HISTORY

EXAMINATION
CLINICAL NOTES
IN BRIEF
Part 1
(1) Swellings and ulcers
(2) Salivary glands
(3) Thyroid gland
(4) Hernia
(5) Breast
(6) Varicose veins

1
 Swelling and ulcer sheet
Personal history
Name Occupation
Age Marital status and children
Sex Menstrual history
Residence Special habits of medical importance
Complaint
Painful or painless swelling with or without skin discolouration.
Painful or painless ulcer or ulcerating mass with or without discharge.
Present history
Swelling Pain
Onset, Course, Duration. Onset, Course, Duration.
Relation …..Constitutional manifestations Site and Radiation.
……Trauma Severity and character.
…….Pain Aggravating and Relieving factors.
Possible Cause Other symptoms.
Special characters
Surroundings
Other swellings (order of appearance)
Ulcer Discharge
Onset, Course, Duration. Onset, Course, Duration.
Relation …..Constitutional manifestations Amount, colour, odour.
……Trauma
…….Pain Skin discolouration
Possible Cause Onset, course, duration.
Special characters Sites of distribution.
Surroundings Colour.
Other swellings (order of appearance)
Special history

Previous treatment for the condition Symptoms of the other systems

Past history Family history

Similar condition Hemolytic anemia
DM, HTN, HD, Drug allergy DM
Medical, surgical, irradiation Atherosclerosis
General exam
G. appearance Vital signs Systems exam
Mental state Pulse Head and neck
Face Bl.pr Thorax
Posture Temp Abdomen and back
Body built Resp.rate Upper and lower limbs
Local examination

2
 Position
Patient according to site of the lesion.
Examiner on Rt side of the patient.
Exposure
Should include the lesion and anatomical sites of the draining LNs.
Inspection
Swelling
Number, site, size, shape, surface, skin, special signs, surroundings, other swellings
Ulcer
Number, site, size, shape, edge, margin, floor, LNs, Discharge (amount, colour, odour).
Palpation
Swelling
Tenderness, Temperature, edge, consistency,
Number, site, size, shape, surface, skin, special signs, surroundings, other swellings
Ulcer
Tenderness, temperature, floor, base, Fixity to underlying tissues, draining LNs.
Special signs
Lipoma…Lobulated surface, slippery edge, pseudo-fluctuation.
Sebaceous cyst… all hairy sites except palm and sole, punctum 50%cases, attached to the skin.
Dermoid cyst…lines of dermatomes fusion, fluid thrill, not attached to the skin.
Haemangioma…
Lymphangioma…
Aneurysm…Expansile pulsations along anatomical course of an artery.
Proximal Pressure…decrease in size. Distal pressure…increase in size.
Baker's cyst…
A-V malformation…
Neurofibromatosis…
Malignant swelling…
Ischemic ulcer…trophic changes and weak or absent pulsations.
Painful, deep ulcers usually over pressure points.
Venous ulcer…Lipodermatosclerosis, edema and dilated veins.
Gaiter area, shallow ulcers.
Neuropathic ulcer…change or loss of sensations, weak motor power and loss of reflexes.
Painless, deep ulcers, usually over pressure points.
Sloping edge…healing ulcer, venous ulcer, traumatic ulcer.
Punched out edge…ischemic ulcer, syphilitic ulcer.
Undermined edge…TB ulcer.
Rolled edge…BCC ulcer.
Everted edge…SCC ulcer.
Percussion

Auscultation

3
 Ulcer staging
Stage I Stage II Stage III Stage IV
Non blanchable Loss epidermis or Damage of SC tissue. Damage underlying
erythema dermis tissues.
Melanoma Staging
T N M
T1 < 1 mm N1 One LN M0 No metastasis.
T2 1 – 2 mm N2 2 – 3 LNs M1 Skin or any distant.
T3 2 – 4 mm N3 > 4 LNs
T4 > 4 mm
Clark's classification “Melanoma”
Stage I Stage II Stage III Stage IV Stage V
Only epidermis Papillary dermis Fills papillary dermis Reticular dermis SC tissue
Provisional diagnosis
Anatomical
Pathological
Etiological
Functional
Association
Complication
Fitness for surgery
Staging (Cancer)

4
 Salivary glands sheet
Personal history
Name Occupation
Age Marital status and children
Sex Menstrual history
Residence Special habits of medical importance
Complaint
Painful or painless swelling.
Present history
Swelling Pain
Onset, Course, Duration. Onset, Course, Duration.
Relation …..Constitutional manifestations Site and Radiation.
……Trauma Severity and character.
…….Pain Aggrevating and Relieving factors.
Possible Cause Other symptoms.
Special characters
Surroundings
Other swellings (order of appearance)
Malignancy symptoms
Parotid gland Submandibular gland
Facial N Inability to raise eyebrow lingual N Numbness ant 2/3 tongue.
Inability to close eye Hypoglossal N Deviated tongue same side
Mouth asymmetry
Food accumulation
Saliva drippling.
Metastases Lung liver bone brain Metastases Lung liver bone brain
Special history
Oral symptoms
Relation of the pain and swelling to eating.
Sjogren syndrome …. Dryness eye, dryness mouth and Rheumatoid arthritis.
Previous treatment for the condition Symptoms of the other systems

Past history Family history

Similar condition Salivary gland diseases
DM, HTN, HD, Drug allergy
Medical, surgical, irradiation
General exam
G. appearance Vital signs Systems exam
Mental state Pulse Head and neck
Face Bl.pr Thorax
Posture Temp Abdomen and back
Body built Resp.rate Upper and lower limbs
Local examination
Position

5
Patient sitting with slight neck extension
Examiner during inspection in front of the patient
Examiner during palpation behind back of the patient
Exposure
From above till the level of the nipples
Inspection
Number, site, size, shape, surface, skin, special signs, surroundings, other swellings.
Palpation
Flex the neck anteriorly and to the same side during examination (submandibular gland).
Tenderness, Temperature, edge, consistency,
Number, site, size, shape, surface, skin, special signs, surroundings, other swellings.
Special signs
Oral cavity examination must be done (Duct orifice).
Bimanual examination….Solitary swelling filling floor of the mouth can't be rolled.
Parotid swelling …. Raise lobule of the ear.
Skin attachment …. Pinching skin, sliding skin, moving swelling under skin.
Facial N …. Raise eyebrow, close eyelid, absent nasolabial fold, blowing and showing teeth.
Hypoglossal N ….ask patient to protrude tongue and notice direction.
Superfacial temporal artery pulsations.
Facial artery pulsations.
Attachment to Sternomastoid ms …. turn face to opposite side against resistance & move swelling.
Attachment to Masseter ms …. Ask patient to clinch teeth & move swelling.
Attachment to ms of the mouth floor …. Ask patient to elevate tongue & move swelling.
Tenderness and swelling in bone of the mandibule.
Percussion
Over mandibule …. Tenderness in Cancer infiltration.
Auscultation

Staging “ Cancer Salivary glands”

T N M
T1 > 2 cm N1 Single LN M0 No distant metastasis
T2 2 – 4 cm N2 LNs < 6 cm M1 Distant metastasis
T3 < 4 cm N3 LNs > 6 cm
T4 Fixed
Provisional diagnosis
Anatomical
Pathological
Etiological
Functional
Association
Complication
Fitness for surgery
Staging (Cancer)

6
 Thyroid sheet
Personal history
Name Occupation
Age Marital status and children
Sex Menstrual history
Residence Special habits of medical importance
Complaint
Painful or painless neck swelling Hyperthyroid symptoms
Eye symptoms Hypothyroid symptoms
Present history
Swelling Pain
Onset, Course, Duration. Onset, Course, Duration.
Relation …..Constitutional manifestations Site and Radiation.
……Trauma Severity and character.
…….Pain Aggrevating and Relieving factors.
Possible Cause Other symptoms.
Special characters
Surroundings
Other swellings (order of appearance)
Hyperthyroid symptoms Hypothyroid symptoms
General Weight loss General Weight gain
Good appetite Husky Voice
Hot intolerance Cold intolerance
GIT Diarrhea GIT Constipation
Genital Impotence and menstrual disturb Genital Menstrual disturbance
Eye Exophthalmos Eye Puffiness eyelids
Diplopia Loss outer 1/3 eyebrow
Heart Palpitation
Renal Polyuria
CNS insomnia, nervousness, tremors
Pressure symptoms Malignancy symptoms
Trachea Dyspnea RLN Hoarsness of the voice
Esophagus Dysphagia Vagus.N Ear pain
IJV Facial edema Symp.chain Horner syndrome
CCA Fainting attacks Metastases Lung liver bone brain
Previous treatment for the condition Symptoms of the other systems

Past history Family history

Similar condition Thyroid diseases
DM, HTN, HD, Drug allergy
Medical, surgical, irradiation

7
 General exam
G. appearance Vital signs Systems exam
Mental state Pulse Head and neck
Face Bl.pr Thorax
Posture Temp Abdomen and back
Body built Resp.rate Upper and lower limbs
Eye signs
Eye Eyelid Extraocular ms
Exophthalmos (Naffziger and Frazer) Lid lag (Von Graefe's sign) ↓ Convergence (Mobius sign)
Staring look (stellweg's sign) Lid tremors (Rosenbach's sign) ↓ Wrinkling (Joffery sign)
Rim of sclera (Darlymple sign) Lid pigmentation (Jellinek's sign)
Pericorneal congestion (Topolansky sign)
Local examination
Position
Patient sitting with slight neck extension
Examiner during inspection in the front of patient
Examiner during palpation in the back of patient
Exposure
From above till the level of the nipples
Inspection
Pizzillo method can be done
Number, site, size, shape, surface, skin, special signs, surroundings, other swellings.
Palpation
Crile's method and Lahey's method can be done.
By the fingers of both hands and thumb over the nape and mastoid process
Flex the neck anteriorly and to the same side during examination
Tenderness, Temperature, edge, consistency,
Number, site, size, shape, surface, skin, special signs, surroundings, other swellings.
Special signs
Pulse…rate, rhythm, volume, equality on both sides, equality with heart apex.
Movement of the gland up and down with deglutition but not with movement of the tongue.
Skin attachment …. Pinching skin, sliding skin, moving swelling under skin.
Sternomastoid attachment …. Pinching ms during swallowing.
Tracheal displacement …. Insinuate index finger in the suprasternal notch in both sides.
Fixity to the trachea …. Moving swelling vertically over it.
Kocher's test …. Slight compression on thyroid lobes produces stridor.
Berry's sign …. Absent common carotid pulsations in malignant goiters.
Thrill over upper pole in 1ry toxic goiter.
Pemberton's sign …. Patient elevates both arms for 3 mins result in facial plethora in RSG.
Percussion
Dull in RSG….direct percussion on medial ends of 1st intercostal spaces and manubrium.
Auscultation
Systolic murmur over upper pole in case of toxic goiter.

8
 Provisional diagnosis
Anatomical
Pathological
Etiological
Functional
Association
Complication
Fitness for surgery
Staging (Cancer).

9
 Hernia sheet
Personal history
Name Occupation
Age Marital status and children
Sex Menstrual history
Residence Special habits of medical importance
Complaint
Painful or painless swelling.
Present history
Swelling Pain
Onset, Course, Duration. Onset, Course, Duration.
Relation …..Constitutional manifestations Site and Radiation.
……Trauma Severity and character.
…….Pain Aggrevating and Relieving factors.
Possible Cause Other symptoms.
Special characters
Surroundings
Other swellings (order of appearance)
Special history
Chronic cough, constipation, Straining, Lifting heavy objects, previous operations.
Expansile impulse with cough.
Desire to micturate on pressure on the swelling …. Sliding hernia.
Inflammation, irreducibility, obstruction, strangulation.
Previous treatment for the condition Symptoms of the other systems

Past history Family history

Similar condition Weak mesenchyme (VV, RP, Piles, flat foot)
DM, HTN, HD, Drug allergy
Medical, surgical, irradiation
General exam
G. appearance Vital signs Systems exam
Mental state Pulse Head and neck
Face Bl.pr Thorax
Posture Temp Abdomen and back
Body built Resp.rate Upper and lower limbs
Local examination
Position
Patient standing.
Examiner in front of the patient
Exposure
From nipples till the level of the knees.
Inspection
Ask patient to cough and inspect.
Number, site, size, shape, surface, skin, special signs, surroundings, other swellings.

11
 Palpation
Tenderness, Temperature, edge, consistency, size of the defect and it's layer.
Number, site, size, shape, surface, skin, special signs, surroundings, other swellings.
Special signs
Examine other hernial orifices.
Examine abdomen for organomegaly or ascites.
Incisional hernia….give a full description on the incision (site, direction, length, healing….)
Internal ring test….lying down or standing…reduce hernia...close 1/2 inch above mid-point of
inguinal ligament…ask patient to cough…appear (Direct H)…Not appear (Indirect H).
External ring test…lying down or standing…reduce hernia…close by fold of scrotum on little
finger…ask patient to cough…impulse at the tip (Direct H)…impulse at the side (Indirect H).
Zeiman's test…standing…index finger on internal ring (Indirect H)…middle finger on inguinal
canal (Direct H)…ring finger on femoral canal (Femoral H)…ask patient to cough…feel impulse.
Pubic tubercle test…follow adductor longus tendon…reach pubic tubercle…inguinal H above
and medially…femoral H below and laterally.
Scrotal neck test…hold scrotal neck bilaterally at the same time…determine inguinal H or
inguino-scrotal H (thickening of spermatic cord due to hernial sac…called Silk sign)
Percussion
Dull …. Omental content. Resonant …. Intestinal content.
Auscultation
Intestinal sounds.
Provisional diagnosis
Anatomical
Pathological
Etiological
Functional
Association
Complication
Fitness for surgery
Hernial content

11
 Breast sheet
Personal history
Name Occupation
Age Marital status and children
Sex Menstrual history
Residence Special habits of medical importance
Complaint
Painful or painless swelling. Skin changes.
Nipple discharge. Shape distortion.
Present history
Swelling Pain
Onset, Course, Duration. Onset, Course, Duration.
Relation …..Constitutional manifestations Site and Radiation.
……Trauma Severity and character.
…….Pain Aggrevating and Relieving factors.
Possible Cause Other symptoms.
Special characters
Surroundings
Other swellings (order of appearance)
Discharge Skin changes
Onset, Course, Duration. Nipple…direction, retraction, erosion, pigmentation
Spontaneous or on squeeze. Areola… eczema (Itchy, vesicles, oozing)
From single or multiple openings. Skin proper…dimpling, puckering, nodules, ulceration
Amount, colour and odour. Breast contour…shape distortion.
Special history
Menstrual history…menarche, menstrual cycles, pregnancy, lactation, OCP, HRT, menopause.
Previous treatment for the condition Symptoms of the other systems

Past history Family history

Similar condition Breast diseases (mother and sister).
DM, HTN, HD, Drug allergy Uterine or ovarian cancer.
Medical, surgical, irradiation
General exam
G. appearance Vital signs Systems exam
Mental state Pulse Head and neck
Face Bl.pr Thorax
Posture Temp Abdomen and back
Body built Resp.rate Upper and lower limbs
Local examination
Position
st
Patient sitting 45 during inspection and 1 time palpation.
Patient lying down with pillow under back during 2nd time palpation.
Examiner in front of the patient during inspection.
Examiner in the Rt side during palpation.

12
 Exposure
From above till the level of the umbilicus.
Female nurse should be present.
Inspection
Inspect both sides with comparison.
Breast
Site, size, shape, symmetry
Ask patient to leaning forward…detect degree of protrusion
Ask patient to raise arms upwards…inspect undersurface and detect any abnormality.
Nipple
Direction, retraction, erosion, pigmentation, level, discharge (ask patient to squeeze her breast).
Areola
Eczema (vesicles, oozing), erosion, pigmentation, size.
Skin
Signs of inflammation. Scars and pigmentation
Dilated veins. Peau d'orange
Dimpling, teathering, puckering. Ulceration and nodules
Mass
Number, site, size, shape, surface, skin, special signs, surroundings, other swellings.
Palpation
Palpate both sides starting with normal side by finger tips and palmer surface of the hand.
Breast
Palpate four quadrants, nipple and areola, axillary tail and undersurface.
Search for tenderness, temp change and masses.
Mass
Tenderness, Temperature, edge, consistency,
Number, site, size, shape, surface, skin, special signs, surroundings, other swellings.
LNs
Axillary and supraclavicular LNs on both sides.
Special signs
Inspect and palpate breast, axilla, supraclavicular region and upper limb on both sides starting usually
with normal side and compare. (Don't forget to examine umbilicus).
Palpate edge of the mass by the side of your hand.
Palpate both frontal and undersurface of the mass.
Detect consistency of the mass via fluctuation test in 2 directions with mass fixation or by Paget's test.
Skin attachment… Pinching skin, sliding skin, moving swelling under skin.
Nipple attachment…hold nipple by one hand and move swelling away by the other hand.
Breast tissue…hold breast by one hand and move swelling in both directions by the other hand.
Pectoralis major attachment…ask patient to put her hands relaxed in her waist… and then ask patient to
press (feel pectoral fold)…move the swelling in both directions in both times and detect mobility.
Serratus anterior attachment…ask patient to put her outstretched hands relaxed on your shoulders…
and then ask patient to press...move the swelling in both directions in both times and detect mobility.
External oblique attachment…can't be examined
Mobile with relaxation and contraction…not attached.
Limited with relaxation…attached to the fascia or muscle.
Fixed with contraction…attached to the muscle.

13
Fixed from the start…attached to the bone.
Anterior group axillary LNs…from front of the patient…ask patient to put her arm on your
shoulder…palpate by your fingers and support pectoral fold from outside by your thumb.
Medial group axillary LNs… from front of the patient…ask patient to raise her arm…put your fingers high
up in the axilla…relax patient arm by her side…roll against chest wall.
Apical group axillary LNs… from front of the patient…relax patient arm by her side… put your fingers
high up in the axilla…press by the other hand supraclavicular fossa.
Lateral group axillary LNs…from side of the patient…put your fingers of both hands in the inner aspect of
the upper part of patient's arm and rest your thumbs on deltoid ms.
Posterior group axillary LNs…from behind of the patient…put your fingers in the inner aspect of posterior
axillary fold…support fold from outside by the other hand.
Supraclavicular group LNs… from behind of the patient…ask patient to elevate and push her shoulders
forwards…examine both sides at the same time.
Percussion
Directly over the vertebrae to detect tenderness.
Auscultation

Staging
T N M
T1 > 2 cm N0 No palpable LN M0 No distant metastasis
T2 2 – 5 cm N1 Ipsilateral mobile axillary LN M1 Contralateral superaclav LN
T3 < 5 cm N2 Ipsilateral fixed axillary LN Distant metastasis
T4 Fixed N3 Ipsilateral supraclav or arm edema
Manchester staging
Stage I Stage II Stage III Stage IV
Skin Tethering Peau d'orange Cancer en cuirasse
Tumour Mobile Mobile Fixed to muscle Fixed to chest wall
LN No Axillary LN Supraclav LN Distant metastasis
Provisional diagnosis
Anatomical
Pathological
Etiological
Functional
Association
Complication
Fitness for surgery
Staging (Cancer)

14
 Varicose veins
Personal history
Name Occupation
Age Marital status and children
Sex Menstrual history
Residence Special habits of medical importance
Complaint
Heaviness Disfigurement
Present history
Swelling Pain
Onset, Course, Duration. Onset, Course, Duration.
Relation …..Constitutional manifestations Site and Radiation.
……Trauma Severity and character.
…….Pain Aggrevating and Relieving factors.
Possible Cause Other symptoms.
Special characters
Surroundings
Other swellings (order of appearance)
Ulcer Discharge
Onset, Course, Duration. Onset, Course, Duration.
Relation …..Constitutional manifestations Amount, colour, odour.
……Trauma
…….Pain Skin discolouration
Possible Cause Onset, course, duration.
Special characters Sites of distribution.
Surroundings Colour.
Other swellings (order of appearance)
Special history

Previous treatment for the condition Symptoms of the other systems

Past history Family history

Similar condition
DM, HTN, HD, Drug allergy
Medical, surgical, irradiation
General exam
G. appearance Vital signs Systems exam
Mental state Pulse Head and neck
Face Bl.pr Thorax
Posture Temp Abdomen and back
Body built Resp.rate Upper and lower limbs

15
 Local examination
Position
Standing 1st time and lying flat another time.
In front of the patient.
Exposure
From umbilicus downwards
Inspection
Inspect both sides with comparison “Dilated, elongated, tortuous blue vessels”.
Site “Medial…Long saphenous, Lateral …Short saphenous” unilateral or bilateral.
Site, Shape “spider, tubular, saccular, serpentine”
Surface, skin complications “edema, eczema, pigmentation, ulceration, dermatosclerosis”.
Special signs, surroundings, other swellings.
Palpation
Patient standing
Thrill at saphena varix (S-F junction) on cough.
Fegan’s test: - mark veins while standing.
- Lying down and elevate LL …Detect venous emptying time and palpate defects
In the deep fascia at the sites of blowouts.
Patient lying down
Artery: Dorsalis pedis pulse.
Vein: Thrombophlebitis.
Nerve: Sensation & motor power.
Lymphatic: Draining L.Ns
Muscle: tone & tenderness…Homan’s sign ”Dorsiflexion in ankle…Pain in the calf muscles”.
Skin: ulcers, edema, ……..
Percussion
Schwartz test: “Percuss upper end of the vein…Palpate impulse at lower end”
All valves incompetent in-between.
Chevrier sign: “ percuss lower end of the vein…Palpate impulse at upper end”
Medial impulse…Long saphenous, Lateral impulse…Short saphenous.
Auscultation
A-V shunt … Continuous murmur.
Special signs
(A) To detect Incompetent perforators: (B) To detect deep system competence:
Trendlenberg test Perthe’s test
Multiple Tournique test Modified Perthe’s test
Two finger test
Trendlenberg’s test
Patient lying down, elevate lower limbs and empty veins.
S-F junction compressed by thumb or Tournique (4 cm below and lateral to pubic tubercle).
Patient stand, observe for half minute and then remove compression.
Results Normal Incompetent S-F Incompetent
junction perforators
Before compression Filling slowly below Slowly below Rapid from below
removal upwards upwards
After compression Continues slowly Rapid above
removal below upwards downwards

16
 Multiple tourniquet test
Patient lying down, elevate lower limbs & empty veins.
Apply 3 Tourniquets as follow:
One at the upper 1/3 of the thigh, lower 1/3 & below knee.
Patient stands ….. Segment filled ….. Contains Incompetent perforator.
Two finger test
Patient stands……Two index fingers empty segment by segment from below upwards.
Segment filled before indices removal…. Contains Incompetent perforator.
Perthe’s test
Patient lying down, elevate lower limbs & empty veins.
Apply an elastic band over the whole lower limb till the upper 1/3 of the thigh.
Patient walks for 5 minutes in place.
Feel pain …..Occluded deep system. “Subjective test”
Modified perthe’s test
Apply Tourniquet below Saphenous opening ….Walk for 5 minutes
Varicosities increase …… Occluded deep system “Objective test”
Hoffman’s test
Patient lying down, elevate lower limbs & empty veins.
Apply Tourniquet below knee.
Patient exercises in situ for 5 minutes.
Veins engorged below knee …..2ry vv.
Veins collapsed below knee …..1ry vv.
Milking test
Patient lying down or standing.
Milk & empty a segment of the vein by two indices.
Remove one index and notice direction of vein filling.
Repeat the procedure with removal of the other index.
Detect the direction of blood flow “Veins crossing groin”.
CEAP classification
C = Clinical E = Etiological
C1 Less than 3mm Ep Primary
C2 More than 3mm Es Secondary
C3 Edema
C4 Skin or SC change
C5 Healed ulcer
C6 Active ulcer
P = Pathophysiological A = Anatomical
Pr Reflux As Superfacial
Po Obstruction Ap Perforator
Pr,o Reflux & obstruction AD Deep
Provisional Diagnosis
Anatomical
Pathological
Etiological
Functional
Complication
Association

17
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