctuation

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Discharge
Milk each quadrant towards the nipple to know which duct is the source of the
discharge
Axillae "axillary L.N.s" (anterior, medial, posterior, lateral and apical)
Supraclavicular fossae
General examination
Abdomen
Hepatomegaly, Ascites and Nodule in Douglas pouch
Chest
Lumbar spine
Percussion, Movements, Straight leg raising and Ankle jerks

Approach for diagnosis for Breast Lump


Simplified plane for diagnosis of common breast lumps
Define the surface and the shape and then define the consistence
Irregular and indistinct

Smooth and well defined

Hard

Rubbery

Hard

Rubbery

Carcinoma

Nodularity

Cyst

Fibroadenoma

Triple assessment
1. History and examination
2. Diagnostic imaging by mammography and/or ultrasound scanning
3. Cytology or histology

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Peripheral arterial system


Inspection
1. Color changes
a. Red
b. white
2. Trophic changes and tissue loss
a. Pressure areas and between toes (Ischemic ulceration Gangrene)
b. Skin and appendages (Temperature - Loss of hair - Loss of
sebaceous and sweat glands - Dry skin - Deformed and brittle nails Loss of nail luster - Xanthelesmata and xanthomata)
c.

Subcutaneous tissues (Loss of subcutaneous fat - Thin skin - Tapered


toes)

d. Venous guttering
e. Muscles and tendons (Wasted muscle)
f.

Bones and joints (Osteoporosis)

3. Vascular angle (Buerger's Angle)

Palpation
1. Temperature (and tenderness)
2. Capillary refill
3. Peripheral pulses

Complete

Auscultation (Bruit Ankle-Brachial index - Blood pressure)

Abdominal examination

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Ischemic ulceration
Examination
Inspection
Number

Single or multiple

Site

Tips of toes - Over pressure points

Shape

Most often elliptical

Size and depth

Vary from small, deep lesions, a few millimeters across, to large, flat ulcers 10 cm or more wide
on lower leg
Usually very deep and may penetrate down to and through deep fascia tendons bone or even
underlying joint

Floor

Grey-yellow sloughs covering flat, pale, granulation tissue

Edge

Punched out if no attempt at healing


Sloping if begin to heal

Margin

Blue-grey color
No lipodermatosclerosis

Discharge

Clear fluid Serum - Pus

Surroundings
Arteries

Distal pulse is invariably absent

Nerves

There may be loss of superficial and deep sensations, weakness of movement and loss of reflexes
if the ulcer is caused by neuropathy

Bones and joints

May be exposed

Palpation
Lymph nodes

Not normally enlarged

Base
Extent and motility

May stuck to, or be part of, any underlying structure


And it is quite common to see bare bone, ligaments and tendons exposed in the base of an
ischemic ulcer

Induration
Tenderness

Very tender
Removing of dressing can cause exacerbation of pain lasts for several hours

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Gangrene
Aim of examination
Gangrene or not?
What is the cause?
Demarcated or not?
Which type?
Cardinal signs (Gangrene or not?)
Oh! Press and see how color fades
Oh!

Odor

Press

Pulse

Loss of pulsation
Sluggish capillary circulation

See

Sensation

Loss of sensation

How

Heat

Loss of heat

Color

Color

Fixed color changes


Blue and later black

Fades

Function

Loss of function

What is the cause?


Traumatic

Direct trauma

Crushing
Pressure 'bed sores'

Indirect trauma

Injury of main vessel

Delayed

Vascular repair after tissue death

Physicochemical

Infective

Arterial

Burn
Frost-bite
Trench foot
Specific

Clostridial gas gangrene

Non specific

Carbuncle
Anaerobic cellulitis
Cancrum oris
Noma vulvae
Phegendena
Melenery's ulcer
Fournier syndrome

Thrombosis

Atherosclerosis
Diabetes
Beurger's disease
Arthritis

(Skin)
(Mouth)
(Vulva)
(Breast)
(Perineum and abdominal wall)
(Scrotum)

Embolic
Vasospastic
Venous
Neuropathic

Raynaud's disease
Ergotism

Major outflow
obstruction
Diabetes
Syringomyelitis
Leprosy

Demarcated or not?
Demarcation
Depend on (Vascularity Infection Trauma)
Stages (Zone of demarcation - Line of demarcation - Plane of demarcation)
Line of demarcation should be (Complete 'all around' - Well defined - Constant place)
Plane of separation may be
Ulceration at the expense of dead tissue 'depth'
Suppurative at the expense of living tissue 'abrupt stop'
Failure of demarcation (In continuity - Skip lesions - Dye back phenomenon)

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Which type?
Moist

Dry

Swollen

Shrunken

Stretched skin

Wrinkled skin

With bullae

No bullae

Soft

Hard

Less dark

Darker in color

Less odor

With characteristic odor

May be septic or aseptic


Causes

Sudden arterial obstruction


Venous obstruction
Generalized edema
Liquefaction of tissues

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Varicose Veins
Inspection
1. Site and size of varicosities including Saphena varix
2. Skin changes and scars
3. Swelling of the ankle

Palpation
1. State of skin and subcutaneous tissue
2. Sites of fascia defects
3. Site of incompetence (Trendelenburg test + cough impulse)

Percussion
1. Tape test (Chevrier's tape sign)
2. palpation of the varicosities and pulse

Complete by Auscultation
1. Spheno-femoral incompetence by hand-held Doppler
2. If any bruit
3. Examine the abdomen

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Chronic Venous Insufficiency


1.
2.
3.
4.

Pigmentation (!lipodermatosclerosis !ulcer)


LEGS
Lipodermatosclerosis
Eczema
Gaps (ulcers) causing white patches "atrophie blanche"
Swelling (edema not in the dorsum of the foot due to subfascial fobrosis)

Venous
Ulcer

Number
Site

Gaiter or ulcer bearing area


Medial and lateral maleolai

Shape

Rounded or any

Size

Usually superficial

Floor

Granulation tissue

Margin

Pigmentation

Edge

Sloping

Discharge

Color Amount odor

As inspection
LNs
Base
Mobility
Induration
lipodermatosclerosis
Extent
Tenderness

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Lymphoedema
Inspection
1. Grossly swollen legs
2. Preserved skin creases
3. Buffalo hump (dorsum of the foot)
4. Square toes

Palpation
1. Non pitting edema
2. Inguinal lymph nodes

Differential diagnosis of swollen lower limb (lymphoedema)


Edema
Local causes
Venous (DVT - 1ry varicose veins - 2ry varicose veins)
Lymphatic obstruction) (Post traumatic - Post inflammatory Neoplastic Primary)
Arterial (Arterio-venous fistula - Post-revascularization)
Traumatic
Inflammatory
General causes
Cardiac Hepatic Renal Nutritional Allergic Hypoalbuminaemia (Hepatic Renal
Nutritional Bowel - Trauma to thoracic duct)
Not edema
Local gigantism - Hemi hypertrophy Tumor - Lipidaema in females (Cyclic - Non cyclic)
Types of primary lymphoedema
Congenita

Praecox

Tarda

Incidence

10%

80%

10%

Age

At or within 1 year of birth

Usually adolescence

After 35 years

Sex

M>F

F>M

M=F

Site

Commonly bilateral and involve the


whole leg

Commonly unilateral and below


the knee

Usually unilateral

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Surgical A-V fistula


Inspection
1. Dilated pulsatile vessels in forearm with an overlying scar
2. Site (radio-cephalic or bracio-cephalic)
3. Puncture site
4. Dilated veins (venous hypertension)

Palpation
1. Thrill
2. Alan's test (on examiners hand)

Auscultation bruit

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Abdominal examination
Inspection
General
Contour
Movement with respiration
Visible peristalsis
Skin (Scar Striae - Scratch marks Veins Haemorrhage)
Specific
Breast
Subcostal angle
Epigastric pulsation
Divercation of recti ()
Umbilicus
Site
Shape (Inverted Everted)
Skin (Pigmentation Nodules Discharge Ulcer Scar)
Impulse on cough ()
Suprapubic hair distribution
Hernia orifices ()
External genetalia

Palpation
Superficial
Tenderness Rigidity - Superficial swelling
Deep
Tenderness - Swelling
Organs
Liver
1st do tidal
percussion

Size
Border
Surface
Consistency
Tenderness
Pulsation 'bimanually'

Spleen

Size
Border
Surface
Consistency
Tenderness
Notch
Pitting

Kidney

Size
Right and left
Surface
Consistency
Tenderness

Bladder

Size
Consistency
tenderness

Colon

Aorta

Lymph nodes

Gall bladder

Percussion
Liver (and Tidal percussion) Spleen (and Truab's area) - For ascites (Transmitted
fluid thrill - Shifting dullness - Knee elbow position Ultrasound) Bladder - Any
mass

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Auscultation
Intestinal sounds - Arterial bruit (Renal - Superior mesenteric Iliac Femoral)
Venous hum
Rub (Perisplinitis Perihepatitis)
Succession splash
Scratch test

Never forget to examine


Hernia orifices
Femoral pulses
Genetalia
Bowel sounds
Anal canal and rectum

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

CHIASMA

Hepatomegaly

Splenimegaly

Congestive

Right heart failure


Tricuspid regurgitation
Budd-Chiari syndrome

Portal hypertension
Hepatic vein obstruction

Heamatological

Lymphoma
Leukemia

Heamolytic anaemia
Sickle cell disease/thalasseamia
Lymphoma
leukemia

Infection

Viral (hepatitis EBV Cytomegalovirus)


Bacterial (TB liver abscess)
Protozoal (malaria amoebiasis hydatid schistosomiasis)

Acute (HIV EBV Cytomegalovirus infective


endocarditis)
Chronic (malaria schistosomiasis brucella toxoplasmosis - leishmaniasis)

Amyloid

Sarcoidodsis

Storage disorder

Wilson's disease
Haemochromatosis

Gaucher's disease

Masses

Primary
Secondary

Autoimmune

Alcoholic (Fatty liver - cirrhosis)

Rheumatoid arthritis
Felty's syndrome

Massive splenomegaly
1. Myelofibrosis
2. Chronic myeloid leukaemia
3. Malaria
4. Tropical splenomegaly
5. Kala-azar (visceral leishmaniasis)

Differential diagnosis of a renal mass


Hydronephrosis
Pyonephrosis
Polycystic kidney
Renal tumors (Hypernephroma - Wilms tumor - Big renal cyst)
Clinical sequelae of portal hypertension
Porto-systemic collaterals
Site

Presentation

Lower part of oesophagus and fundus of


stomach

Oesophageal or gastric varices

Haematemesis
Melena
Fresh bleeding per rectum

Anterior abdominal wall

Caput medusa

Venous hum

Lower rectum and anal canal

Anorectal varices

Retroperitoneum
Splenomegaly
Congestion of whole GIT (Anorexia Dyspepsia Indigestion Malabsorption - Abdominal discomfort)
Ascites

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Peripheral stigmata for abdominal


disease
Hand
1. Clubbing
2. Koilonychias 'spoon-shaped nail' (iron-deficiency anemia)
3. Leukonychia 'white nails' (liver disease fungal infection)
4. Liver flap (uncompensated liver disease)
5. Palmer erthema (liver disease)
Eyes
1. Pallor (anemia)
2. Jaundice
Mouth
1. Hepatic foetor
2. Pallor (anemia)
3. Ulcer
4. Pigmentation (peutz-jeghars)
Neck

Supraclavicular L.N.s

Upper trunk
1. Gynecomastia
2. Spider naevi
3. Scratch marks
4. Pulse
Lower limb

Edema

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Jaundice
Hemolytic

Hepatocellular

Obstructive

Cause

Destruction of RBCs

Liver dysfunction

Outflow obstruction

Color

Lemon yellow

Orange yellow

Olive green

Bilirubin

Indirect

Direct& idirect

Direct

Associations

Evidence of hemolysis

Picture of LCF

Pruritus
other evidence of obstruction

Urine

Darken on standing

Dark

Frothy dark

Stools

Dark

Pale

Clay colored

P a g e | 27
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Inguinal hernia
Ask the patient to stand up (or can done in supine position first)
Always examine both inguinal regions

Look at the lump from in front


Is this swelling a hernia?
Anatomical site of a hernia (groin)
Expansile impulse on cough (except if strangulated) ()
Reducible (except if irreducible, obstructed or strangulated) ()
Opaque by transillumination (except in infants)
Which type (femoral or inguinal)?
Exact site (palpate ASIS and pubic tubercle 'inguinal ligament')
above or below?
Is it recurrent? (Scars)
Scrotum and penis

Feel from in front (same items as inspection +)


Examine the scrotum
If you can "get above it"

Feel from the side


Stand at the side of the patient on the same side as the hernia. Place one hand in the small of
the patient's back to support him And your examining hand on the lump with your fingers and
arm roughly parallel to the inguinal ligament

Examine for (Position Temperature Tenderness Shape Size Tension)


Expansile cough impulse ()
Is the swelling reducible? Direction of reduction ()
Internal ring test (direct or indirect?)

Percuss and auscultate the lump


Gut in the sac may be resonant and there may be audible bowel sounds
What is the content?
Intestine (enterocele)

Omentum (omentocele)

Consistency

Soft

Doughy

Gurgling

Occurs during reduction

None

Ease of reduction

First part is more difficult to


reduce than the last

Last part is more difficult to


reduce

Percussion

May be resonant

Dull

Complete by
Feel the other side and Ask the patient to cough
Examine the abdomen
Cardiovascular and respiratory assessment

P a g e | 28
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

The differential diagnosis of a lump in the groin


Inguinal hernia
Femoral hernia
Enlarged lymph glands
Sapheno-varix
Ectopic testis
Femoral aneurysm
Hydrocele of the cord or hydrocele of the canal of
Nuck
Lipoma of the cord
Psoas bursa
Psoas abscess

Contents of spermatic cord


3 arteries
Testicular artery (abdominal aorta)
1.
Artery of vas (inferior vesical)
2.
Cremasteric (inferior epigastric)
3.
3 nerves
Ilioinguinal
1.
Cremasteric
2.
Sympathetic
3.
3 tubes
Vas deferens
1.
Pampiniform plexus of veins
2.
Lymphatic vessels
3.

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Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Ventral hernias
Ask the patient to stand up (or usually done in supine position first)

Look
Is this swelling a hernia?
Anatomical site of a hernia
Expansile impulse on cough (except if strangulated) ()
Reducible (except if irreducible, obstructed or strangulated) ()
Which type (umbilical, paraumbilical or epigastric)?
Is it recurrent? (Scars)

Feel Examine for (Position Temperature Tenderness Shape Size Tension)


Expansile cough impulse ()
Is the swelling reducible? Direction of reduction ()

Percuss and auscultate the lump


Gut in the sac may be resonant and there may be audible bowel sounds
What is the content?
Intestine (enterocele)

Omentum (omentocele)

Consistency

Soft

Doughy

Gurgling

Occurs during reduction

None

Ease of reduction

First part is more difficult to


reduce than the last

Last part is more difficult to


reduce

Percussion

May be resonant

Dull

Complete by
Feel the other hernial sites and Ask the patient to cough
Examine the abdomen
Cardiovascular and respiratory assessment
Complication of hernia
Irreducibility
Obstruction
Manifestations of intestinal obstruction
Locally hernia becomes (Distended Irreducible Soft)
Strangulation
Acute pain
Sudden enlargement of the hernia
Manifestations of intestinal obstruction
Locally hernia becomes (Tense Tender Irreducible - No impulse on cough)
Inflammation
Locally hernia becomes (Tender - Not tense - Overlying skin is red and oedematous)
Hydrocele of a hernia sac
Torsion of omentum
Causes for raised intra-abdominal pressure or weak abdominal wall?
Occupation
Multiplicity of hernias
Divercation of recti
Bulge of lower abdomen on straining

P a g e | 30
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Scrotal swelling
Hydrocele
1. "Enlarged right side of the scrotum"
2. Look to back of the scrotum and penis
3. "No signs of inflammation (scars, sinuses or dilated veins)"
4. "No cough impulse and not reducible (")
5. "I can get above the swelling so it is pure scrotal swelling"
6. Feel the swelling (relation to testis and epidydimis)
7. Transillumination

Varicocele
1. Examine in supine position after standing
2. Inspection normal
3. Feel bag of worms
4. May feel cough impulse or thrill
5. Separate from testis
6. Can get above it
7.

No transillumination

Common scrotal swellings

Classification of testicular tumors


Germ cell tumors
Seminoma
Teratomas
Combined seminoma and teratoma
Interstitial tumors
Leydig cell tumor
Sertoli cell tumor
Lymphoma

Sebaceous cyst
Indirect inguinal hernia
Hydrocele
Epididymal cyst (spermatocele)
Epididymo-orchitis
Testicular torsion
Testicular tumor
Varicocele
Haematocele
Sperm granuloma
TB
Gumma

Empty scrotum
Maldescended testis
Ectopic testis
Retractile testis
Testicular agenesis
Atrophy of testis (after mumps orchitis)
Hermaphroditism (bilateral)

Maldescended testis in inguinal canal

Ectopic testis in inguinal region

Low mobility

Highly mobile

Hard to feel

Easily felt

Disappear with muscle contraction

Bulges more with muscle contraction

In the cord

Medial to the cord

P a g e | 31
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Approach for diagnosis of scrotal swelling


Swelling confined to the scrotum
Testis and epididymis not definable

Testis and epididymis definable

Opaque
Not tender

Tender

Chronic
heamatocele
Gumma
Tumor

Torsion
Sever epididymoorchitis
Acute
haematocele

Translucent

Vaginal
hydrocele

opaque

Cyst of epididymis

Not tender

Tender

Tuberculous
epididymis
Tumor

Acute epididymoorchitis

Swelling not confined to the scrotum


Cough impulse
Reducible
Testis palpable
Opaque

No cough impulse
Not reducible
Testis not palpable
Translucent

Hernia

Infantile hydrocele

P a g e | 32
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Orthopaedics examination
Standing (gait) ! supine ! prone
General plan for examination of bones and joints of a limb

Look
(inspection)
1. Skin (scar - sinus)
2. Subcutaneous
(swelling)
3. Muscle (wasting spasm)

Feel
(palpation)
Temperature
Tenderness
Soft tissue
related

Move

Measure /
special
tests

Active (1st)
Passive
Against resistance
Full range vs. limited
rang
Painful vs. painless

4. Bone (deformity)
Examination of joint above and joint below
Examination of sensory and motor innervations
Examination of peripheral circulation

P a g e | 33
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Investigation
Labs
1.

Rheumatic profile (ESR CRP rheumatoid factor antinuclear antibody Uric Acid)

2.

Inflammatory profile (CBC TLC total and differential ESR - CRP)

3.

Baseline renal and liver function test (if NSAID being considered)

Radiological
1.

X-ray (2 views 2 joints)

2.

CT (better in trauma than MRI)

3.

MRI (better in soft tissue assessment)

X-ray features of osteoarthritis (LOSS)


1.

Loss of joint space

2.

Osteophyte formation

3.

Subchondral sclerosis

4.

Subchondral cysts

Management
Non-surgical option
1.

Lifestyle modification / rest

2.

Physiotherapy

3.

Analgesics

Surgery
1.

Failure of conservative management

2.

After optimization and assessment of the patient general condition and fitness for surgery

3.

In any rheumatoid patient you have to exclude atlanto-axial sublaxation by cervical spine X-ray

P a g e | 34
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Lumbar spine examination


Standing (gait)

High steppage (foot drop)

Half-shut knife

Look
(inspection)
1. Skin (scar - sinus)
2. Subcutaneous
(swelling)
3. Muscle (wasting spasm)

Feel
(palpation
)
(gentle and
rapid)
Temperature
Tenderness
Erector spinae
muscle
Tender segment

4. Bone
(from beck! scoliosis
from side! lumber
lordidsos dorsal kyphosis)

Move

Measure /
special
tests

Active (1st)
Forward
flexion!5cm
from the
ground
Extension!1
0-30
(support the
patient)
Lateral
flexion!30
or touching
knees
Rotation
while sitting
Passive
Against resistance
Full range vs. limited
range
Painful vs. painless

Supine
1. Straight leg raising (crossed straight raising)
2. Sciatic stretch test
3. Neurological examination
a. Sensation (dermatomes)
b. Power (myotomes)
c.

Reflexes (knee!L2,3&4 ankle!S1)

Prone
1. Femoral stretch test
2. Tender segment

P a g e | 35
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Complete examination
1. Examine joint above (dorsal and cervical spine) and joint below (hip joint)
2. Examine peripheral pulsations
3. Examine abdomen
4. Exclude CAUDA EQUINE
a. One question!incontinence
b. Tow examination! tone of sphincter and sensation of saddle area

!
Myotomes
1. Hip flexion!L2
2. Knee extension!L3
3. Ankle dorsiflexion!L4
4. Big toe dorsiflexion!L5
5. Big toe planterflexion!S1
6. Ankle planter flexion!S2

P a g e | 36
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Examination of the Hip joint on:


http://alasmar.info/2016/06/19/hip-joint/
Examination of the knee Joint on:
http://alasmar.info/2016/06/19/knee-joint-examination/
Examination of Peripheral Nerves of upper limb:
http://alasmar.info/2016/06/19/peripheral-nerves-disorders/

All of them follows the same principles

Home page is: www.alasmar.org

P a g e | 37
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

General sheet
Hello Mr. . Sit down please. I am (position)
Well Mr. . I received a letter from your GP telling me that you have .
Tell me more about that.
Personal history Name - Age Occupation
Complaint Pain Swelling Dysfunction - Others
History of present complaint
Analysis (see next Page for analysis details)
Other symptoms Relation to the main complaint (see Page 40 for details)
History of present investigations and treatment
Tell me more about . What about .? Do you have .?
Systematic direct questions
I'm now going to ask you a series of questions about common medical problems.
This to make sure we do not mess anything that may be important.
CVS
Do you have any trouble with your heart, chest pain or palpitation?
Respiratory
Do you have any trouble with your lungs, shortness of breath, coughing or
sputum?
GIT
Do you have problem in digestion, lose weight, difficulty in swallowing, heart
burn, nausea/vomiting, abdominal pain, swelling, change of bowel habits, rectal
bleeding?
Genitourinary
Do you have any problems passing urine, change of color, pain, smell?
Diabetes Mellitus
Female
Do you have problems in menstruation?
Past history
Have you been admitted to any hospital before?
Did you have any operation before?
Do you have children? How many? How old is the youngest? (Female)
Do you take any medication or contraceptive pills (Female)?
Do you have any allergy?
Family history
Do you have any similar problem in your family (children, parents, brothers,
sisters)?
Does anyone of your family have a heart disease, DM, blood pressure, tumor or
any chronic disease?
Social history
Do you smoke? That do you smoke? How much? For how long?
Do you drink? How much/week?
Patient concern
Are you concerned about anything?
Summery
To summarize . (+ve. findings)

P a g e | 38
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Main symptoms analysis


Pain
Site & referral (where is it? Where it goes?)
Onset (sudden or gradual?)
Course (how often does it happen?)
Duration (when did it start?)
Severity (how bad is it?)
Character (Burning, throbbing, stabbing, constricting, tightness, colicky or just a
pain) (what does it feel like?)
Relieving factors (what eases it?)
Exacerbating factors (what brings it?)
Cause like trauma (why do you think you've got it?)

Swelling
Site (where is it?)
Onset (sudden or gradual?)
Course (does it increase or decrease in size with the time?)
Duration (when did it appears?)
Other swellings (do you have other swellings?)
Relation to other symptoms like pain (is it painful?)
Possible Cause (why do you think you've got it?)

Ulcer
Site (where is it?)
Onset (sudden or gradual?)
Course (does it increase or decrease in size with the time?)
Duration (when did it appears?)
Other swellings (do you have other swellings?)
Relation to other symptoms like pain or swellings
Possible Cause(why do you think you've got it?)
Constitutional symptoms (did you become feverish?)

P a g e | 39
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

System specific symptoms


Chronic limb ischemia
Pain
Intermittent claudicating

Rest pain

Site

Site
Distal arterial
disease

Foot

Superficial
femoral artery

calf

Aortoiliac disease

Gluteal region
Thigh
calf

Onset

insidiously

Foot and toes

Onset

Course

Course

Duration

Duration

Severity

Claudication distance

Severity

Patients spend the night


sitting in chair in attempt to
relieve pain

Character

Cramp-like

Character

Continuous aching

Radiation

Radiation

Referral

Referral

Relieving factors

Rest

Relieving factors

Strong analgesics

Exacerbating factors

Exercise

Exacerbating factors

Night
Elevation of the leg
Warmth

Relation to other symptoms

Tissue loss

Cause

Nerve ischemia

Relation to other symptoms


Cause

Muscular ischemia

Tissue changes and loss


Trophic changes (Loss of skin appendages - Loss of subcutaneous fat - Muscle wasting - Bone osteoporotic)
Ulceration or Gangrene
Symptoms of atherosclerosis elsewhere
Brain (TIAs Stroke)
Heart (Angina pectoris MI)
Kidney (Hypertension Haematuria)
Intestine (Postprandial angina)
Possible cause
Predisposing factors of atherosclerosis
Cigarette smoking Hyperlipidaemia Hypertension - Diabetes mellitus Obesity - Physical inactivity - Diet
high in saturated fats Hyperhomocysteinaemia - Raised Lp(a) lipoprotein concentrations - Hypercoagulable
states
Factors suggesting Burger's disease
Male - Between 20-40 years - No risk factors of atherosclerosis - Smoking

P a g e | 40
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Varicose veins
Cosmetic disfigurement
Pain (Discomfort, restless leg - Dull, heavy, bursting with sense of hotness - At end of the day - On prolonged standing Relieved by elevating the limb)
Night cramps
Vermiculation
Symptoms of complication
Haemorrhage Thrombophlebitis Oedema - Skin pigmentation - Atrophie blanche - Varicose eczema
Lipodermatosclerosis - Venous ulceration
Possible cause
Predisposing factors
Primary varicose veins
Female sex - High parity - Marked obesity - Constricting clothes - Estrogen intake e.g.
contraceptive pills - Occupation requiring prolonged standing
Secondary varicose veins
Presence of complication - History of DVT - History of Traumatic or congenital AV fistula - History
of pelvic tumors - Pregnancy

P a g e | 41
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Lymphatic disorders
Lumps (lymphadenopathy)
Pressure symptoms (according to the site of lymphadenopathy)
Neck lymphadenopathy
Dyspnea

Trachea or larynx

Dysphagia

Oesophagus

Hoarseness

Recurrent laryngeal nerve

Horner's syndrome

Sympathetic chain

Fainting attacks

Carotid artery compression

Face oedema

IJV compression

Abdominal lymphadenopathy
Abdominal pain
Jaundice

Nodes in porta hepatis

Leg edema

Compression of iliac veins or IVC by iliac or


para-aortic LN

Renal pain

Ureteric compression

Chest lymphadenopathy
Chest pain
Cough
Dyspnea
Axillary lymphadenopathy
Oedema of the affected limb

Vein compression

Tingling
Numbness

Nerve compression

Ischemia
Gangrene

Artery compression

Swollen limb (lymphoedema)


Pain
Fever
Hectic

abscess formation

Night fever

TB

Pel Ebstien fever

Hodgkin's lymphoma

History suggesting the cause


If localized lymphadenopathy
Ask about the drainage area for (Infection Malignancy)
If generalized lymphadenopathy
TB manifestations (Night sweat - Night fever - Loss of weight - Loss of appetite)
Leukaemia manifestations (Bleeding tendency - Bone aches)
Lymphoma manifestation (Pruritus - metastasis manifestation)
Secondary lymphoedema
Post-traumatic
Injuries as circumferential scars of the limbs
Operations as block dissection of regional lymph nodes
Burns at the site of lymph nodes
Irradiation of regional lymph nodes
Post-inflammatory
Non-specific infection
Recurrent non-specific lymphangitis
Recurrent cellulitis due to evident focus of infection
Interdigital infection
Chronic leg ulcer
Post-erysipelas lymphoedema
Specific infection (Filarial TB)
Neoplastic

P a g e | 42
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

The Mouth and the tongue


Swelling
Ulcer
Pain
Causes of chronic superficial glossitis that predispose malignancy (six Ss)
Syphilis, Smoking, Sharp tooth, Spirits, Spices and Sepsis
Sequelae of malignancy of the tongue
Spread

Infiltration

Infection

Local (posterior 2/3)

Asphyxia

Lymphatic

Lymph nodes enlargement

Lingual artery

Haemorrhage

Lingual nerve

Pain referred to ear

Recurrent laryngeal nerve

Hoarseness of voice

Halitosis
Pain
Necrosis

Ankyloglosia

Aspiration pneumonia

Dysarthria
Dysphagia

cachexia

Salivary glands
Lump
Pain and Relation to food
Sinus or fistula
Dryness of the mouth
Trismus
Symptoms of malignancy
Symptoms suggesting spread
Local: Facial palsy
Lymphatic: Multiple lumps in the neck
Distant
General symptoms associated with cancer: Malaise, Weight loss and Cachexia
The neck
Lump
Ulcer
Pain (In mouth or throat)
Nasal discharge
Change of voice
Dysphagia
History of its possible cause
Constitutional manifestations (suggesting inflammatory disorder)
Toxic manifestations (suggesting TB)
Symptoms of malignancy

P a g e | 43
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Thyroid gland
Neck symptoms
Swelling and cosmetic problem
Site
Onset

Accidentally: When washing or member of family or friend point it


out

Course

Grow slowly or Grows rapidly if malignant

Duration
Other swellings
Relation to other
symptoms like pain

Painless
May be painful
Acute thyroiditis, Subacute thyroiditis, Hashimoto's
disease and Anaplastic carcinoma

Pain
Pressure symptoms: Dyspnea or Dysphagia
Dysfunction

Metabolic (4w's)

Toxic symptoms

Symptoms of hypothyroidism

Weight

Loss of weight

Weather
Wet
Warm

Intolerance to hot weather


Excessive seating
Hands are warm and wet

Weight
Weight gain but Poor appetite
Weather Likes hot weather and dislike cold
weather
Weakness Tiredness
Warm (not) Feels cold

Neurological

Nervousness and Irritability


Insomnia

Difficult to think
Difficult to speak quickly and clearly
Myxedema madness
Hallucinations
Dementia
Myxedema coma

Cardiovascular

Palpitation
Shortness of breath
Tiredness

Breathlessness
Ankle swelling

Gastrointestinal

Change in appetite
Diarrhea

Constipation
Progressive and obdurate

Genital

Reduction in quantity of menses

Menorrhagia

Cause

Sex: Puberty or Pregnancy


Sepsis
Psyche

Middle and old age


More in women than men

Others

Muscular Weakness
Skin Pigmentation

Symptoms of malignancy
Symptoms suggesting spread
Local: Multiple lumps in the neck and Pain in the ear
Distant: Bone (Pain, Swelling or Pathological fractures), Lung (Breathlessness or Chest pain), Brain (Mental
changes or Fits) and Liver (Jaundice)
General symptoms associated with cancer
Malaise, Weight loss or Cachexia

P a g e | 44
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

The breast
Pain
Lump
A painless lump

A painful lump

Carcinoma
Cyst
Fibroadenoma
An area of fibroadenosis

An area of fibroadenosis
Cyst
Periductal mastitis
Abscess
Sometimes carcinoma

Pain and tenderness but no lump


Cyclical breast pain
Non cyclical breast pain
Very rarely carcinoma

Discharge
Red

Blood

Pink

Serum + Blood

Clear pale yellow

Serum

Brown

Breast secretions and debris

Duct ectasia
Cyst

Creamy white or yellow

Pus

Duct ectasia
Lactation

Thin white

Milk

Green

Duct papilloma
Duct carcinoma
Duct ectasia

Black

Change of breast shape and size


e.g. Pregnancy, Carcinoma, Benign hypertrophy and Rare large tumors
Change in nipple and/or areola
Destruction, Depression (retraction or inversion), Discoloration, Displacement, Deviation, Discharge and
Duplication
e.g. Duct ectasia, Carcinoma, Paget's disease and Eczema
Skin manifestations
Dimpling, Puckering, Peau d'orange, Cancer encrust, Discoloration, Nodule and Ulceration
Symptoms suggesting spread
Local: Swelling of the arm
Distant
Bone: Backache and Pathological fracture
Lung: Dyspnoea and Pleuritic pain
Brain: Mental changes and Fits
Liver: Jaundice
General symptoms associated with cancer
Malaise, Weight loss and Cachexia
Factors associated with increased risk of breast cancer
Race
White
Age
Older
Family history
Breast cancer in mother, sister, or daughter (especially bilateral or premenopausal)
Genetics BRCA1 or BRCA2 mutation
Previous medical history
Endometrial cancer
Proliferative forms of fibrocystic disease
Cancer in other breast
Menstrual history
Early menarche (under age 12)
Late menopause (after age 50)
Pregnancy Nulliparous or late first pregnancy

Abdominal wall and hernia


History
Lump
Anatomical site of hernia
Expansile impulse on cough (except if strangulated)
Reducible (except if irreducible, obstructed or strangulated)
Symptoms suggesting complication
Symptoms of intestinal obstruction (Pain Vomiting Distension - Absolute constipation)
Symptoms suggesting sliding hernia
Urinary symptoms (urinary bladder in inguinal hernia)
Dyspepsia (stomach in epigastric hernia)
History of suggesting cause
Congenital (sense birth)
Acquired
Raised intra-abdominal pressure (Chronic cough - Straining at micturation or stools - Heavy work
Obesity - Huge abdominal swelling)
Weak abdominal wall (Obesity Senility Debility Pregnancy - Weak scar - Damage nerve
supply of the muscles)

P a g e | 45
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Scrotum
Swelling
Pain
Hypo-fertility
Empty scrotum
UTI symptoms
The abdomen
History
Abdominal pain
Abdominal swelling
Related to esophagus and mouth
Halitosis Salivation Dysphagia - Heart burn Reflux - Painful swallowing or odynophagia
Related to upper GIT
Dyspepsia or indigestion Eructation Flatulence Hiccups Vomiting - Retching
Related to lower GIT
Bowel habits Constipation Diarrhea Dysentery - Worms in stool
Related to bleeding
Haematemesis - Rectal bleeding - Melena
Hepatobiliary
Jaundice Itching Encephalopathy - Bleeding tendency - Weight loss
Constitutional manifestations
Fever Headache Malaise Sweating - Fatigue
Rectum and anal canal
Swelling
Pain
Discharge
Bleeding
Pruritus
Change bowel habits
Incontinence
Kidney and the urinary tract
Pain
Renal pain - Ureteric colic - Vesical pain - Prostatic pain - Urethral pain - Testicular and epididymal pain
Lower urinary tract symptoms "LUTS"
Irritative (Frequency Noctorna Urgency - Urge incontinence - Nocturnal enuresis)
Obstructive (bladder outlet obstruction) "BOO"
Difficulty to initiate (Hesitancy)
Difficulty to maintain (Weak stream - Interrupted stream - Forked stream)
Difficulty to terminate (Drippling)
Symptoms related to change in urine
In Volume (Polyuria Oliguria Anuria)
In Content (Heamaturia Pyuria Chyluria - Cloudy urine Necroturia Pneumaturia)
Others
Incontinence Discharge Swelling - Sexual difficulties in men Infertility

P a g e | 46
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)

Very Important
It is not the intention of these note to be a complete comprehensive notes for the
clinical examination in General Surgery or for the OSCE part B MRCS examination.
The main intention of these notes is to create a skeleton upon which you can build
up your plans in clinical examination. In addition to that, it can be used for a quick
revision before the exam.
You can NOT go for the exam without keeping these notes by heart.
But also, you can NOT got for the exam with these notes alone.

Please refer to clinical examination textbooks like


Browse's Introduction to the Symptoms & Signs of Surgical Disease, Fifth Edition
by Kevin G. Burnand (Editor), John Black (Editor), Steven A. Corbett (Editor),
Clinical Cases and OSCEs in Surgery (MRCS Study Guides) by Manoj
Ramachandran (Author), Marc A Gladman (Author)
Note that, you have to practice each examination as much as you can on real
patients, a volunteer or even your colleague.
These notes cover 6 out of 18 stations of the MRCS OSCE part B exam.

For more information and feedback:

visit: www.alasmar.org
Facebook Page: https://www.facebook.com/SurgeryResident/

I will appreciate your feedback very much on the previous links


Yours,
Mohamed Alasmar
Thursday, June 23, 2016

P a g e | 47
Mohamed Alasmar MBBCh. MSc. MRCS FRCS (General Surgery)