Modified by MAW 2009: MRCS Clinical Examination Scheme & Test Interpretetion

MRCS Clinical Examination Scheme & Test Interpretetion Page 1 of 35
Modified by MAW 2009

Swellings (Lumps & Bumps)

History For any swelling examine:
1- Onset (When 1st noticed), Duration (Long/ Short) SKIN & SCT
2- Complaint (Pain / Other lump / Change) MUSCLE
3- Treatment (Previous surgery / Insulin in diabetic ulcer) L.N.
4- Cause (Trauma) VESSELS
Swelling Examination
Introduce yourself
Exposure: till area L.N. drainage
UL → elbow (epitrochlear L.N.) although nonspecific + axillary L.N.
LL → groin (inguinal L.N.) although non-specific + popliteal L.N. for leg
H & N → to (clavicle cervical L.N.)
Trunk & Back → axilla (axillary L.N.)
1- Inspection (4SMS) Be Fluent & very fast in swelling examination even forget points
a- Site
b- Shape
c- Size (in cms)
d- Skin: Scars ‫( في اى جروح او عوليات‬Ask about hidden scars?) – Sinuses – dilated vs – Redness
e- Relation to Muscle: contraction ms → more palpable = superficial to ms
→ less palpable = deep to ms
- Other sweelings (same or L.N.)
f- Special ccc: impulse on cough – thrill – pulsatile
2- Palpation Ask about painful area first (TT ESCR SMSL)
a- Temperature
b- Tenderness
c- Edge (well defined/ Ill defined/ Slippery)
d- Surface (Smooth/ Irregular)
e- Consistency (soft/ firm/ hard/ cystic) - if soft vs cystic do Paget test
f- Relations: Mobility in 2 perpendicular directions
Relation to Skin (not attached/ teethered/ fixed) &
Relation to Muscle: contraction ms → more palpable = superficial to ms
g- Special Tests
Fluctuation (Paget’s test1) & Trans-illumination if suspect cystic (querry soft vs cystic)
Compressibility2 / Reducibility3 Pulsatile4 / Expansile5
Thrill Fixation (with skin & deep structures)
h- L.N. & other swellings (very..very imp.)
3- Percussion (Dull / Resonant)
4- Auscultation (Bruit / Bowel sounds)
I would like to finish my examination by:
1- Examination of draining lymph nodes ‫هام جدا‬
2- Assessing the neurovascular status of the limb/area (feel distal pulse)
1 Paget test: Applying intermittent pressure by the index finger of one hand between two fingers of the other hand
2 Compressiblity: Lump disappears when compressed, then reform spontaneously when compressing hand is removed
3 Reducibility: Lump can be 'pushed' away into a different place, lump will not reform spontaneously and requires an
additional force e.g. gravity, raised intra-abdominal pressure
4 Pulsatile : If a finger is placed on either side of a lump → pushed one direction (lump is near to an artery)
5 Expansile: If a finger is placed on either side of a lump → forced apart with every pulsation
Ulcer Examination
Introduce yourself
Exposure: till area L.N. drainage
1- Inspection (3S FED 2S)
a- Site
b- Shape (circular / oval / irregular / healing)
c- Size (in cms)
d- Skin surrounding
e- Floor (granulation tissue / slough [dead tissue])
f- Edge (sloping / raised / everted / punched out / undermined)
g- Discharge (serous / blood stained / purulent) Depth
h- Surrounding structures (lymph nodes, V→ Varicose, A → Ischemia, Trophic ulcers)
2- Palpation Ask about pain [NOT done (painful)]

a- Tenderness
b- Edema
c- Base hold edges between fingers & move to feel (indurated / attached to deeper structures)
d- Surrounding structures (Other Swelling, A→ Feel the PULSE)
Lipoma
Introduce yourself
Exposure: till area L.N. drainage [Common sites: Back, Shoulder, Thigh, Trunk, Neck, forearm]
1- Inspection (4SMS)
a- Site b- Shape c- Size (in cms) d- Skin: Scars (Ask about hidden scars?)
e- Relation to Muscle: contraction ms → more palpable = superficial to ms (SC lipoma)
→ less palpable = deep to ms (IM or subfascial lipoma)
[- Back→1Serratus ant.& 2Latiss.dorsi - Shoulder→1+2+trapezius –Thigh→adductors & quadriceps]
‫زق الحيطة‬ ‫كوعك لورا‬ ‫ارفع كتفك‬ ‫ضم رجلك‬ ‫افرد رجلك‬
Test all against resistance except serratus ant.
a- Temperature b- Tenderness
c- Edge → Slippery(Slip sign)
d- Surface → Lobulated (usually in SC)
e- Consistency → soft
Relation to Skin → not attached

Dermoid cyst (Cong. Or acquired)

Introduce yourself
Exposure: till area L.N. drainage [C. Sites: Cong.→Ext.&Int.angular, Pre&post-auric.& midline]
Acq. (Implantation) → at site scar
a- Site b- Shape c- Size (in cms) d- Skin: Scars (Ask about hidden scars?) in implantat.
(e.g, angular dermoid → contract occiptofrontalis ‫)ارفع حواجبك‬
c- Edge → well defined d- Surface → smooth
e- Consistency → cystic
Relation to Skin → not attached (cong)/ teethered (implantation)
g- Special Tests Fluctuation (Paget’s test) & Trans-illumination
Sebaceous cyst
Introduce yourself
Exposure: till area L.N. drainage [C. Sites: Hairy area (esp, scalp & scrotum) never in palm or sole]
a- Site b- Shape c- Size (in cms) d- Skin: Scars (Ask about hidden scars?)
c- Edge → well defined d- Surface → smooth
e- Consistency → soft/ firm (thick sebum)
Relation to Skin → attached at punctum (50%)
Ganglion (As above but,…)

e- Consistency → cystic
f- Relations: Mobility in 1 direction only & become limited after ms contraction
Relation to Skin → not attached
Relation to Muscle: contraction ms → less palpable & limited (related to tendon)
g- Special Tests Fluctuation (Paget’s test) & Trans-illumination
h- L.N. & other swellings
General Neck Examination

Examine neck? (usually L.N. or Normal neck)
Introduce yourself
Exposure: to clavicle
Position: Sitting (Push the chair away from wall)
1- Inspection (From Front) look at front & sides 3 positions
Rest
Tongue protrusion → move/ does not move with tongue protrusion.(skip if lat. swelling)
Swallowing ‫( اشرب الواء وال جبلعه اال لوا اقول لك‬skip if lat. swelling)
→ 5S ☺”Swelling at (upper/lower), (front/Lat.), at (parotid region/ant.triangle/ post.triangle) of neck,
….X…cm, … shape, no other sweelings, skin…, not attached to ms, not move with….., not pulsatile”
2- Palpation (From Front → From back)

From Front  TT (temp. & tenderness)
 Tracheal position (from front or from back) → central/ deviated to (Rt/Lt)
From Back
Rest
Tongue protrusion → move/ does not move with tongue protrusion. (skip if lat. swelling)
Swallowingfor midline swellings (skip if lat. swelling)
Up & Down technique (for masses & Cervical L.N.s)
a- Start from the chin, along the lower border of the mandible till the ear
b- Along the anterior border of Sternomastoid → upper border of clavicle (ant.triangle)
c- Along the posterior border of Sternomastoid (post. Triangle)
d- Back of the skull (occipital L.N.s)
→ Swelling (TT- ESCRS)
Unilateral Lumps in the NECK

Multiple Solitary
Anterior Triangle Posterior Triangle
Midline Doesn’t move with swallowing Solid Cystic
Moves with swallowing
L.N.s
Solid Cystic Solid Cystic L.N. 1- Pharyngeal pouch
Thyroglossal 1-L.N. 1-Branchail cyst 2- Cystic hygroma
Thyroid
gland cyst 2-Carotid 2-Collar stud
body tumor abscess
Thyroid Gland
General Examination (Thyroid Status: Hyper or Hypo)
Hand Signs Eye Signs (fix head) Leg Signs
Fine Tremors ‫ورقة‬  Lid Retraction, Staring look & Pretibial myxedema
Sweaty hands infrequent blinking (Stelwag s)
Pulse →  True Exophthalmos 1
Tachycardia(Hyperthyroidism)  Lack of Wrinkling (Joffroy’s)2
 Lid Lag (VonGrave’s)
or Bradycardia(Hypothyroidism)
- Lack convergance (Mobiu’s)3
 Water Hammer Pulse (elbow 90°
 Exophth by (Naffziger’s)
& feel volar forearm)
Examine eyes movements (close one eye)
to exclude ophthalmoplegia
Neck Examination
Introduce yourself
Exposure: till clavicle (remove scarf & googles)
1- Position (Push the chair away from wall)
2- Inspection (From Front) look at front & sides in 3 positions
Rest
Tongue protrusion (skip if butterfly swelling) → does not move with tongue protrusion.
Swallowing ‫ → اشرب الواء وال جبلعه اال لوا اقول لك‬moves with swallowing.
→ 5S ☺”Swelling at the lower part of the front of the neck, ….X…cm, butterfly in shape, no other
sweelings, moves with swallowing, but not with tongue protrusion ”
3- Palpation (From Front 3→ From Back 3) Ask about pain
From Front  TT (temp. & tenderness)
 Tracheal position (from front or from back) → central/ deviated to (Rt/Lt)
From Back
 Thyroid : TT- ESCRS
- Rest: Edge → well defined/ ill, Surface →Diffuse / Nodular, Consistency → firm/ hard,
not attached to skin (pinch skin) or sternomastoid ms (‫وشك الناحية الثانية‬+ feel), Mobility
- Swallowing: moves with swallowing & Lower edge → felt/ not (not= retrosternal extension)
 Cervical Lymph Nodes
Circular gr.: submental, submandibular, pre-auricular, post-auricular, occipital
Midline gr.: pre-laryngeal, pre-tracheal
Longitudinal gr. (along sternomastoid- relax it): upper deep cerv. & lower deep cerv.
Supraclavicular L.N.s (while shrugging shoulder)
 Carotid pulsation (med. to sternomastoid- relax it) → felt & equal/ felt & displaced/ not felt
(for infiltration)
4- Percussion (over upper sternum) → resonant/ dull (for Retrosternal extension)
5- Auscultation (over upper pole thyroid) → No bruit/ Bruit (Bruit in Primary Toxic Goiter)
1- Examination of thyroid status (if not done yet)
Causes of thyroid enlargement (Goitre)

Diffuse Nodular
Toxic Non-Toxic
Solitary Nodule Multi Nodular
Grave’s disease 1- Simple colloid Goiter
2- Thyroiditis
1 Sclera visible all around the iris 2 Looking up without wrinkling of forehead skin 3 Difficulty in conversion
Parotid Gland
Introduce yourself
Exposure: till clavicle (remove scarf & googles)
Position the patient (Push the seat away from the wall)
1- Inspection (From front- Look at front & sides in 2 positions)
Rest
Clench teeth ‫عض علي سنانك‬
→ ☺”Swelling at the parotid region in anterior triangle of the neck (Rt/Lt/Bilat.) elevating the lobule of the ear, more
prominent with cont. masseter ms”
2- Palpation (2 from the back & 3 from front)
From Back
Parotid: TT- ESCRS ‫عض علي سنانك‬
→ ☺”Swelling at the parotid region, not hot, not tender, measure …X…, edge well defined, surface smooth, firm
consistency, not attached to overlying skin or muscle”
 Cervical Lymph Nodes :
Circular gr.: submental, submandibular, pre-auricular, post-auricular, occipital
Midline gr.: pre-laryngeal, pre-tracheal
Longitudinal gr. (along sternomastoid- relax it): upper deep cerv. & lower deep cerv.
Supraclavicular L.N.s (while shrugging shoulder)
From Front
 Facial nerve examination:
Inspection: face symmetry, nasolabial folds, angle mouth → preserved
Muscles:
Occiptofrontalis: raise eyebrows ‫( ارفع حواجبك‬not affected in UMNL)
Orbicularis occuli: close your eyes tightly against resistance ‫اقفل عينك جاهد‬
Orbicularis oris: whistle ‫صفر‬
Buccinator: blow out your cheeks ‫انفخ خدك‬
Depressor angularis: show me your teeth ‫وريني سنانك‬
→ facial muscles symmetrical & intact
 Superficial temporal artery: feel infront tragus by 3 fingers longitudinally → felt
 Parotid duct: open mouth & inspect opposite upper 2nd molar
→ no inflammation, no discharge (Donot palpate duct bec. stones rare, Pain, difficult &)

1- ENT examination
2- examination scalp (if L.N.)
3- examination teeth & tongue (if L.N.)
Breast Examination
Introduce yourself
Exposure: to umbilicus (not infront other pt. & ask for chaperon)
1- Inspection (45o → RAISING ARM → ELEVATE BREAST→ HAND ON WAIST)
45o Foot of bed  Symmetry → Br. symm.& Nipples same level  contour → regular/irregular
OR Side  4 Quadrants → Mass/ No
Nipple → retraction/ erosion/ discharge & areola→ fissure
Skin: scar (ask), stage IV signs (peau d’orange 1, ulcer 2, red, dimples)
RAISING ARM  Axillary tail & Arm for mass Teethering of skin
ELEVATE BREAST Back of breast → Mass/ No Teethering of skin
HAND ON WAIST  4 Quadrants → Mass/ No Teethering of skin
→ Describe Mass: 5S
3- Palpation (45o→ HAND ON WAIST) Ask about ds breast & Start by NORMAL breast
1- Superficial palpation: for mass (using pulp of middle 3 fingers) & If do not find ask pt.
 4 quadrants  Areola
 Axillary tail  Back of breast (inframammary area)
→ Mass 3S TT ESCRS
- Site, Shape, Size - Temperature, Tenderness
- Edge → well/ ill defined, - Surface → smooth/ irregular,
- Consistency → firm/ hard, - Mobility in 2 planes → mobile/ fixed
- Relation to Skin (pinch) → teethered (1 point)/ fixed (all mass)/ not
- Relation to pectoralis ms 3 (Hand on waist) → fixed/ not
2- Axillary & Supra-clavicular L.N.s (support by ipsilateral hand & palate by contralat.
hand by tip of fingers & rolling movement)
1-Anterior group 2- Central group 3- Lateral (humeral) group
4- Apical group (bimanual below clavicle) 5- Posterior group (reverse hands)
6- Supra-clavicular L.N. ( pt. shrug shoulders & examine from behind)
3- Discharge: Ask pt. to express any discharge
3- Percussion of vertebrae → tender/ not (for metastasis)

1- Auscultation of lung base (for malignant lung effusion)
2- Examination of Abdomen (for hepatomegaly or ascites due to liver metastasis)
3- Percussion of back for tender segment (if not done)
1 Ulcer = cancer encurise 2 Peau d’orange = superficial edema
3 Ask the patient to put her hands in her waist, move the mass in 2 perpendicular directions, then ask her To press against
her hips, move the mass in 2 directions (inline & perpendicular to the fibres of the pectoral muscles), if the movement is
limited then the mass is fixed to the muscle.
Peripheral vascular Disease (Ischemia)

History
1- Risk Factors (smoking, DM, HTN, IHD, Hyperlipidaemia)
2- Intermittent Claudication
Site
a- Buttocks (Aorto-iliac)
b- Thigh (Iliac)
c- Calf (Femoral)
Severity: Claudication distance
3- Rest Pain
Site: Forefoot
Severity: Hang the leg out of bed / Type of analgesia
4- Functions Critical Limb Ischemia
Lifestyle – Shopping – Walking aids – Limping 1-Rest Pain > 2 weeks
2-Ulcer or Gangrene
Ischemia LL Examination 3-ABPI < 0.5
Introduce yourself
Exposure: Upto groin & lower abdomen
1- Inspection ‫من تحت لفوق‬
 Color changes in sole (Pallor – Rubor – Cyanosis)
 Trophic changes: - Loss of Hair
- Brittle nails
- Taper toes
- Interdigital fungal inf. (open between toes)
- Ulcer (heel, head metatars, bet.toes, sole) →3S FED SS
- Heel ulcer (elevate leg)
- Gangrene – amutated toe
Venous guttering
Scar of previous operation (leg, groin, abdomen)
 Burger’s test (Lower limb) OR
1- Elevate one LL till pallor (+/-) venous guttering & notice degree (look from side)
If < 30 degrees → critical ischemia
If > 30 degrees → chronic ischemia
2- Hang both LL out of the bed till rubor (+/-) venous refilling (due to accumulation
metabolites) & notice time
2- Palpation Ask about pain
 Temperature from distal to proximal & compare (very imp…) Tenderness)
 Capillary refill time: press on big toe away from nail ( Normal: 2-3 sec)
3- Pulses (one side as examiner ask & compare only femoral)
 Abdominal aorta ( above umbilicus & just Lt to midline) - normally not felt
 Femoral by 3 fingers (midinguinal point bet SP & ASIS in skin crease) (compare)
Popliteal: knee 160 degrees (relax muscles) fix knee by 2 thumbs & feel by rest of
fingers meeting laterally in popliteal fossa (difficult & variable site)- be lat.
Posterior tibial: midway between med. malleolous & tendo-achilis
Dorsalis pedis: lat. to ext. hallucis longus tendon on navicular bone –may be absent
4- Auscultations (over Femoral artery for bruit = stenosis) +/- carotid

1- Performing ABPI.
2- Examination of other pulses
Diabetic Foot
Introduce yourself
Exposure: Upto groin
1- Inspection as Ischemia (Color & Trophic changes, scars, Burger angle) +
 Local amputation.
 Charcot’s joint.
 Signs of PN (Burns – injuries – Ingrowing toe nail).
2- Palpation Ask about pain as Ischemia (TT, capillary refilling).
3- Pulses as Ischemia (Aorta, Femoral, Popliteal, Post. Tibial, dorsalis pedis).
4- Sensation (PN) → stock hypothesia ‫هن جحث لفوق‬
1 Performing ABPI (in DM > 1).
2- Examination of other pulses
3- Neurological examin. & fundus examin.
Ischemia UL
Exposure: Upto groin & lower abdomen
 Color changes in sole (Pallor – Rubor – Cyanosis)
 Trophic changes: - Loss of Hair - Brittle nails - Nicotine stain (edge 2 adj.fingers)
- scar or Ulcer (vasospastic ds) - Gangrene
 Temperature from distal to proximal & compare (very imp…) Tenderness)
 Capillary refill time: press on thumb away from nail ( Normal: 2-3 sec)
 Radial ( Lat. Fl.carpi radialis)
 Ulnar (Lat. Fl.carpi ulnaris)
Brachial (Lat. biceps aponeurosis):
Posterior tibial: midway between med. malleolous & tendo-achilis
Subclavian (behind middle 1/3 clavicle)
4- Special testsAllen’s test 1 & Addison test
5- Auscultations (over carotid Fartery for bruit = stenosis)
1 Allen test: A test for integrity of the radial & ulnar arteries, pt. make a fist then the examiner compresses the patient's
radial and ulnar arteries at the wrist. The patient is then asked to open and close the hand rapidly until the palm appears
white. The examiner then releases either the radial or the ulnar artery and looks for return of pink colour and circulation to
the hand. The test is then repeated releasing the other artery. Colour returns to pink 6 seconds if circulation through that
artery is adequate. Compare radial & ulnar to determine dominant artery of hand
Post-Thrombotic Syndrome (PTS)

Introduce yourself
1- Inspection
Inverted champagne bottle appearance (due to lipodermatosclerosis)
 Ulcer: 3S FED SS → ulcer in gaiter area), …X… cm, edge sloping, floor (healthy / necrotic),…..
 Signs Chr.Venous Insuffeciency around ulcer: Edema, Eczema, Hyperpigmentation,
Lipodermatosclerosis (area of subfascial fibrosis & ischemis), V.V.
 Secondary Varicose Veins (need to be examined while standing later)
 TT
 dema & level
 Ulcer: TEBS (NEVER)

1- Examination of Pulse & ABPI & sensation (exclude ischemic & neuropathic &
mixed ulcer for priority of ttt)
2- Examination for V.V. (while standing)
Varicose Veins Examination (standing)

Introduce yourself
1- Inspection (standing) ‫لف قدامى‬
V.V. & its site (med. Side → LSV (long saph.v.) & lat. Side → SSV(short saph.v.)
Signs CVI (ulcer, pigmentation, eczema (purple), Lipodermatosclerosis1)
Blow-out (fascial defects)
SFJSaphina varix at skin crease) + thrill on cough ‫ كح‬
Scar of previous oper. (leg – groin)
→☺”I can see dilated elongated tortuous veins on the -------aspect of the (leg/thigh) along the distribution of the
(long/short) Saphenous venous system. I can see also (Blow outs /Ulcer/Eczema/ lipodermatosclerosis 1) “

Temp. Tenderness) Edemal & Level
 Fascial defects (at sites of perforators) (Blow-outs) (Fegan test) 2
SFJ: feel thrill with cough → incompetent SFJ
nguinal L.N. (vertical & horizontal groups)
☺” I am palpating the vein to feel the blow outs 2, the SF junction, cough please, I can feel a thrill, now will proceed to...”
3- Percussion (Tapping test)

4- Tests
 Tapping test 3 (percuss vein below by index & receive by index other hand) → +ve
 Tourniquet test 4 see below
 Doppler 5(SF junction – SP junction), examiner or u carry it (not pt.)- locate artery
(midinguinal point below crease)- locate vein just 1 cm below & med. to artery –
squeeze quadriceps (or ask pt. to cough) → hear bidirectional flow → incompetent SFJ

1- Auscultating over V.V. for bruit = AVF.
2- Examination of Abdomen & PR (for 2ry V.V.)
3- Exclude ischemia (examine pulse & ABPI)
1Lipodermatosclerosis= skin changes due to Chronic venous hypertension = sclerosis of skin & subcutaneous fat by
fibrin deposition , tissue death and scarring
2 Blow-out= Fascial defect at site of perforator veins (which communicate between superficial & deep venous systems)
3 Tap test = Percuss the vein with one hand and feel the thrill with the other. Repaet on reverse
4 Tourniquet test = Patient lies down, squeeze his L.L. to evacuate the veins, apply the tourniquet below the SF junction
and make him stand up. Wait 30 secs If the vein doesn’t fill/fills slowly then the defect is from the SF junction,
otherwise the defect is from the perforators. If partially controlled then ↑ = both SFJ & perforators.
5 Doppler = to asses SFJ incompetence→ Carried by examiner or in your pocket (not by pt.) - At site of thrill: Locate
artery (below skin crease) then vein just below &med. (1cm) - Squeeze quadriceps (punch of veins) or ask pt.
to cough - Hear 2nd sound (bidirectional flow)
= to asses SPJ incompetence (rare) - Flex knee (to relax muscles) - Locate artery in midline & vein lies beside
Surgical A-V fistula (spot diagnosis)

Introduce yourself
Exposure: to elbow (area lymph drainage)
1- Inspection
→ ☺”dilated pulsatile vessels in the forearm, with an overlying scar”
2- Palpation Ask about pain ”there is a thrill that can be felt, the distal limb is well perfused”
Feel synthetic material or loop graft (only if examiner asked)
1- Indications : Renal failure (for regular haemodialysis)

2- Site: Upper Limb (start by non-dominant hand & distal first)
3- Types
 Direct: End to side (better) OR Side by side (venous hypertension)
 Bridge graft a- Autologous : Saphenous vein
b- Synthetic: PTFE
 Loop graft
4- Complications
 Nerve injury (especially radial & median)
 Infection (especially in synthetic)
 Thrombosis & Occlusion
 Steal phenomenon: Claudication due to inadequate perfusion
Lymphedema (spot diagnosis)

Introduce yourself
1- Inspection
Lymphedema of LL because:
 In dorsum of foot
 Unhealthy skin & mottled (due to recurrent lymphangitis)
(recurrent lymphangitis → obstructed lymphatics → ↑ lymphedema)
 Preserved ankle crease
 +/- Fungal inf. (between toes)
Edema & level
Inguinal L.N.
Abdominal Examination
Introduce yourself
Exposure: submammary area to bikini line (ideally to midthigh)
General Examination “ I will start by general examination”

1- Hands (Clubbing1 (tangentially)– Koilonychia=spooning nail2 (tangentially)– Pallor –
Palmar erythema3 – Dupuytren contracture4 – Flapping tremors)
2- Eyes – retract both lower eyelids together (Jaundice in sclera– Pallor in conjunctiva)
3- Mouth (Fetor Hepaticus – Cyanosis – Pigmentation of Peutz Jhugar synd.)
4- Chest & Neck (Supra-clavicular L.N.s (abd. malignancy) – Spider naevi5 – Gyaencomastia6)
5- LL (edema)
Local Examination
1- Inspection 3 POSITIONS
Foot of bed  Symmetry
 Contour (scaphoid/ normal/ distended flanks)
 mass
Rt Side (on knees =Tangential) Movement with resp. → moves freely
Epigastric pulsation ‫ → اكحن نفسك‬no
 Visible peristalsis → no
Rt Side (standing)  Subcostal angle
 Skin (Scars, Dilated veins, Redness)
Divarication of recti (‫)هن برأسك‬
Umbilicus: site (N / shifted downwards), shape (N / Everted), H, scars.
Hair distribution: masculine (triangle apex up) or feminine (apex down)
Hernial orifices (expose & cough): intact
2- Palpation On knees & hand at level of elbow

A- Superficial : rest hand on abdomen
& feel by phalanx 4 fingers the 9 quadrants
(for tenderness & superficial masses) 7
B- Deep: rest hand on abdomen

& press by phalanx 4 fingers
9 quadrants & Organs(for deep masses)
 9 Quadrants: Mass 3S TT ESCRSS: mass is felt …cm

below C.M., …X…cm, edge (well defined), surface (smooth/irreg),
consistency (soft/firm/hard) – attachment (mobile in 2 directions)
not attached to skin & ‫(هن برأسك‬intra/extra-abdominal)-
reducible (/not) – pulsatile (/not) – expansile imp. on cough (/not)
 Rt lobe liver: start at RIF (Rt iliac fossa) & upward + ‫ & خد نفس‬feel during inspiration
→ ESC (not felt / felt …cm below C.M.), edge (well defined), surface (smooth/irreg), consistency
(soft/firm/hard) CONFIRM BY PERCUSSION & TIDAL PERCUSSION
 Lt lobe liver: start in midline above umbilicus & upward + ‫ & خد نفس‬feel during inspiration
→ ESC (not felt / felt …cm below C.M.), edge (well defined), surface (smooth/irreg), consistency
(soft/firm/hard) CONFIRM BY PERCUSSION
 Spleen: start at RIF to below umbilicus then toward Lt hypochondrium

If not felt → pt. on lat. position, Lt hand support lower ribs laterally & palpate by Rt hand
If not felt → percussion Traub’s area (Lt thumb on lower rib & ant. to MAL). if dull →
percuss below till RIF CONFIRM BY PERCUSSION & Differentiate from kidney
→ ESC (not felt / felt …cm below C.M.), edge (well defined), surface (smooth/irreg), consistency (soft/hard)
 Kidneys (Bimanual examination): Lt hand on renal angle & Rt hand on lumbar (laterally)
→ ESC …..
3- Percussion
a- Liver (Upper border → Tidal percussion) [OR with palpation] ‫خد نفس و اكحوه‬
b- Spleen [OR with palpation]
c- Ascites (Shifting dullness) just above umbilicus downwards then from midline laterally
→ If not dull→ no ascites
If dull → lat. position, wait 30 secs & percuss again,
→ If change note → +ve shifting dullness = ascites,
→ If still dull → -ve shifting dullness = fixed dullness
d- Bladder
4- Auscultation
LIF → Bowel sounds
 over Liver → Bruit (HCC or alcoholic hepatitis) or Venous hum (P.H.)
 over Epigastrium → Bruit (AAA)

1- Auscultation of abdomen
2- Examination of genitalia & PR (DRE) (+PV in females) & back
1 Clubbing = Obliteration of angle between nail & nail bed – chr. disease
2 Koilonychia = Spooning of nails in iron deficiency anaemia
3 Palmar erythems (sign of liver decompensation) in hypothenar, thenar, head of metacarpals & tip fingers
4 Dupuytren contracture = nodular or cord like fibrosis of palmar fascia of ring +/- little finger in (alcohol, CLD, DM, drug, manual
workers) – D.D. ulnar claw hand
5 Spider naevi is sign CLD- central arteriole with radiating branches – in H& N (area drainage SVC)- > 5 is pathological
6 Gynecomastia is sign CLD- other causes: structural- drugs (cimitidine-spironolactone)- hormonal ttt – tumors secr hs
7 Midclavicular plane: Between mid clavicular point & mid point of inguinal ligament
Transpyloric plane: (L1) midway between suprasternal notch & symphysis pubis
Intertubercular plane: (L4) between the highest points of iliac crest
Subcostal plane: (L3) lowermost limit of costal margin
Scrotal & Inguinoscrotal swellings (Standing)

Groin Hernia (Inguinal / Femoral) Answer 3 questions
Introduce yourself - Can I get above it?

Exposure: upto groin - Is it separate from the testis?
1- Inspection (from the Front - Patient Standing) - Does it transilluminate?
a- Swelling 5S →☺”I can see a (Rt./Lt./Bilateral) groin/ Inguinoscrotal swelling,
OR fullness at (Rt./Lt./Bilateral) scrotal neck”
b- Cough ‫ → كح‬expansile impulse on cough (becomes more prominent)
c- Scrotum & back scrotum → 2 full compartments, symmetrical, with median
raphe. No dilated veins, no scars (ask) or sinuses)
d- Penis → No Hypospadius, Episapdius, Meatal stenosis
2- Palpation Ask about pain 2T
 from the Front - Patient Standing
a- 2 testes: Size (average size/small), Consistency (N/soft).
b- Scrotal Neck test & cord ‫ → كح‬I cannot get above swelling → inguinoscrotal
→ Swelling above my hands → inguinal
+ expansile impulse on cough
 From the Side -Patient Standing (for Hernia)
a- Hand on swelling (if groin swelling only) ‫ → كح‬expansile impulse on cough
b- Other side: hand on groin ‫ → كح‬NO expansile impulse on cough = no hernia
3- Special testStanding (for time) OR Supine (better)
a- Relation to P.T. (better supine): above& med.PT= Inguinal/ below& lat.PT=
femoral
b- Reducibility (ask pt. if reducible). If reducible → try reduce standing.
If fail → try reduce supine.
If fail → ask pt. reduce it
c- Internal ring test (better supine): Pubic tubercle - ASIS → mid-point ing.canal
(int.ring). close by 2 fingers. If controlled → Indirect / If not controlled→ Direct
Auscultation (if suspect strangulation)

1- Examination other side
2- Examine Abd. & Ask about ppf: Chest problems: chr.bronchitis.
Bowel problems: constipation.
Urinary problems: BPH.
Occupation: wt lefting.
Varicocele
Introduce yourself
Exposure: upto groin
1- Inspection (from the Front - Patient Standing)
a- Swelling 5S →☺”I can see a (Rt./Lt./Bilateral) Inguinoscrotal swelling/fullness”
b- Cough ‫ → كح‬expansile impulse on cough
c- Scrotum & back scrotum → 2 full compartments, Asymmetrical, with median
raphe. multiple dilated veins on Lt scrotum, no scars (ask) or sinuses.)

a- 2 testes: Size (average sie/small), Consistency (N/soft).
b- Scrotal Neck test & cord ‫ → كح‬I cannot get above swelling → inguinoscrotal &
sensation bag warms & cough → thrill
a- Both sides : hand on groin ‫ → كح‬NO expansile impulse on cough = intact hernial
orifices
3- Special testSupine
Elevate scrotum (to evacuate veins). If ↓ →1ry varicocele
1- Examination other side
Scrotal Swelling (Hydrocele, Spermatocele, Encysted H cord)

Introduce yourself
Exposure: upto groin
1- Inspection (from the Front - Patient Standing)
a- Swelling 5S →☺”I can see a (Rt./Lt./Bilateral) scrotal swelling”
b- Cough ‫ →”☺→ كح‬NO expansile impulse on cough
c- Scrotum & back scrotum (2 full compartments, symmetrical, with median raphe, no
scars(ask) or sinuses.)
a- 2 testes: Size (average sie/small), Consistency (N/soft).
b- Scrotal Neck test → I can get above swelling → purely scrotal
c- relation to testis: can be separated from testis → encysted H - Spermatocele
/ cannot be separated from testis → vaginal hydrocele
c- Both sides : hand on groin ‫ → كح‬NO expansile impulse on cough = intact hernial
orifices
3- Special testStanding
a-Bipolar fluctuation: +ve → cystic swelling
b- Transillumination test (torsh laterally & light off or opaque tube by examiner) →
if +ve → hydrocele
if –ve → may be complicated hydrocele (common) or solid swell. (rare in exam)
Contents of Spermatic Cord

3 Arteries 3 Nerves 3 Tubes
Testicular artery (Aorta) Ilioinguinal nerve Vas deferens
Artery to vas (Inferior Vesical a.) (infront cord) Pampiniform plexus of vs
Cremasteric artery (Inf. Epigasteric a.) Cremasteric nerve Lymphatic vessels
(branch genitofemoral n.)
Sympathetic fibers
General Orthopedic Examination Scheme

Introduce yourself
Exposure: to joint above
Standing
1- Look From back, From side, From Front
 Skin → Scars, sinuses  SCT → swelling  
Muscles → Wasting or Spasm
 Bones → Deformity
2- Walk (Gait) ‫اهشي لحد الباب وارجع‬
ormal (most propably)
Abnormal (Antalgic ‫ بيعرج‬, Trendlenberg‫ بيرقص‬, Half Shut knife)
3- Feel For tenderness
 Bony landmarks
 Soft tissue
4- Move
 Range → full ….-….) / limited (….-….)
Pain → painful/ painless
5- Special Tests
6- Measure
Supine
1- Look 
 Soft tissue
3- Move
4- Special Tests
5- Measure
Prone ‫مفيش وقت‬
1- Look 
 Soft tissue
3- Move
3- Examination of joint above & joint below.
4- Examination of neurovascular status of both LLs.
5- Ask for X-ray (Bilat. & 2 views).
Investigations
Lab: ESR, CRP, ASOT, Rheumatoid profile, HLA-B27 (for ankylosing spondyolitis)
X-ray: plain X-ray bilat. & 2 views at least
CT: If suspect fracture (better 3D CT)
MRI: If suspect pathology
TTT
Conservative ttt: bed rest, analgesic (NSAIDs), lifestyle modification (wt.loss), physioth.
Surgery: if failed conservative ttt inform of ……..
-after general assessment for fitness to surgery
N.B. urgent surgery may be needed (e.g, in dislocations, foot drop, cauda equine lesion)
Lumbar Spine Examination

Introduce yourself
Exposure: naked except underware
Standing
1- Look
From back
 Skin → Scars, sinuses  SCT → swelling  
Muscles → Erectoe spinae spasm - LLs muscles (check later by measurement)
 Bones → - Leveling of iliac crest → Leveled/ Pelvic tilt toward (Rt/Lt)
- Soliosis toward (Rt/Lt) (keep n. away from n.root)
From side
 Bones: → Lumbar lordosis → N/ flattened, N Dorsal Kyphosis
ormal (most propably)
ORHalf-shut knife
ORHigh steppage (foot drop) (rare & emergency)
8- Feel
 Erector spinae spasm
 Spine segment tenderness at level of …… (iliac crests = L4)
 Iliac crests, PSIS, Lumbo-sacral junction
9- Move
 Forward flexion → range & Pain (N= 5cm from floor or touch toes)
Extension → range & Pain (N= 10-30 degrees)
 Lateral flexion → range & Pain (N=30 degrees or touching knee)
Rotation (while sitting to fix pelvis) → range & Pain (N= 45 degrees) (Th.V.)
Supine
5- Tests
1- Straight Leg Raising test (SLR)1 4 Parts ‫الوجع فين‬
→ passive SLR → +ve & limited at …. Degrees / –ve (N= 80°, <60° → Positive)
→ 10 degree below and Sciatic stretch test 2→ +ve or –ve
→ Hip internal & external rotation 3 (at 90-90 position) → range & pain
→ Sacroiliac joint strain (FABER test = Flex. + Abduction + Ext.Rot.)
(figure of 4 position, hand on knee & hand on iliac crest) → +ve / -ve
1 SLR: Elevate leg to 90 o & If pain < 80o ask about site (below knee → +ve & Above knee → -ve)
2 Sciatic stretch test: After SLR, 10° below to relieve pain + dorsiflexion of the foot → pain & Patient flexes
his extended knee to relieve the pain
3 Hip rotation: hip 90 o - knee 90o, hand on knee & other moves leg (inside → ext. rot.) (outside → int.rot.)
2- Rapid Neurological examination

Sensation (Dermatomes) close eyes, compare both sides & ask
L1 = below skin crease
L2 = upper thigh
L3 = lower thigh
L4 = inner side of leg
L5 = outer side of leg →1st dorsal web (autonomus area of L5)
S1 = plantar foot
→ there is hypothesia on segment… (Rt /Lt) side or both equal
Power (Myotomes) against resistance & compare both sides
L2 = hip flexion
L3 = knee extension
L4 = ankle dorsiflexion
L5 = big toe dorsiflexion
S1 = ankle plantar flexion
→ there is weakness on segment… (Rt/Lt) side or both good power
 Reflexes preserved or lost & compare both sides

→ Knee reflex (L2,3,4) look at quadriceps → preserved or lost
→ Ankle reflex (S1) look at calf ms → preserved or lost

Femoral stretch test (L2,3,4 root) flex knee & extend hip
→ pain infront thigh = +ve =high disc prolapse

1- Examination of joint above (dorsal & cervical spine) & joint below (hip).
2- Examination of peripheral pulsation (to exclude vascular claudication).
3- ask for X-ray.
4- Examination of abdomen (to exclude abdominal causes of back pain).
5- Exclude CAUDA EQUINA by:
ONE question → sphincter function (retention early & incontinence later)
TWO tests → sphincter tone (S2)
→ saddle area sensation (S2,3,4)
Hip Joint Examination

Introduce yourself
Exposure: naked except underware
Standing
1- Look
From back
 Skin → Scars, sinuses  SCT → swelling  
Muscles → Gluteal ms wasting (lost buttock crease)
 Bones → - Leveling of iliac crest → Leveled/ Pelvic tilt toward (Rt/Lt)
- Soliosis toward (Rt/Lt) (Compensatory & opposite to pelvic tilt)
(Scoliosis with pelvic tilt is compensatory to adduction deformity)
From side
 Skin → Scars, sinuses  SCT → swelling
 Bones→ Lumbar lordosis →N/ Exaggerated (compensatory to FFD), dorsal kyphosis.
From front
 Skin → Scars, sinuses  SCT → swelling
 Trendlenberg test
2- Tests
Trendelenburg test (S.S.S)1 → -ve/ +ve = abductor deformity .....‫اقف علي رجلك ال‬
3- Walk (Gait) ‫ اهشي لحد الباب وارجع‬according to Trendlenberg test
If Trendlenberg test +ve → Trendlenberg gait
If Trendlenberg test -ve → Antalgic gait
4- Feel (Standing or Supine)
Hip joint (skin crease) → pain= arthritis
 Greater trochanter → pain= trochanteric bursitis
Supine
Look Confirm Feel (if not done standing)
5- Move active then passive (fix pelvis)
 Thomas test 2 → +ve = fixed flexion deformity or –ve
Flexion → range & Pain (N= 0-140 o)
 Extension (I will test later in prone) → range & Pain (N= 0-10 o) (skip if FFD)
Abduction (fix pelvis by hand & elbow) → range & Pain (N= 0-45 o)
 Adduction (fix pelvis by hand & elbow) → range & Pain (N= 0-30 o)
Internal rotation (hip 90°& knee 90°- fix knee-leg out) → range & Pain (N= 0-40 o)
 External rotation (hip 90° & knee 90° -fix knee -leg in) → range & Pain (N= 0-40o)
1 Trendlenberg test: Standing on one leg tests the abductors of supporting leg (gluteus medius & minimus) which pull on
the pelvis → other side to rise (Normal is negative test) [SSS= sound site sag]
2 Tomas test: left hand behind back (to feel flattening of hyperlordosis) flex hip to abdomen & notice flexion of other hip (>10 o → +ve)
6- Measure (square the patient with pelvis 90 degrees to long body axis)
Apparent length (from Xiphisternum to Med. maleollus)→ No/ shortening on (Rt/Lt) side of
…. cm → If no true shortening = adduction deformity
True Length (from ASIS to Medial maleollus)→ No/ shortening on (Rt/Lt) side of … cm
= shortening of femur or tibia
(if true shortening) Do rough test (Knee 90o& look from side)→ femoral or tibial
(if femoral shortening) measure Supratrochanteric length (from greater trochanter to point
same line opposite ASIS) → supra-trochanteric or infra-trochanteric

1- Examination of joint above (lumbar spine) & joint below (knee).
2- Examination of neurovascular state of both LLs.
3- Ask for X-ray
Knee Joint Examination

Introduce yourself
Exposure: Both Knees / Examine both knees (mirror image)
Standing
1- Look
From front
 Skin → Scars, sinuses  SCT → swelling 
Muscles → Quadriceps muscle wasting
 Bones → Genu Varus , Genu valgum
From side
 Skin → Scars, sinuses  SCT → swelling
 Bones → Genu recurvatum , Flexion deformity
From back (popliteal fossa)
 Skin → Scars, sinuses  SCT → swelling (+/-) pulsatile
Normal
ORAntalgic
Supine
3- Feel
Tenderness (Bony Land Marks & soft tissue):
→ quadriceps ms, quadriceps tendon, patella (patellar grinding test in 2 directions),
patellar tendon, tibial tuberosity
→ med. femoral condyle, med.tibial condyle, lat. femoral condyle, lat. Tibial condyle.
→ med. collateral lig., lat. Collateral lig. → head of fibula
Effusion: Start by Patellar tap test (moderate effusion)

if patellar tap –ve → Fluid shift test [Stroke test] (small effusion )
if patellar tap +ve → Fluctuation test (large effusion) 
4- Move
Extension (Active then Passive) → range & Pain (N= 0o)
Flexion (Active then Passive) → range & Pain (N= 0-135 o) (buttocks to heels 1.5 cm)
5- Measure Quadriceps Circumference (15 cm above patella) → equal/ wasting on (Rt/Lt) side
6- Tests
Knee stability tests
ActiveStraight Leg Raising test (SLR) → +ve = weak extensor apparatus/ –ve
Medial & Lateral Collateral ligaments (at 20°)
 Stress valgus1 Knee 0°: support leg medial and push on lateral knee medially.
Stress valgus1 Knee 20°:
→ no opening joint= -ve = intact
→ opening joint= +ve → confirm by other side (if bilat.=laxity, unilat.=torn)
 Stress varus: Knee 0°: support leg lateral and push on medial knee laterally.
Stress varus Knee 20°:
→ no opening joint= -ve = intact
→ opening joint= +ve → confirm by other side (if bilat.=laxity, unilat.=torn)
Anterior & Posterior Cruciate ligaments (at 90° + sit on pt. toes)
 posterior sag test: -ve/ +ve → PCL injury at sagged side (Rt/Lt)
 Posterior drawer test: push tibia (for PCL)
 Anterior drawer test: pull tibia (for ACL)
 Lachman test Pivot shift (Painful- only idea)
Mac Murray test 2 (for medial & lateral menisci) not sure test
 Med. meniscus: maximum flex→ ext. rot with extension → click or pain = +ve
 Lat. meniscus: maximum flex→ int.rot. with extension → click or pain = +ve

Back of knee (popliteal fossa) 1- Flexed → Popliteal region
2- Extended → Palpate for bursa

1- Examination of joint above (hip) & joint below (ankle).
2- Examination of neurovascular state of both LLs.
3- Ask for X-ray
4- Examin back of knee (popliteal fossa) 1- Flexed → Popliteal region
2- Extended → Palpate for bursa
1Grasp knee with one hand (heels on lateral side of the knee), grasp lower tibia with the other hand, push the tibia laterally
2Leg is flexed, loosen hamstring by rotatory mvt, Foot internally/externally rotated, and Hip is adducted, clicks or
pain are felt while leg is smoothly extended. If +ve compare because bilat.= lax & unilat.= inj. meniscus
Shoulder examination (rare)

Introduce yourself
Exposure: Expose upper half of body &both shoulders & examine from behind pt.
1- Look
 Skin →Scars, sinuses  SCT → swelling 
Muscles → Swelling or Wasting (Deltoid, Supraspinatus, Infraspinatus, Trapezius,
Pectoralis)
Bone → Deformity (Sterno-clav. j., Clavicle, Acromio-clav. j., winging scapula,).
2- Feel Bony land marks & soft tissue (for tenderness)
Sternoclavicular j., clavicle, +/- coracoid, acromioclavicular, acromion, spine of scapula
(if protruding= wasting supra- & infra-spinatus), supraspinatus, infraspinatus, head of humerus,
(coracoid is 1.5 inch below lateral end of clavicle in deltopectoral groove)
3- Move
Forward flexion → range & Pain (N=180°)
Extension → range & Pain (N=60°)
Abduction → range & Pain (N=180°) →
0-15° = supraspinatus,
15-90° = deltoid (gleno-humeral j. mainly)
90-180° = trapezius, Rhomboides & Levator scapulae (scapulo-thoracic j. mainly)
Adduction → (N= blocked by body)
Medial (internal) rotation → range & Pain (N=80°) fix elbow at body & forearm inside
Lateral (external) rotation → range & Pain (N=80°) fix elbow at body & forearm outside
4- Muscle strength
Pectoralis major ☺”Push your hands in your waist.” Trapezius ☺“Raise your shoulders.”
Serratus Anterior ☺“Push against the wall.”
5- Special tests
Painful arc (supraspinatus tendonitis)
Apprehension test (for recurrent shoulder dislocation) -if asked only
Reduction of Dislocated Shoulder (TEAR)
Traction - External rotation - Adduction - Rotation (Internal)
Elbow Examination (very rare)

Introduce yourself
Exposure: Up to shoulder & hand supinated (palms up)
1- Look
 Skin → Scars, sinuses  SCT → swellings (joint or localized olecranon bursa)
 Muscles ( flexors & extensors forearm) → Wasting
 Bone → Deformity Cubitus valgus = exaggerated carrying angle (N= 10-15° valgus)
Cubitus varus = decreased carrying angle
Cubitus recurvatum = hyperextension elbow
3- Feel TT
 Temperature
 Tenderness: over bony prominences & ulnar n.
Olecranon bursitis
Tennis elbow: pain over common extensor origin (lat. Epicondyle) due to extensor use
Golfer’s elbow: pain over common flexor origin (med. Epicondyle) due to flexor use
4- Move
 Flexion→ range & Pain (N= 145 degrees)
Extension → range & Pain (N hyperextension upto 15 degrees)
 pronation & supination (start at mid-prone position)
5- Special tests (elbow stability tests) (elbow extended because no locking unlike knee)
Stress valgus test: elbow extended, support wrist and push on lateral elbow medially
Stress varus test: elbow extended, support wrist and push on medial elbow laterally
If opening in med.side →+ve valgus test, lat. Side → +ve varus test
Hand Examination (Rheumatoid or Nerve inj.)

Introduce yourself
Exposure: Up to elbows & hand supinated
1- Look
 Skin → Scars (esp, palm & wrist), sinuses  SCT → swellings  nodules(imp)
 Muscles → Wasting (Dorsal interossei, Thenar, Hypothenar)
 Bone → Deformity (Ulnar dev. MPJ & compensatory radial dev. wrist 1, MPJ swellings 2,
finger drop, hyper-extended finger, Swan-neck 3, Boutonniere deformity 4, Z-thumb 5,
Mallet finger 6, Piano-key 7)
2- Feel TT
 Temperature
 Tenderness: Joints, knuckles, tendons.
3- Move (wrist, MPJ, PIPJ) Active then Passive (to complete range) 
 Wrist: flexion, extension & circular movement
Fingers movements: - Flexion & Extension (at MPJ) - Abduction & Adduction (acc. to
middle finger axis) (Middle finger has abd. on 2 sides & no add.)
 Thumb movements (hand on table): - Abduction (upward) & Adduction
- Flexion & Extension (at IPJ) & Opposition
Tendon: FDS & FDP
4- Nerve
5- Special tests (tests for carpal tunnel syndrome & nerve injury)
Ulnar n. inj. Median n. inj. Radial n. inj.

Look -Claw hand -Ape hand (thenar wasting) -Wrist drop
-Wasted hypothenar eminence
-Wasted interossie (guttered dorsum of
hand)
Sensory -Loss of sensation of Little finger - Loss of sensation of index finger -Loss of sensation of 1st
Assessment dorsal interosseus space
(autonomus
area of nerve)
-Palmar interossie (card test) 9 -Opponens pollicis 12 Fix proximal joint then
Motor -Dorsal interossie (spread test) 10 -Finger ext. at MPJ →
Assessment -Adductor pollicis (froment test) 11 Lost
-Wrist ext. → Weak or
Lost (acc.to level)
- Finger ext. at PIPJ →
preserved extension by
lumbricals (supplied by
median & ulnar n.)
-Abductor pollicis brevis 13
(hand on table)
+ Phallen test 14 & Tinnel test 15

(in carpal tunnel synd.)
Level of inj - Scar - Scar - Scar

(If asked only) - Ulnar paradox - FDS - Wrist ext.→ weak in post.
- FCU - lat. ½ FDP Interosseus inj. & Lost in main
- med. ½ FDP - Pronator teres & quadratus radial inj.
1 Ulnar deviation of fingers (MPJ) & compensatory radial deviation of Wrist (Zig-Zag mech.) (pathognomonic to rheumatoid hand)
2 MPJ swellings (nodules or subluxation of head metacarpals)
3 Swan-neck: rupture tendon FDS → PIPJ extended & DIPJ flexed by FDP (compens)
4 Boutonniere deformity: rupture central slip of extensor expansion → PIPJ flexed & DIPJ extended by 2 distal slips
5 Z-thumb: rupture Fl.Poll.longus tendon → MPJ flexed & IPJ extended
6 Mallet finger: rupture extensor tendons → DIPJ flexed & cannot be extended except passively (IPJ normal)
7 Trigger finger (Stenosing tenosynovitis): inflamm.nodule prevent active extension of finger PIPJ & DIPJ(cannot be extended except
passively with lag & snap)
8 Piano key sign: subluxation of lower radio-ulnar joint → popup lower ulna
9 Card test: Piece of paper between fingers - PAD
10 Spread test: Prevent pushing of spread fingers - DAP
11 Fromet’s test: Piece of paper between index & thumb & try to catch against resistance → Flex. instead abd, thumb
12 Opponens polices: Oppose patient’s thumb & little finger, ask him to stop you from pulling the fingers apart
13 Abd.poll.br..: Hand on table & Abd. Thumb against resistance
14 Phalen test: flex. Wrist → tingeling & pain
15 Tinnel test: tapping on median n. under flexor retinaculum → tingeling & pain
CLINICAL EXAMINATION FOR MRCS BY DR ADEL
Clinical examination
Systems examination:
CNS …………………………………………………………………………………….CRANIAL NERVE & CEREBELLUM
RESPIRATORY……………………………………………………………………….PE
CVS……………………………………………………………………………………….PREOPVALVULAR LESION AND PACEMAKER
ABDIMINAL……………………………………………………………………………A CUTE ABDOMIN, STOMA, HERNIA
VASCULAR …………………………………………………………………………….UL- LL- VARICOSE VEIN- A-V FISTULA
ORTHOPEDIC …………………………………………………………………………SHOULDER-HAND-SPINE-HIP-KNEE-FOOT
BODY PARTS AND ISOLATED LESION EXAMINATION:
SUPERFICIAL LUMP…………………………………………………………………….LIPOMA-DERMOID- SEBACEOUS CYST
EAR………………………………………………………………………………………………## SKULL BASE & HAEMOTYPANUM
PAROTID ………………………………………………………………………………………..SWELLING
SUBMANDIBULAR…………………………………………………………………………..SWELLING
NECK AND THYROID…………………………………………………………………………ENLARGED THYROID & NODULE
BREAST……………………………………………………………………………………………CANCER MALE & FEMALE
HERNIA…………………………………………………………………………………………INGUINAL, INCISIONAL, PARAUMBILICAL
SCROTUM………………………………………………………………………………………….HYDROCELE, VARICOCELE, HERNIA
NB: ACUTE ABDOMIN (Anastomotic leak- peritonitis) – CHEST PAIN (DVT &PE)>>>>>>>>>>>>>CCRISP PROTOCOL
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Cranial nerve examination

 Scenario 1 >>>> bitemporal hemianopia + headache + VA >> sellar and suprasellar
tumour.
 Scenario 2 >> conductive hearing loss + trauma +/-facial nerve palsy >>> # skull base +
haemotympanum.
 Scenario 3 >>>> headache + memory >>>>>>>>>> ant. Cranial fossa tumour >>>>AMTS.
WATCH GEEKYMEDIC AND PRACTICE THEN MARK YOUR SELF

WIPER
olfactory nerve:
With eyes closed, ask patient to identify various scents – e.g. coffee,vinegar
optic nerve: (5) VA- COLOUR – FIELD- PUPILS - FUNDUS

Visual acuity:
1. Stand the patient at 6 metres from the Snellen chart.
2. If patient normally uses distance glasses, ensure they wear them for the assessment.
3. Ask the patient to cover one eye & read to the lowest line they can manage.
4. Visual acuity is recorded as chart distance (numerator) over number of lowest line read
(denominator).
5. Record the lowest line the patient was able to read (e.g. 6/6 which is equivalent to 20/20)
Colour vision :( not done)

Pupils:
 Direct reflex– shine torch into eye – look for pupillary constriction in that eye
 Consensual reflex – shine torch into eye – look for pupillary constriction in opposite eye
 Swinging light test– move light in from side of each eye rapidly – relative afferent(RAPD)
 Accommodation reflex:
1) Ask patient to focus on a distant point (clock on a wall / light switch).
2) Place your finger/object approximately 15cm in front of the eyes.
3) Ask the patient to switch from looking at the distant object to the nearby finger / object.
4) Observe the pupils, you should see constriction & convergence bilaterally.
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Visual fields ( visual inattention, confrontation):

 Visual inattention (visual neglect): open eyes
 Confrontation: one eye is covered
Fundoscopy:
Assess for red reflex
1. Position yourself at a distance of around 30cm from the patient‟s eyes.
2. Looking through the ophthalmoscope observe for a reddish / orange reflection in the pupil.
N.B: An absent red reflex may indicate the presence of cataract, or in rare
circumstances neuroblastoma.
Move in closer & examine the eye with the fundoscope

- Begin medially & assess the optic disc – colour / contour / cupping
- Assess the retinal vessels – cotton wool spots / AV nipping / neovascularization
- Finally assess the macula – ask to look directly into the light – drusen noted in macular
degeneration.
occulomotor + trochlear+ abducent:( eye movement)

 1. Ask the patient to keep their head still & follow your finger with their eyes.
 2. Move your finger through the various axis of eye movement (“H” shape).
 3. Ask the patient to report any double vision.
 4. Observe for restriction of eye movement
trigeminal nerve:
 Sensory: close your eyes, use a cotton wool
o Ophthalmic : forehead , corneal reflex ( not done)
o Maxillary: cheek bones
o Mandibular: jaw angles
 Motor: muscles of mastication

o Close and open your jaw against resistance
o Clench your teeth and feel temporalis and masseter
 Reflexes: corneal reglex , jaw jerk ( not done)
facial nerve:
*Temporal ( raise your eye brows)
*Zygomatic ( close your eyes against resistance)
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* Buccal ( blow your cheeks)

* Marginal mandibular( show your teeth)
* Cervical ( tense and flare your neck muscles)
* Chorda tympani( is there any taste sensations)
* Stapedius ( hyperacusis)
vestibulochoclear nerve:
*Whisper no. And repeat
 Rinne test:
1. Tap a 512HZ tuning fork & place at the external auditory meatus & ask the patient if they
are able to hear it (air conduction)
2. Now move the tuning fork (whilst still vibrating), placing its base onto the mastoid process
(bone conduction)
3. Ask the patient if the sound is louder in front of the ear (EAM) or behind it (mastoid process)
Normal = Air conduction > Bone conduction (Rinne‟s positive)

Neural deafness = Air conduction > Bone conduction (both air & bone conduction reduced equally)
Conductive deafness = Bone conduction > Air conduction (Rinne‟s negative)
 Weber test:
1. Tap a 512HZ tuning fork & place in the midline of the forehead.
2. Ask the patient where they can hear the sound:
Normal = sound is heard equally in both ears
Neural deafness = sound is heard louder on the side of the intact ear
Conductive deafness = sound is heard louder on the side of the affected ear
glossopharyngeal+ vagus:
*Open your mouth and say AAH ( look for any deviation of uvula and soft palate) to healthy side .
* Ask the patient to cough( asses adduction of both vocal cords by vagus nerve)
* Gag reflex ( not done)……drink water.
spinal accessory:
Trapezius( shrug shoulder against resistance)
Sternomastoid ( turn head against resistance)
hypoglssal nerve:
Protrude your tongue ( deviation towards the affected side)
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questions
 Scenario 1 >>>> bitemporal hemianopia + headache + VA >> sellar and suprasellar
tumour.
Where might the lesion be to cause this symptoms?

A bitemporal hemianopia is suggestive of a lesion affecting the optic chiasm, where the more
medial fibres cross over to the contralateral eye. This may be either a lesion of the optic chiasm
itself or a mass pressing on it (e.g. a pituitary tumour).
If a mass arises from above the chiasm (e.g. pituitary craniopharyngioma), the initial symptoms
may be of a bitemporal inferior quadrantanopia, progressing to a bitemporal hemianopia.
Conversely, masses arising below the chiasm may present at first with bitemporal superior
quadrantanopia.
DDX? Pituitary adenoma- meningioma- rathkes cyst- craniopharyngioma- mets
What else might you expect if a pituitary tumour were the cause of this lady's
bitemporal hemianopi?
General - raised intracranial pressure may cause papilloedema (as seen on fundoscopy) or
headaches, visual field defect.
Specific - hyperpituitarism: this depends on the type of hormone secreted. The most common are
growth hormone and prolactin from pituitary adenomas. The former causes acromegaly and the
latter hyperprolactinaemia.
Signs of acromegaly - prognathism, prominent brow, macroglossia, thickening of the

skin, enlargement of hands and feet, hyperhidrosis, carpal tunnel syndrome.
Signs of hyperprolactinaemia - increased lactation, loss of libido, erectile dysfunction in

males, amenorrhoea and infertility (anovulatory) in females.
What is the Management?

 Invesigations: hormone assays, MRI with gadolinium contrast, CT sella
 Treatment: Antiprolactin (bromocryptine)…..mechanism?? Dopamine agonist
 Surgery (trans-sphenoidal, trans-frontal)
What is the the main complication of transsphenoidal? CSF leak
What is the the main concern after surgery? Long term hormonal replacement therapy
Who should be involved in management??? Ophthalmologist for perimetry- Endocrinologist- ENT for the transnasal
approach.
 Scenario 2 >> conductive hearing loss + trauma +/-facial nerve palsy >>> # skull base +
haemotympanum.
Cause of conductive hearing loss in this patient?
 Hemotypnum secondary to skull base fracture or rupture drum.

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What cranial nerves to examine together?
Vestibulochoclear+ facial (they exit together from IAM)
How to fit otoscope?

1. Pull the pinna upwards & backwards – to straighten the external auditory meatus
2. Position otoscope at the external auditory meatus:
Otoscope should be held in your right hand for the patient’s right ear and vice versa
Hold the otoscope like a pencil and rest your hand against the patient’s cheek for stability 3. Advance the
otoscope under direct vision.
4. Look for any wax, swelling, erythema, discharge or foreign bodies

5. Examine the tympanic membrane.
6. Withdraw the otoscope carefully
Findings:
 -Colour : pearly grey & translucent (normal) / erythematous (inflammation)
 -Erythema or bulging of the membrane? inspect for a fluid level e.g. otitis
media .
 Perforation of the membrane? note the size of the perforation.
 Light reflex present? absence / distortion may indicate ↑ inner ear pressure e.g. otitis
media .
 Scarring of the membrane? tympanosclerosis – can result in significant hearing loss.
Management???? Ct brain , audiogram , ENT review
 Scenario 3 >>>> headache + memory >>>>>>>>>> ant. Cranial fossa tumour >>>>AMTS.
Do AMTS (Abbreviated mental test scoring): PT-TIME- DATE- PLACE- PUBLIC INFO.
*How old are you?
*What time is it to the nearest hour?
*Can you remember this address? 24 West St. I will ask you this at the
end
*What year is it?
*What is the name of this place?
*What is my job? And what is the job of this person (e.g. a nurse)?
Page 6
*What is your date of birth?
*When did WW2 end?
*Who is the current prime minister?
*Can you count backwards from 20-1?
*What was that address I asked you to remember?
N.B: Score less then 6/10 suggests dementia / delerium
What do you want to look for in fundoscopy?
 Papilloedema suggestive of sustained raised intracranial pressure (e.g. caused by a

tumour or hydrocephalus).
 This may be normal in the context of acutely raised intracranial pressure.
 atrophic changes in longstanding chronic inceased ICP.
 Haemorrhage into the vitreous humour (Terson's syndrome) or other intraocular

haemorrhage secondary to a subarachnoid haemorrhage.
Differential diagnosis of anterior cranial fossa tumour?
Meningioma, olfactory neuroblastoma, sinonasal malignancies, astrocytoma, oligodendroglioma.
Management??
 CT scan
 MRI with gadolinium
 Streotactic biopsy
 Involve neuro-oncology MDT
 treatment is by surgical resection +/- proton beam radiotherapy- chemo
NB: History of old trauma may be misleading , dementia and memory problem is the key.
Cerebellar examination (Gait- head- arm-leg)

Gait:
 a broad based gait is noted in cerebellar disease

 Stability – can be staggering and often slow & unsteady – can appear similar to a drunk person
walking
 Tandem („Heel to toe‟) walking – Ask patient to walk in a straight line with their heels to their
toes
 This is a very sensitive test and will exaggerate any unsteadiness.
 Romberg‟s test – ask patient to put their feet together, keep their hands by their side and close
their eyes (be ready to support them in case they are unsteady!)
 This is a test of proprioception – a positive Romberg‟s test indicates that the unsteadiness is due to a
sensory ataxia (damage to dorsal columns of spinal cord) rather than a cerebellar ataxia.
Head:
 Speech ( stacatto): say british constitution.

 Nystagmus : follow my fingers by your eyes.
Arms:
*Pronator drift:
1. Ask patient to close eyes & place arms outstretched forwards with palms facing up
Page 7
2. Observe the hands / arm for signs of pronation / movement
A slow upward drift in one arm is suggestive of a lesion in the ipsilateral cerebellum.
*Rebound phenomenon:
Whilst the patient‟s arms are still outstretched and their eyes are closed:
1. Ask the patient to keep their arms in that position as you press down on their arm.
2. Release your hand.
Positive test = Their arm shoots up above the position it originally was (this is suggestive of
cerebellar disease).
*Tone:
1. Support the patient‟s arm by holding their hand & elbow.
2. Ask the patient to relax and allow you to fully control their arm.
3. Move the arm‟s muscle groups through their full range of movements .
4.Is the motion smooth or is there some resistance?
* reflexes:
Assess the patient‟s upper limb reflexes, comparing left to right.
1. Biceps(C5, C6)
2. Triceps (C7)
3. Supinator (C6)
In cerebellar disease, there is often mild hyporeflexia.
*Co-ordination:
Finger to nose test:
Dysdiadokinesia:
Intention tremors:
Legs:
 tone: leg roll, leg lift

 Reflexes: ( knee, ankle)
 Co-ordination ( heel to shin)
To complete my examination, I would do: full neurological examination including:
 Cranial nerves
 Upper and lower limbs
questions
Patient has (DANISH): dysdiadokinesia, ataxic gait, nystagmus, intention tremors, stacatto speech,
hypotonia.
What is the DDX? Main diagnosis will be cerebellar ataxia due to posterior fossa tumour,
 Congenital: Hypoplsia
 Traumatic: hematoma
 Infection: cerebellar abscess
 Vascular: TIA, infarction , AVM
 Neoplastic: tumour – mets
 Demylinating: MS
Page 8
Mention names of post. Fossa tumours ? astrocytoma, medulloblastoma, ependymoma,
Choroid plexus papilloma and carcinoma, brain stem glioma, hemangioblastoma, mets
Management???
investigations: TTT?? EXCISION IF POSSIBLE
* MRI brain ( enhanced) with gadolinium, CT not accurate due to artifact

* CT ( whole body) : to detect any primary cancer
* Stereotactic guided biopsy
Respiratory examination
Scenario 1………………………………………………………preop clinic >>COPD
Scenario 2…………………………………………………chest pain POD 7 >>DVT &PE
Inspection+ palpation:
 general: o2 , medications, SOB, ask to take a deep breath and cough

 Hand: tar satining, clubbing, radial pulse, repsp. Rate
 Mouth: central cyanosis
 Lymph nodes: cervical
 Trachea: central or not
 Chest:
*Scars for thoracotomy: can you put your hand on your hips and bend your elbows forward.
*Chest expansion
Percussion: 1st : supraclavicular
2nd: medial 1/3 of the clavicle
Auscultation:
Ask patient to take deep breaths in and out through their mouth.
* Assess quality – Vesicular (normal) / Bronchial (harsh sounding) – consolidation

* Assess volume – quiet breath sounds suggest reduced air entry – consolidation / collapse /
* Added sounds:
Wheeze – asthma / COPD
Coarse crackles – pneumonia / fluid
Fine crackles – pulmonary fibrosis
*Vocal resonance: Ask patient to say “99” repeatedly & auscultate the chest again.
Increased volume over an area suggests increased tissue density – consolidation/fluid/tumour
DONOT FORGET REPEATING EXAMINATION FROM THE BACK
Scenario 1………………………………………………………preop clinic >>COPD
questions
What is your differential diagnosis? Main diagnosis is COPD in a smoker of this age; however asthma is
also a possibility.
Who would you inform about this?
I would inform an anaesthetist, ideally the consultant who will be doing the case, otherwise the coordinating
anaesthetic consultant and the operating surgeon.
Page 9
What further investigations would you arrange?
 A chest X-ray to rule out a preop pneumonia or underlying malignancy

 Spirometry and respiratory function tests
 A baseline ABG to identify preoperative paO2 and PaCO2
How could you try to reduce the risks in a patient with COPD about to undergo an operation?
1. I would ask the GP to optimise medication before the operation and refer to a respiratory medic.
2. Any infection should be treated before the operation.
3. The patient should be encouraged to stop smoking
4. I would arrange chest physio before and after surgery to encourage excretion of excess mucus
5. In addition I would inform HDU in case more intensive care is required post operatively
6. Use open surgery, not laparoscopic because of co2 pneumoperitoneum
7. Use regional anathesisa instead of general anathesia
Scenario 2…………………………………………………chest pain POD 7 >>DVT &PE

This is a potentially unwell patient, therefore you should approach him according to CCRISP:
A – AIRWAY-You know his airway is patent as he is talking to you
B – BEATHING- SYSTEMATIC APPROACH
 Look for ABG and chest X-ray.
C- CIRCULATION:
 Inspect for cyanosis, and look at the JVP.

 Feel the pulse, making note of any rhythm abnormalities and tachycardia, and peripheries (cold
and poorly perfused v hot and septic).
 Auscultate the heart – muffled heart sounds could indicate tamponade, OR murmur .
 Measure the blood pressure.
 Look for ECG.
D – GCS
E – The left calf is swollen and tender

REVIEW CHARTS: Check the drug chart for SC heparin and TEDS – have they been
signed for Check the fluid chart to ensure they are not overloaded
Questions
DDX? My top differential is a pulmonary embolus.
WHY? This patient presented with acute pleuritic chest pain and shortness of breath 4 days after a hip
operation. I note from their drug chart that they have missed two dose of their subcutaneous heparin.
He is haemodynamically stable, but had saturations of 88% on 2L. This improved with high flow oxygen.
They also had a swollen left calf. Otherwise examination showed a clear chest with good bilateral air entry
and a normal percussion note making a pneumonia and pneumothorax unlikely. An MI is possible but less
likely due to the nature of the pain; however I am awaiting an ECG and troponin.
What investigation would you arrange now?

 Chest x ray.
 Assuming renal function was within acceptable limits I would arrange a CTPA to exclude a PE.
 ABG, D- dimer.
 An ECG (sinus tachycardia) and troponin.
Page 10
Interpret this ABG result??
The ABG was taken from Mr. Jones when he was on 2L of oxygen. It shows a type one respiratory failure with a PaO2 of 7. It is
otherwise normal.
Can you see anything abnormal on the chest X-ray? This is the chest radiograph of Simon Jones
taken on 13/6/12. It is an adequate film.Lung fields appear clear with no pneumothorax evident.
There are no obvious rib fractures, the heart is a normal size, and there is no air under the
diaphragm. Essentially it is a normal chest X-ray.
Define D- dimer? Degradation product of cross- linked fibrin by factor XIII
What is the value of d- dimer? High –ve predictive value (PREGNANT 100%- OLD AGE 99%)
What are ECG changes in PE? SI-QIII-TIII pattern (deep S in lead I- Q wave and inverted Tin lead III).
What is the management of a pulmonary embolism?
1. Massive PE: characterised by haemodynamic compromise and may require thrombolysis. I would put
out a crash call if the patient presented in this way to get urgent help.
2. Non-massive PE: If the patient is stable, treatment initially with a therapeutic dose of subcutaneous
heparin, followed by warfarin is warranted.
3. I would involve hematologist and pulmonologist
Cardiovascular examination
Mitral reguarge , aortic stenosis, valve replacement, pacemaker
Inspestion:
General: walking aids, o2, medications, observation charts, ECG, midline sternotomy scar
 Hands: Signs of IE( splinter Hges, janeway lesions)

Tar staining
Capillary refill
Palpate the radial pulse ( rate , rhythm, radioradial delay, collapsing pulse)
Clubbing
 Blood pressure measurement
 Neck: JVP assesment, palpate the carotid pulse, hepato-jugular reflux.
 Eye: mucous membranes, corneal arcus, xanthelasma
 Mouth: oral hygiene, central cyanosis
 Face: malar flush
 Chest : scars( sternotomy, thoracotomy, infraclavicular)
Visible apex pulsation
palpation:
Palpate for: apex beat (5 ICS midclavicular line)
Heaves (ventricular hypertrophy)
Thrills (palpable murmurs)
Page 11
Auscultation:
(Put your left hand on the carotid pulse to time systole and diastole)
- Mitral area: 5th ICS midclavicular line Pan
systolic murmur radiating to the axilla
- Tricuspid area: 4th ICS left parasternal edge
- Pulmonary area: 2nd ICS left parasternal edge
- Aortic area: 2nd ICS right parasternal edge Ejection
systolic murmurs radiating to the carotids
- Accentuation maneuvers:
These maneuvers cause particular murmurs to become louder DURING expiration:
*Roll onto left side & listen to mitral area with bell during expiration – mitral murmurs (stenosis & regurgitation)
*Lean forward & listen over aortic area during expiration – aortic murmurs are louder (stenosis & regurgitation)
- Metallic heart sounds:
One metalic click corresponding to S1= mitral valve replacement Two

metalic clicks corresponding to s2 = aortic valve replacement
- Carotid bruits
- Lung bases
Check lower limb for: Edema - Vein graft harvest scars
Questions
Causes of mitral regurge???? MVP - RF – IHD - Marfan –Ehler danlos – ventricular dilatation.
What investigations would you order preoperatively?
1. A baseline ECG and echo preoperatively.

2. An INR as he is on warfarin.
How would you manage this patient’s anticoagulation?
N.B: Note the pacemaker spikes, no p- waves
The patient presents with fever 5 days postoperatively, WT should you be concerned about?
Might have infective endocarditis.

What is the mechanism of action of pacemaker??
It iniate and control the frequency of heart beat through a generator- battery- powed unit gives electrical
impulse passing through electrodes to reach SA node through SCV.
Page 12
Indications of pacemaker??
Class I indications include the following:

1. Sinus node dysfunction
2. Acquired atrioventricular block in adults
3. Chronic bifascicular block
4. After acute myocardial infarction
5. Hypersensitive carotid sinus syndrome and neurocardiogenic syncope
6. After cardiac transplantation
7. Pacing to prevent tachycardia
8. Patients with congenital heart disease
N.B: temporary cardiac pacing is most commonly used for patients with symptomatic bradyarrhythmias,
most frequently due to atrioventricular (AV) nodal block.
Who would you inform about the pacemaker?
An anaesthetist, ideally the consultant who will be doing the case. I would ensure it is clearly
documented in the notes.
What precautions would you take?
1. I would arrange a pacemaker check pre- and postoperatively and contact their pacemaker follow-
up clinic to inform them of the operation and ask for advice.
2. During the operation I would avoid monopolar completely, or limit its use to short bursts only.
3. The return electrode should be placed so that the pathway between the diathermy electrode and
return electrode is as far away from the pacemaker and leads as possible.
4. I‟d ensure that appropriate resuscitation equipment was available
What are the complications with using monopolar in presence of pacemaker?
Reprogramming – arrhythmia - Heart burn
Abdominal Examination
WIPER
Exposure: submammary area to bikini line (ideally to midthigh)
General Examination “ I will start by general examination”
 1-Hands (Clubbing (tangentially)– Koilonychia=spooning nail (tangentially)–
Pallor – Palmar erythema – Dupuytren contracture4– Flapping tremors)
 2-Eyes – retract both lower eyelids together (Jaundice in sclera– Pallor in conjunctiva)
 3-Mouth (Fetor Hepaticus – Cyanosis – Pigmentation of Peutz Jhugar synd.)
 4-Chest & Neck (Supra-clavicular L.N.s (abd. malignancy) – Spider naevi –
Gyaencomastia)
 5- LL (edema)
Local Examination
1-Inspection : 3 POSITIONS
Foot of bed
Rt Side (on knees =Tangential)

& visible peristalsis or pulsation
Page 13
Rt Side (standing): Subcostal angle
 Skin (Scars, Dilated veins, Redness)
 Divarication of recti (‫)هم برأسك‬
 Umbilicus: site (N / shifted downwards), shape (N / Everted), H, scars.
 Hair distribution: masculine (triangle apex up) or feminine (apex down)
 Hernial orifices (expose & cough): intact
2-Palpation : On knees & hand at level of elbow

A- Superficial : rest hand on abdomen & feel by phalanx 4 fingers the 9 quadrants (for
tenderness & superficial masses) 7
B- Deep: rest hand on abdomen & press by phalanx 4 fingers 9 quadrants & Organs(for deep
masses)
9 Quadrants: Mass 3S TT ESCRSS: mass is felt …cm below C.M., …X…cm, edge (well
defined), surface (smooth/irreg), consistency (soft/firm/hard) – attachment (mobile in 2
directions) not attached to skin & ‫(هم برأسك‬intra/extra-abdominal)- reducible (/not) – pulsatile
(/not) – expansile imp. on cough (/not)
Rt lobe liver: start at RIF (Rt iliac fossa) & upward + ‫ & خد نفس‬feel during inspiration →
ESC (not felt / felt …cm below C.M.), edge (well defined), surface (smooth/irreg), consistency
(soft/firm/hard) CONFIRM BY PERCUSSION & TIDAL PERCUSSION
Lt lobe liver: start in midline above umbilicus & upward + ‫ & خد نفس‬feel during inspiration
→ ESC (not felt / felt …cm below C.M.), edge (well defined), surface (smooth/irreg),
consistency (soft/firm/hard) CONFIRM BY PERCUSSION
Spleen: start at RIF to below umbilicus then toward Lt hypochondrium….If not felt → pt. on
lat. position, Lt hand support lower ribs laterally & palpate by Rt hand…….If not felt →
percussion Traub‟s area (Lt thumb on lower rib & ant. to MAL). if dull → percuss below till RIF
CONFIRM BY PERCUSSION & Differentiate from kidney→ ESC (not felt / felt …cm below
C.M.), edge (well defined), surface (smooth/irreg), consistency (soft/hard)
Kidneys (Bimanual examination): Lt hand on renal angle & Rt hand on lumbar (laterally)→
ESC …..
3-Percussion
a- Liver (Upper border → Tidal percussion) [OR with palpation] ‫خد نفس و اكتمه‬
b- Spleen [OR with palpation]
c- Ascites (Shifting dullness) just above umbilicus downwards then from midline laterally
o → If not dull→ no ascites
o →If dull → lat. position, wait 30 secs & percuss again,
o → If change note → +ve shifting dullness = ascites,
o → If still dull → -ve shifting dullness = fixed dullness
d- Bladder
4- Auscultation
Page 14
1- Auscultation of abdomen
2- Examination of genitalia & PR (DRE) (+PV in females) & back
3- Ext. genitalia..atrophy in ch. Liver disease.
4- LL for oedema
1ST SCENARIO................................................................................. Appendicitis

2ND SCENARIO…………………………………………..…………. cholecystitis
3RD SCENARIO………………………….………. post operative anastmotic leak
4TH SCENARIO………………………………………………… acute diverticulitis
5TH SCENARIO……………………………………………………. incisional hernia
N.B: don not forget to examine the observational charts
1ST SCENARIO................................................................................. Appendicitis

Female patient who presents with right iliac fossa abdominal pain:
Perform classical abdominal examination + special signs
special signs:
1. Tenderness on palpation in the RLQ over the McBurney point is the most important sign in
these patients.
2. Rebound tenderness.
3. The Rovsing sign (RLQ pain with palpation of the LLQ) suggests peritoneal irritation in the
RLQ precipitated by palpation at a remote location.
4. The obturator sign (RLQ pain with internal and external rotation of the flexed right hip)
suggests that the inflamed appendix is located deep in the right hemipelvis.
5. The psoas sign (RLQ pain with extension of the right hip or with flexion of the right hip
against resistance) suggests that an inflamed appendix is located along the course of the
right psoas muscle.
6. The Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough) may be helpful in
making the clinical diagnosis of localized peritonitis.
N.B: don not forget to examine the observational charts..FEVER-TACHCARDIA-LEUCOCYTOSIS
Please present your findings?

Sarah Jones is a 20-year-old lady who presents with right iliac fossa abdominal pain. On
examination, she is clearly in pain. She has no peripheral stigmata of liver or gastrointestinal
disease. On closer inspection of the abdomen, there are no scars, and no obvious distension. She is
very tender in the right iliac fossa, particularly over McBurney’s point but there is no guarding.
Rovsing’s sign is positive, Murphy’s sign is negative. Her symptoms are consistent with
appendicitis. I would like to rule out an ectopic pregnancy.
DDX:
 Pelvic inflammatory disease (PID) or tubo-ovarian abscess

 Endometriosis
 Ovarian cyst or torsion
 Diverticulitis
 Crohn disease
 Rectus sheath hematoma
 Cholecystitis
Page 15
 Mesenteric adenitis and ischemia

 Biliary colic
 Renal colic
 Urinary tract infection (UTI)
 Gastroenteritis
 Enterocolitis
 Pancreatitis
 Perforated duodenal ulcer
What investigations would you like to perform?

1. The most important initial investigation is a serum or urine beta HCG to rule out a ruptured
ectopic pregnancy.
2. I would send bloods looking for raised inflammatory markers,
3. Complete Blood Cell Count Studies consistently show that 80-85% of adults with
appendicitis have a white blood cell (WBC) count greater than 10,500 cells/µL. Neutrophilia
greater than 75% occurs in 78% of patients.
4. An ultrasound if I thought the diagnosis were equivocal.
5. Urinary 5-hydroxyindoleacetic acid (U-5-HIAA) levels could be an early marker of
appendicitis.
6. Computed tomography (CT) scanning with oral contrast medium or rectal Gastrografin
enema has become the most important imaging study in the evaluation of patients with
atypical presentations of appendicitis.
What is the TTT?? Appendectomy remains the only curative treatment of appendicitis, but
management of patients with an appendiceal mass can usually be divided into the following 3
treatment categories:
 Patients with a phlegmon or a small abscess: After intravenous (IV) antibiotic therapy, an
interval appendectomy can be performed 4-6 weeks later.
 Patients with a larger well-defined abscess: After percutaneous drainage with IV antibiotics is
performed, the patient can be discharged with the catheter in place. Interval appendectomy can
be performed after the fistula is closed.
 Patients with a multicompartmental abscess: These patients require early surgical drainage.

Open versus lap. Appendectomy???
What is the most important advantage of lap. Appendectomy?? Exploration of other organ
You found blood in the peritoneal cavity, what will u do??? This means it is a ruptured ectopic pregnancy
Call obstetrician- arrange for blood- perform appendectomy.
Page 16
2ND SCENARIO…………………………………………..…………. cholecystitis

Female patient who presents with right upper quadrant abdominal pain:
Perform classical abdominal examination + special signs
special signs: a positive Murphy‟s sign

N.B: don not forget to examine the observational charts..fever- leucocytosis- high AST&ALT
DDX?
 Abdominal Aortic Aneurysm
 Acute Gastritis
 Acute Mesenteric Ischemia
 Acute Pyelonephritis
 Appendicitis
 Biliary Colic
 Biliary Disease
 Cholangiocarcinoma
 Cholangitis
 Gallbladder Cancer
 Gallbladder Mucocele
 Gallstones (Cholelithiasis)
 Peptic Ulcer Disease
 Lower lobe pneumonia
What are you looking for on examination?
I would complete a full systemic examination, looking particularly for RUQ tenderness, and a
positive Murphy‟s sign. In addition, I would be checking they did not have guarding, pain out of
proportion to the findings or hypotension which could suggest perforation, mesenteric ischaemia, or
ruptured AAA respectively.
What investigations would you arrange to confirm your suspicions that this is cholecystitis?
I would send bloods looking for raised inflammatory markers and arrange an ultrasound
Laboratory Tests
Although the laboratory criteria are not reliable in identifying all patients with cholecystitis, the
following findings may be useful in arriving at the diagnosis:
 Leukocytosis with a left shift may be observed in cholecystitis.
 Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are used to
evaluate for the presence of hepatitis and may be elevated in cholecystitis or with common
bile duct obstruction.
 Bilirubin and alkaline phosphatase assays are used to evaluate for common bile duct
obstruction.
 Amylase/lipase assays are used to evaluate for the presence of pancreatitis. Amylase may also
be elevated mildly in cholecystitis.
 An elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis.
 Urinalysis is used to rule out pyelonephritis and renal calculi.
 All females of childbearing age should undergo pregnancy testing.
Imaging recommendations
The 2010 American College of Radiology (ACR) Appropriateness Criteria offer the following
imaging recommendations :
 Sonography is the preferred initial imaging test for the diagnosis of acute cholecystitis, and
scintigraphy is the preferred alternative.
 CT is a secondary imaging test that can identify extrabiliary disorders and complications of
acute cholecystitis, such as gangrene, gas formation, and perforation.
Page 17
 CT with intravenous contrast is useful in diagnosing acute cholecystitis in patients with
nonspecific abdominal pain.
 MRI, often with intravenous gadolinium-based contrast medium, is also a possible secondary
imaging modality useful in confirming a diagnosis of acute cholecystitis.
 MRI without contrast is useful to eliminate radiation exposure in pregnant women for whom
sonograms have not indicated a clear diagnosis.
 Contrast agents should not be used in patients on dialysis unless absolutely necessary.
 ERCP, MRCP if intrahepatic biliary dilatation is present.
What might you see on ultrasound in acute cholecystitis?
You may see gallstones, a thickened gallbladder wall of greater than 4mm, pericholecystic fluid and
a sonographic Murphy‟s sign.
How do the symptoms differ depending on location?
A stone is in the gallbladder is generally asymptomatic. If it moves and blocks the cystic duct,
biliary colic can occur. This is classically a constant (not colicky) dull epigastric or right upper
quadrant pain lasting 1-5 hours, often coming on hours after a meal. Cholecystitis can occur if the
cystic duct obstruction is prolonged as inflammation of the gallbladder wall ensues. Here,
symptoms are more prolonged lasting more than 6 hours, mostly located to the right upper quadrant
and associated with a low-grade pyrexia.
A stone in the common bile duct is called choledocholithiasis. It can block flow of bile to the
ampulla of Vater, presenting as abdominal pain and jaundice. The stagnant bile above it often
becomes infected causing cholangitis, and a triad of fever, right upper abdominal pain and jaundice
(Charcot triad).
An obstructed pancreatic duct can cause pancreatitis, which presents as a dull boring, constant
central abdominal pain radiating to the back.
Finally if a large stone (>2.5cm) passes through the ampulla of Vater, it can case a gallstone ileus,
leading to abdominal pain and distention.
What is the management?

A) Initial Therapy and Antibiotic Treatment:
In acute cholecystitis, the initial treatment includes bowel rest, intravenous hydration, and
correction of electrolyte abnormalities, analgesia, and intravenous antibiotics. For mild cases of
acute cholecystitis, antibiotic therapy with a single broad-spectrum antibiotic is adequate. Some
options include the following:
 The current Sanford guide recommendations include piperacillin/tazobactam (3.375 g IV q6h
or 4.5 g IV q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or meropenem (Merrem, 1 g IV
q8h). In severe life-threatening cases, the Sanford Guide recommends imipenem/cilastatin
(Primaxin, 500 mg IV q6h).
 Alternative regimens include a third-generation cephalosporin plus metronidazole (Flagyl, 1 g
IV loading dose followed by 500 mg IV q6h).
 Bacteria that are commonly associated with cholecystitis include Escherichia coli
and Bacteroides fragilis, as well as Klebsiella, Enterococcus, and Pseudomonas species.
 Emesis can be treated with antiemetics and nasogastric suction.
 Supportive medical care should include restoration of hemodynamic stability and antibiotic
coverage for gram-negative enteric flora and anaerobes if biliary tract infection is suspected.
 Daily stimulation of gallbladder contraction with intravenous cholecystokinin (CCK) has been
shown by some to effectively prevent the formation of gallbladder sludge in patients receiving
total parenteral nutrition (TPN).
 Antiemetics, such as oral/rectal promethazine (Phenergan) or prochlorperazine (Compazine),
to control nausea and to prevent fluid and electrolyte disorders
 Analgesics, such as oral oxycodone/acetaminophen or hydrocodone/acetaminophen
B)Laparoscopic cholecystectomy: is the standard of care for the surgical treatment of cholecystitis.
Page 18
C) Percutaneous Drainage
 For patients at high surgical risk, placement of a sonographically guided, percutaneous,
transhepatic cholecystostomy drainage tube coupled with the administration of antibiotics
may provide definitive therapy. But the Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES) guideline describes radiographically guided percutaneous
cholecystostomy as a temporizing measure until the patient can undergo cholecystectomy.
D) Endoscopic retrograde cholangiopancreatography (ERCP) allows visualization of the anatomy
and can provide therapy by removing stones from the common bile duct.
What is the advantage of early cholecystectomy??
early laparoscopic cholecystectomy resulted in shorter total hospital stays, less overall morbidity,
duration of antibiotic therapy, as well as reduced cost compared with delayed cholecystectomy, It is
reported that the best outcomes and lowest costs were achieved when laparoscopic cholecystectomy
was performed within 2 days of presentation of acute cholecystitis.
what is the recommendation for prophylactic antibiotic in cholecystectomy?
Preoperative antibiotics should be considered only to reduce the possibility of wound infection in
high-risk patients, and then limited to one preoperative dose.
What is the most serious complication of cholecystectomy? Bile duct or biliary injury
How to deal with?
 Intraoperative cholangiography may improve injury recognition and decrease the risk of bile
duct injury.
 If bile duct injury occurs, the patient should be referred to an experienced hepatobiliary
specialist before any repair is undertaken, unless the primary surgeon has experience with
biliary reconstruction.
Contraindications of laparoscopic cholecystectomy include the following?
 High risk for general anesthesia
 Morbid obesity
 Signs of gallbladder perforation, such as abscess, peritonitis, or fistula
 Giant gallstones or suspected malignancy
 End-stage liver disease with portal hypertension and severe coagulopathy
 previous abdominal surgery that impedes the procedure.
3RD SCENARIO………………………….………. post operative anastmotic leak
Post- operative anastmotic leak after elective left hemicolectomy for cancer… pod 5 peritonitis,
sepsis, subphrenic collection.
PT will simulate SOB and abdominal pain with left shoulder pain, abdomin covered with dressing.
You will start abdominal exam but pt is in severe pain so…….. This is a potentially unwell patient,
therefore you should approach him according to CCRISP:
A – AIRWAY-You know his airway is patent as he is talking to you
B – BEATHING- SYSTEMATIC APPROACH
 Look for ABG and chest X-ray.
C- CIRCULATION:
 Inspect for cyanosis, and look at the JVP.

 Feel the pulse, making note of any rhythm abnormalities and tachycardia, and peripheries (cold
and poorly perfused v hot and septic). Neck vein.
 Auscultate the heart – muffled heart sounds could indicate tamponade, OR murmur .
 Measure the blood pressure.
 Look for ECG.
D – GCS …alert
E – The left calf is swollen and tender & Dressing is wet
Page 19
REVIEW CHARTS: rising temp., risinig pr, increasing O2 requirements,

increased WBC's, ECG …AF
Management??? Where & how? RESUS-MONITORING- LABS- INAGING- DEFINITIVE TTT
 NPO
 I.V fluids
 Antibiotics
 IDC
 NG tube if vomiting
 CTPA (to rule out PE)
 Ultrasound….collection
 CT with gastrograffin enema…localizes the site of leaking.
TTT ??????? urgeny laparotomy…Hartmann + peritoneal toilet and drainage.
4TH SCENARIO………………………………………………… acute diverticulitis

Acute diverticulitis( 35y old man 2 day history of left lower abdominal pain , nausea,
vomiting, chills, rigors, referred by GP for suspicion of an acute abdomen.
Investigations ???
1. Laboratory: FBC, U&E,ABG

2. Imaging: u/s, CT scan, delayed barium.
If CT shows only sigmoid wall thickening with one locule of gas seen, what will be your
management?
 Antibiotics: co-amoxiclav, garamycin, clindamycin

 Bowel rest
 DVT prophylaxis
no response to antibiotics , what will you do ??percutaneous drainage
What kind of operations will you do? Hartman's procedure - exteriorization of the sigmoid ( colostomy) -
primary resection and anastmosis ( interval procedure).
Page 20
Peripheral vascular Disease (Ischemia)
History :
Risk Factors (smoking, DM, HTN, IHD, Hyperlipidaemia)

2- Intermittent Claudication
 Site
o Buttocks (Aorto-iliac)
o Thigh (Iliac)
o Calf (Femoral)
 Severity: Claudication distance
3- Rest Pain
 Site: Forefoot
 Severity: Hang the leg out of bed / Type of analgesia
4- Functions
Lifestyle – Shopping – Walking aids – Limping
Ischemia LL Examination
WIPER
Exposure: Up to groin & lower abdomen
Inspection ‫من تحت لفوق‬
 Color changes in sole (Pallor – Rubor – Cyanosis)

 Trophic changes:
1. Loss of Hair
2. Brittle nails
3. Taper toes
4. Interdigital fungal inf. (open between toes)
5. Ulcer (heel, head metatars, bet.toes, sole) →3S FED SS
6. Heel ulcer (elevate leg)
7. Gangrene
8. amutated toe
9. Venous guttering
10. Scar of previous operation (leg, groin, abdomen)
 Burger’s test (Lower limb) OR
1- Elevate one LL till pallor (+/-) venous guttering & notice degree (look from side)
If < 30 degrees → critical ischemia
If > 30 degrees → chronic ischemia
Page 21
2- Hang both LL out of the bed till rubor (+/-) venous refilling (due to accumulation metabolites) & notice time
2-Palpation Ask about pain
 Temperature from distal to proximal & compare (very imp…) & Tenderness.
 Capillary refill time: press on big toe away from nail (Normal: 2-3 sec)
3-Pulses (one side as examiner ask & compare only femoral)
 Abdominal aorta ( above umbilicus & just Lt to midline) - normally not felt.
 Femoral by 3 fingers (midinguinal point bet SP & ASIS in skin crease) (compare).
 Popliteal: knee 160 degrees (relax muscles) fix knee by 2 thumbs & feel by rest of fingers
meeting laterally in popliteal fossa (difficult & variable site)- be lat.
 Posterior tibial: midway between med. malleolous & tendo-achilis .
 Dorsalis pedis: lat. to ext. hallucis longus tendon on navicular bone –may be absent.
N.B: Do not forget capillary refill and radio-femoral delay.
4-Auscultations (over Femoral artery for bruit = stenosis) +/- carotid
1. Full neurological examination of lower limb.

2. Full cardiovascular examination.
3. Perform a vascular examination of upper limb.
4. Feel abdomen for aortic pulsation and auscultate for renal and aortic bruit.
Questions
What are causes of chr. ischemia = causes of ischemic ulcer?
 Atherosclerosis (commonest cause): Large vessel disease.
 Thrombangitis obliterans (Beurger ds): Large vessel disease.
 DM: Large (cause atherosclerosis) & Small vessel disease.
 PAN: Small vessel disease.
 Rh. Arthritis: Small vessel disease.
What are risk factors of ischemia? Smoking - IHD - DM - HTN – Hyperlipidemia- FH- postmenopausal.
What ABPI???
Page 22
What is definition of critical ischemia?

European working group definition:
1- Presence of an arterial ulcer or gangrene OR
2- Rest pain ≥ 2 weeks relieved only by opioids OR
3- Absolute ankle pr. < 50mmHg.
Other features:
4- ABPI < 0.5.
5- Burger angle < 30 .
What are the classification of PVD???
Commonest sites of leg ischemic ulcers? 1- Heel. 2- Head of metatarsals. 3- Between toes.4- Sole.
Is capillary filling a good test for ischemia? NO, because may be normal due to return of venous blood.
How to diagnose pt. with ischemia?
1- Angiography (goldstandard)- now CT angio- MRA
2-Duplex (less invasive).
What labs??Blood glucose level---Lipid profile (LDL)

What to do for pt. with only femoral pulse felt? (Common on exam) Angiography (standard).
Which artery is commonest to be occluded? Superficial femoral.
What is ttt of chronic ischemia in most cases ? in most of cases superficial femoral occluded → Femoro-popliteal
bypass.
What is value for angiography?
1- Diagnostic: site (aorto-iliac, femoral-popliteal or distal) & extent of thrombus
& distal run-off (=good collaterals =good prognosis).
2- Therapeutic: ballon angioplasty +/- stent (if short segment).
What are precautions of angiography in DM pt.?
1. Ensure normal Serum Creatinine, good hydration & non-ionized dye
(usually mild renal impairment).
2. Stop metformin (cause lactic acidosis with dye).
What is treatment of ischemia?
A. Conservative ttt: (if claudication pain)
1. Stop smoking, control DM, HTN & hypercholest.
2. Regular aspirin 75mg.
3. Analgesiaacc.toanalgesicladder(paracetamol→NSAIDS- oral→IM→oral opioids →IM)
B. Surgery with conservative ttt:
(if claudic. & failed conservative OR critical ischemia OR rest pain)
1. Angioplasty +/- stent (if short segment).
2. Bypass Graft (if long segment).
3. Amputation (if failed or no distal run-off).
4. Lumbar sympathectomy (if ischemic ulcer).
Page 23
What are contraindications of sympathectomy? DM (autosympathectomy) & Gangrene.
What is ttt of this pt. with ischemic ulcer?

1. Angioplasty +/- stent (if short segment).
2. Bypass Graft (if long segment).
3. Amputation (if failed).
What are types of bypass grafts?
1- Natural: saphenous v.
2- Synthetic: Dacron or PTFE (Gortex).
D.D. claudication pain?
1- Vascular: PVD or DVT or PTS.
2- Neurological: spinal stenosis (spinal claudication) or sciatica.
3- Musculoskeletal: pathology of hip, knee orankle (e.g, osteoarthritis).
Pathology of ischemia by DM? Mixed
1- Vasculopathy: Macro- angiopathy & Micro- angiopathy.
2- Periph. Neuropathy:
3- Infection → Macro & Micro- angiopathy
Which type of DM is worest? IDDM (type I) because:
o Usually P.N. (poorvresponse to surg.).
o ↓ immunity → more inf.
o More plat. Aggregation.
What if auscultate over carotid & bruit is heared? Do duplex if carotid stenosis for intervention →
angioplasty or endarterectomy.
What is endarterectomy. How it is done? Done in carotid thrombosis only.
Peel Intima & part of media (leave part of media + adventitia).
Ask this pt. with diabetic toe 1 question? Are you on insulin or not?
 If on insulin (type I) → amputation (no ischemia but neuropathy=bad prognosis).
 If on oral hypoglycemics (type II) → angioplasty (ischemia due to vasculopathy).
Diabetic Foot
Exposure: Up to groin
1- Inspection as Ischemia (Color & Trophic changes, scars, Burger angle) +
 Local amputation.
 Charcot‟s joint.
 Signs of PN (Burns – injuries – Ingrowing toe nail).
 Diabetic ulcer :
1. On pressure points.
2. Smaller than venous ulcers.
3. May be punched out.
4. May be infected.
5. Painless with normal surrounding skin.
2- Palpation: Ask about pain as Ischemia (TT, capillary refilling).
3- Pulses as Ischemia (Aorta, Femoral, Popliteal, Post. Tibial, dorsalis pedis).
4- Sensation (PN) → stock hypothesia ‫من تحت لفوق‬
Page 24
1. Performing ABPI (in DM > 1).

2. Examination of other pulses
3. Neurological examin. & fundus examin.
Post-Thrombotic Syndrome (PTS)

Exposure: Up to groin
1-Inspection
 Inverted champagne bottle appearance (due to lipodermatosclerosis)

 Ulcer: 3S FED SS → ulcer in gaiter area), …X… cm, edge sloping, floor (healthy /
necrotic),…..
 Signs Chr.Venous Insuffeciency around ulcer: Edema, Eczema, Hyperpigmentation,
Lipodermatosclerosis (area of subfascial fibrosis & ischemis), V.V.
 Secondary Varicose Veins (need to be examined while standing later)
2-Palpation Ask about pain
 TT
 edema & level
 Ulcer: TEBS (NEVER)
1- Examination of Pulse & ABPI & sensation (exclude ischemic & neuropathic &
mixed ulcer for priority of ttt)
2- Examination for V.V. (while standing).
Varicose Veins Examination (standing)

Inspection (standing):
 V.V. & its site (med. Side → LSV (long saph.v.) & lat. Side → SSV (short saph.v.)
 Signs CVI (ulcer, pigmentation, eczema (purple), Lipodermatosclerosis1)
 Blow-out :(site of perforator) (fascial defects)
 SFJ
 Saphina varix at skin crease) + thrill on cough
 Scar of previous oper. (leg – groin)
”I can see dilated elongated tortuous veins on the -------aspect of the (leg/thigh) along the distribution of the
(long/short) Saphenous venous system. I can see also (Blow outs /Ulcer/Eczema/ lipodermatosclerosis 1) “
Palpation: Ask about pain

 Temp.
 Tenderness
 Edemal & Level
 Fascial defects (at sites of perforators) (Blow-outs) (Fegan test)
 SFJ: feel thrill with cough → incompetent SFJ
Page 25
 Inguinal L.N. (vertical & horizontal groups)
I am palpating the vein to feel the blow outs 2, the SF junction, cough please, I can feel a thrill, now will
proceed to...”
Percussion (Tapping test): (Chevrier's percussion test (tap test))

1. Tap proximally (retrograde transmission) to detect valve incompetence.
2. Tap distally (orthograde transmission) to assess venous patency.
Special Tests:
 Tapping test (percuss vein below by index & receive by index other hand) → +ve
 Trendlenburg's sign: Thrill transmission with cough at site of SFJ (=saphaen varix).
 Telendenberg's test
 Tourniquet test see below
 Perthe's test
 Doppler (SF junction – SP junction), examiner or u carry it (not pt.)- locate artery (midinguinal point
below crease)- locate vein just 1 cm below & med. to artery – squeeze quadriceps (or ask pt. to cough)
→ hear bidirectional flow → incompetent SFJ
1. Perform a full arterial examination & ABPIs of the lower limb.

2. Perform Perthes' test to assess the deep venous drainage.
3. Assess for causes of 2ry varicose veins by: abdominal examination & PR to exclude pelvic mass.
4. Auscultate the dilated veins to exclude AV- fistula.
Telendenberg's test: with the patient lying supine, lift his/her leg to about 45 degrees and gently empty the veins (this
may be aided by “milking” the veins). Occlude the sapheno-femoral junction and ask the patient to stand up ensuring
that the finger or thumb is firmly over the junction- If the superficial veins do not fill and the varicosities are controlled
at the level of the sapheno-femoral junction by occluding it, it strongly suggests sapheno-femoral incompetence.
This can be confirmed by releasing the pressure from the sapheno-femoral junction that will cause the blood to return
from the femoral vein into the saphenous vein (through the incompetent sapheno-femoral junction), resulting in the
varicosities becoming prominent. As the patient stands, if the veins fill from below with the sapheno-femoral junction
occluded, incompetent perforators are the most likely cause for the varicosities.
Touniquet test: The tourniquet test follows the same principle but is easier to perform than Trendelenberg’s test as it uses
a tourniquet to control the sapheno-femoral junction rather than the examiner’s fingers. It also has the added advantage
that if varicosities are due to perforator incompetence, it can be performed further down the leg to identify the level of the
incompetence. Once the superficial venous system has been controlled with the tourniquet you can perform Perthe’s test
to assess the patency of the deep venous system, particularly important if considering varicose vein surgery.
Perthe's test: With the patient standing and with the tourniquet still around the thigh ask the patient to go up and down
on his/her tiptoes or ask him/her to walk, thus exercising the calf muscles. If the deep venous system is intact, the calf
pumps encourage venous return. However, if the deep venous system is occluded or valves incompetent, when the
patient performs this action venous return is restricted and blood is forced into the superficial system from the deep
system, causing engorgement of the superficial veins associated with a bursting pain.
hand held doppler assesment: hold the Doppler probe at a 45 degree angle to the skin at the level of the sapheno-femoral
junction and the squeeze the patient’s calf. In a patient with a competent sapheno-femoral junction you will hear a short
“swoosh” as you squeeze, but this ceases as soon as you let go of the calf. If however, the sapheno-femoral junction is
incompetent, there is a more prolonged “swooooosh” of blood as it regurgitates back down though the incompetent valve.
Page 26
Questions
Present your case ? On closer inspection of the legs, she has obvious varicosities bilaterally. There were no
ulcers, but I noted venous eczema, lipodermatosclerosis and haemosiderin deposition reflecting chronic venous
insufficiency. Doppler assessment demonstrated incompetence at the saphenofemoral junction.
How to diagnose? A. Duplex for deep & superficial system assessement.

1. Contrast venography the most sensitive.
2. MRV.
3. Colour flow ultrasound.
4. Physiologic test e.g venous refilling time, MVO max.venous out flow, MOEF muscle pump ejection
fraction.
Q. How can duplex help me in surgery? A. mark perforators.
Q. Management?
1. Conservative TTT: avoid longstanding standing & sitting - graduated pr. Compression stockings G II &
lifestyle modification (exercise & ↓ weight & ↓ standing)- leg elevarion
2. Surgical TTT: (non invasive)
 Injection sclerotherapy (cosmetic) use ethanolamine oleate or sclerovein.
 Injection of foam.
 Subcutaneous Endosc. Perforator Surg. (SEPS) for severe skin changes or ulcer.
 Radiofrequency (intraluminal)…. New.
 Laser (intraluminal)…. New.
3.Surgical TTT of long saphenous V.V.: Flush tie ligation of SFJ + stripping from groin to just above knee +
multiple stab avulsions below.
4.Surgical TTT for short saphenous: Ligation of SPJ + Multiple avulsion + No stripping.
Test for deep venous occlusion (Perthe's test)??? Palce a high tourniquet around the top of the patien's thigh and
ask them to walk. If the deep venous system is occluded, the leg will become swollen and blue with dilated
superficial veins distal to the tourniquest. If the presenting complaint of venous insufficiency and engorgerment of
the superficial veins has these problems secondary to a non-functioning deep venous system then stripping of the
superficial system on which the patient is relying will only make it worse. To avoid this:
1. Ask about a history of DVT.
2. Be suspicious of unilateral V.V. or those in an usual distribution.
3. Confirm by U/S the patency and competence of the deep venous system in any patients in whom
doubt exists.
What is pathogenesis V.V.? Fibrous tissue invades intima & media & broke ms tone.
What are tributaries of Saphenous vein ?

1.Superficial circumflex iliac.
2.Superficial inferior epigastric.
3.Superficial external pudendal.
4.Deep external pudendal.
5.Antero-lateral & postero-medial veins of the thigh.
What is fegan test (sign)? Palpation of fascial defects.
What are indications of duplex in V.V.? Some surgeons perform it as routine but:
 History DVT.
 Venous ulcer.
 Recurrent V.V.
Page 27
 Pre-operative: for perforators & SPJ (both are variable anatomicaly).

 If cannot determine SFJ incompetence.
What is role of duplex in V.V.?
1. Diagnostic: for deep system patency & competence (exclude DVT which contraindicate surg.) & Superficial
system SFJ & perforator competence.
2. Therapeutic: site of perforators & SPJ for surg. (both are variable anatomicaly).
What is treatment of this case (severe V.V. + SFJ incomp. + perforator incomp.)?
Surgery (skip conservative) ….most of exam cases.
Why stripping of LSV till just below knee?

To avoid inj. saphenous v. (near LSV in leg) → parathesia & numbness med. Leg.
Why no stripping of SSV? To avoid inj. sural n. → parathesia & numbness lat. leg.
What to tell pt. about his surgery (consent for stripping)?
1- Daycase.
2- No driving 1 wk.
3- May not improve skin changes.
4- May not improve aching pain.
5- Risk inj. saphenous or sural n.
6- Risk DVT.
7- Risk recurrent vs (20 % at 5 years).
What are common sites for perforators?
Mid-thigh, Above med. malleolus by 2, 4, 6 & Above lat. malleolus by 1, 3, 5 inches.
Where is gaiter area? Lower 2/3 of leg.
What is Klippel Trenauny syndrome?
Severe V.V. in abnormal site (e.g, lat.thigh)+ giant limb+ portwine stain.
Ischemia UL
Exposure: Up to groin & lower abdomen

 Color changes in sole (Pallor – Rubor – Cyanosis)
 Trophic changes: - Loss of Hair - Brittle nail - Nicotine stain (edge 2 adj.fingers)- scar or
Ulcer (vasospastic ds) - Gangrene
 Temperature from distal to proximal & compare (very imp…) Tenderness

 Capillary refill time: press on thumb away from nail ( Normal: 2-3 sec)
 Radial ( Lat. Fl.carpi radialis)
 Ulnar (Lat. Fl.carpi ulnaris)
 Brachial (Lat. biceps aponeurosis):
 Posterior tibial: midway between med. malleolous & tendo-achilis
 Subclavian (behind middle 1/3 clavicle)
4- Special tests Allen’s test 1 & Addison test
5- Auscultations (over carotid artery for bruit = stenosis
Page 28
Surgical A-V fistula (spot diagnosis)

Exposure: to elbow (area lymph drainage) + complete vascular examination of UL
1. Inspection → ☺”dilated pulsatile vessels in the forearm, with an overlying scar”
Before operation of A-V fistula any test we can do? A. Allen's tets.
2. Palpation Ask about pain

 there is a thrill that can be felt, the distal limb is well perfused.
 Feel synthetic material or loop graft (only if examiner asked).
 Temperature.
 Tenderness.
 Compressible.
3. Percussion: Dull.
4. Auscultation: Machinery murmer (bruit).
Questions
1-Indications : Renal failure (for regular haemodialysis)
2-Site: Upper Limb (start by non-dominant hand & distal first)
3-Types :
OR Side by side (venous hypertension)
Bridge graft a- Autologous : Saphenous vein
b- Synthetic: PTFE
4-Complications
Comment of A-V fistulae (spot diagnosis):

There is a grossly dilated pulsatile vessel in the forearm of the non-dominant arm with an
overlying scar. There is an audible bruit. The distal limb is well perfused with good
pulses and no signs of venous insufficiency. There are/are no signs of previous, moe
distal surgery or surgery on the opposite arm. There is a scar on the neck compatible with
a previous central venous line. The patient isn't uraemic and looks well nourished and in
good health. This is a surgical artriovenous fistula created for ease of venous access,
probably for haemodialysis in a patient with renal failure.
What is AVF ? type of vascular malformation
What is the most dangerous AV malformations? Berry aneurysm → subarachnoid hemmorhage.
What is its treatment? Transfemoral embolization or coiling.
How to access carotid (e.g, transluminal angioplasty)? Transfemoral.
Page 29
Where are the sites of surg. AVF?

Start by non-dominant hand & distal first
1. Radiocephalic.
2. Brachiocephalic.
3. Brachiobasilic (need superficialization).
How to know dominant artery of hand? Allen test.
What is usual dominant artery of hand? Ulnar artery
What if radial is the dominant? Do brachiocephalic (instead of radio-cephalic).
Is there is ulno-basilic. Why? NO, because

Difficult access of canula (applied from lat. Side).
Basilic v. is deep in most of its course.
What are complications?

1. Failure (thrombosis).2. Infection.
3. Rupture & bleeding.4. High COP HF.
5. Steal syndrome (ischemia due to blood stealed to veins).
What is ttt steal syndrome? ligation of distal vein
How to determine degree of shunt & general effect of AVF?

Branham test: measure carotid pulse before & after closure fistula by cuff.
If pulse ↓ > 10 = general effect (Lt to Rt shunt).
What else you want to do?

 Ask about hemodialysis or prev. transplantation.
 Examine neck for prev. access & abdomen for transplantation scar.

What does thrill & needle marks indicate? Functioning AVF.
What does pulsation indicate? Distal obstruction.

What is Parkes Weber synd.? Multiple AVF + limb hypertrophy
What is Parkes Weber synd.? Multiple AVF + limb hypertrophy.
Page 30

Modified by MAW 2009: MRCS Clinical Examination Scheme & Test Interpretetion

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Modified by MAW 2009

Swellings (Lumps & Bumps)

2- Palpation Ask about pain [NOT done (painful)]

I would like to finish my examination by:

Dermoid cyst (Cong. Or acquired)

Ganglion (As above but,…)

General Neck Examination

2- Palpation (From Front → From back)

Unilateral Lumps in the NECK

Causes of thyroid enlargement (Goitre)

I would like to finish my examination by:

3- Percussion of vertebrae → tender/ not (for metastasis)

Peripheral vascular Disease (Ischemia)

I would like to finish my examination by:

5- Auscultations (over carotid Fartery for bruit = stenosis)

Post-Thrombotic Syndrome (PTS)

I would like to finish my examination by:

Varicose Veins Examination (standing)

2- Palpation Ask about pain

3- Percussion (Tapping test)

I would like to finish my examination by:

Surgical A-V fistula (spot diagnosis)

1- Indications : Renal failure (for regular haemodialysis)

Lymphedema (spot diagnosis)

General Examination “ I will start by general examination”

2- Palpation On knees & hand at level of elbow

B- Deep: rest hand on abdomen

 9 Quadrants: Mass 3S TT ESCRSS: mass is felt …cm

 Spleen: start at RIF to below umbilicus then toward Lt hypochondrium

I would like to finish my examination by:

Scrotal & Inguinoscrotal swellings (Standing)

Introduce yourself - Can I get above it?

I would like to finish my examination by:

2- Palpation Ask about pain 2T

Scrotal Swelling (Hydrocele, Spermatocele, Encysted H cord)

Contents of Spermatic Cord

General Orthopedic Examination Scheme

Lumbar Spine Examination

2- Rapid Neurological examination

 Reflexes preserved or lost & compare both sides

Prone ‫مفيش وقت‬

I would like to finish my examination by:

Hip Joint Examination

I would like to finish my examination by:

Knee Joint Examination

Effusion: Start by Patellar tap test (moderate effusion)

Prone ‫مفيش وقت‬

I would like to finish my examination by:

Shoulder examination (rare)

Elbow Examination (very rare)

Hand Examination (Rheumatoid or Nerve inj.)

Ulnar n. inj. Median n. inj. Radial n. inj.

+ Phallen test 14 & Tinnel test 15

Level of inj - Scar - Scar - Scar

CNS …………………………………………………………………………………….CRANIAL NERVE & CEREBELLUM

CVS……………………………………………………………………………………….PREOPVALVULAR LESION AND PACEMAKER

ABDIMINAL……………………………………………………………………………A CUTE ABDOMIN, STOMA, HERNIA

VASCULAR …………………………………………………………………………….UL- LL- VARICOSE VEIN- A-V FISTULA

BODY PARTS AND ISOLATED LESION EXAMINATION:

SUPERFICIAL LUMP…………………………………………………………………….LIPOMA-DERMOID- SEBACEOUS CYST

EAR………………………………………………………………………………………………## SKULL BASE & HAEMOTYPANUM