Review Notes in History &

Physical Exam in General

Surgery

By
Ahmed Fa’iz al-Mousawi
M.B.C.h.B.
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Copyright
Review Notes in History & Physical Exam in General Surgery.

1st Edition @ 2015 Ahmed Fa’iz al-Mousawi

ISBN: pending.

You may download, view, copy and print this documents without prior
permission from the author

Disclaimer
 I'm not responsible for any harm or exam failure that may result from
the use or misuse of information provided in this book.
 I also assume no responsibility for errors, omissions, or other
inconsistencies therein.
Table of Contents:
History ............................................................................................................ 4
Acute Appendicitis .............................................................................................. 4
Acute Cholecystitis ............................................................................................. 5
Breast Mass ......................................................................................................... 7
Hernia ................................................................................................................... 9
Thyroid Swelling................................................................................................ 10
Operative Hx ...................................................................................................... 11
Post-op Hx ......................................................................................................... 12
Notes .................................................................................................................. 13

Physical Exam .............................................................................................. 14

General Examination ......................................................................................... 14
Abdominal Examination .................................................................................... 16
Thyroid examination ......................................................................................... 19
Hernia Examination ........................................................................................... 22
Mass Examination ............................................................................................. 23
Ulcer Examination ............................................................................................. 23
History

Acute Appendicitis
History taking:

Chief complaint: abdominal pain or right lower abdominal pain for ## days
or hours
History of present illness:
1) Analysis of pain:
- Duration of pain: when did the pain start?
- Mode of onset of the pain: gradual or sudden.
- Site & radiation or shifting: for example; "started as central abdominal pain
then shifted to right lower aspect of abdomen". Avoid using right iliac fossa
because it's a medical term.
- Character: dull, colicky.
- Severity: whether the pain interferes with daily activity or sleep.
- Aggravating or relieving factors.
- Associated symptoms: complete GIT and GUT review (arranged from the
more important to less important)  nausea, vomiting, loss of appetite,
fever, change in bowel habits, change in color of stool, dysphagia,
odynophagia, abdominal distention, yellowish discoloration of skin or
sclera (jaundice), loin pain, burning on urination, change in color of urine,
change in amount of urine, frequency of urination, nocturia, hesitancy,
intermittency.
2) Patient reaction: what did the patient do about the pain and where did
he/she go (e.g. private doctor, hospital)?
3) Hospital reaction:
- What investigations were done and what are the results?
- What treatment did the patient receive?
4) Condition of the patient now: improved, same or worse.

Example:
Chief complaint: abdominal pain for 2 days duration.
History of present illness:
Pre-op Hx: Patient's condition started 2 days ago in the evening as
abdominal pain of gradual onset, central in location, dull in nature, moderate
in severity, no aggravating or relieving factors. After 10 hours the pain shifted
to right lower abdomen & became more severe. The pain is associated with 2
episodes of vomiting, loss of appetite and low grade fever. There is no change
in bowel habits or color of stool, no dysphagia, no odynophagia, no abdominal
distention, no yellowish discoloration of skin or sclera, no loin pain, no burning
on micturition, no change in urine color, no change in amount of urine or
frequency of urination, no nocturia, no hesitancy or intermittency.
Yesterday at 7:00 PM, the patient went to the emergency department, He was
examined, investigations were done in the form of blood & urine tests and he
was diagnosed with appendicitis. He received IV fluids & IV medications, then
he was referred to operating theater.

Op Hx: The patient was admitted to operating theater at 11:00 PM for

appendicectomy. The operation was done under general anesthesia. There
were no known complications & no blood transfusion. The patient was
discharged from the operating theater at 12:30 AM. He regained partial
consciousness at 12:30 AM and full consciousness at 2:00 AM.

Post-op Hx: Day 0: the patient had cough, sputum, mild pain at the site of
operation. But there was no fever, no nausea or vomiting, no oral intake, no
chest pain, no shortness of breath. He passed urine but hasn't passed flatus
or stool. No leg pain & hasn't started mobilizing yet. He received IV fluids & IV
medications.

Acute Cholecystitis
History taking:

Chief complaint: right upper abdominal pain for ## days or hours

History of present illness:
1) Analysis of pain:
- Duration of pain: when did the pain start?
- Mode of onset of pain: gradual or sudden.
- Site & radiation or shifting: for example; "Right upper abdominal pain
radiating to the right shoulder". Avoid using right hypochondrial pain
because it's a medical term.
- Character: dull, colicky, sharp.
- Severity: whether the pain interferes with daily activity or sleep.
- Aggravating or relieving factors: usually aggravated by food especially
fatty food.
- Associated symptoms: complete GIT and GUT review (arranged from the
more important to less important)  nausea, vomiting, yellowish
discoloration of skin or sclera (jaundice), loss of appetite, change in color
of stool (pale 'clay-colored' stool), change in urine color (dark 'tea-colored’
urine), itching.* fever, change in bowel habits, dysphagia, odynophagia,
abdominal distention, loin pain, burning on urination, change in amount of
urine, frequency of urination, nocturia, hesitancy, intermittency.
2) Patient reaction: what did the patient do about the pain and where did
he/she go (e.g. private doctor, hospital)?
3) Hospital reaction:
- What investigations were done and what are the results?
- What treatment did the patient receive?
4) Condition of the patient now: improved, same or worse.

* Note: jaundice, pale stool, dark urine & itching occur in obstructive jaundice
when a stone moves from gallbladder into the biliary tree and obstructs the
common bile duct.

Example:

Chief complaint: right upper abdominal pain for 3 days duration.

History of present illness:
Patient's condition started 3 days ago as right upper abdominal pain of
sudden onset, radiating to right shoulder, the pain is continuous, moderate in
severity, aggravated after eating & no relieving factors. The pain is associated
with 4 episodes of nausea & vomiting, the vomiting contains undigested food
from previous meal but no blood or bile & no specific taste or odour. The pain
is also associated with mild fever which is continuous but no sweating or rigor.
There's no yellowish discoloration of skin or sclera, no change in color of
stool, no change in color of urine, no itching, no loss of appetite, no
dysphagia, no odynophagia, no abdominal distention, no loin pain, no burning
on urination, no change in amount of urine or frequency of urination, no
nocturia, no hesitancy, no intermittency.
On the next day (2 days ago), the patient went to a private doctor which
examined her and send her for blood tests, urine tests and ultrasound and he
diagnosed her as acute cholecystitis and then referred her to the hospital for
admission. The patient was admitted to the hospital yesterday at 9:00 AM. In
the hospital, blood and urine tests were done & she received IV fluids, IV and
oral medications.
Regarding her condition now, the pain, fever and nausea and vomiting are
subsided and she is waiting for further evaluation and management.

Breast Mass
History taking:

Chief complaint: breast mass for ## duration.

History of present illness:
1) Analysis of mass:
- Time and mode of discovery: when and how did the patient discover the
mass?
- Site.
- Size: approximate size.
- Painful or painless.
- Aggravating or relieving factors.
- Associated symptoms: ask about local symptoms such as nipple
discharge, skin changes. Systemic symptoms such as fever, fatigue,
headache, back pain, shortness of breath, jaundice (suggests metastatic
breast cancer).
- Changes in the mass from discovery until now (e.g. increased in the size,
became painful).
- Risk factors of breast cancer (some doctors may not agree on this): ask
about age menarche, age of menopause, number of children, breast
feeding, use of oral contraceptive pills (OCP), and family history of breast
cancer.
2) Reaction: where did the patient go, and what investigations were done?
(e.g. fine needle aspiration biopsy, excisional biopsy).
3) Condition of the patient now.
Example 1: Painless breast mass (possibly
tumor):

Chief complaint: breast mass (swelling) for 2 weeks duration.

HPI: Patient’s condition started 2 weeks ago when she accidently discovered
a mass in her breast while she was taking shower. The mass is located in the
upper outer aspect of the right breast and is small in size. The mass is
painless. There are no associated symptoms such as nipple discharge, skin
changes of the mass, fever, fatigue, headache, shortness, jaundice, bone
pain. The mass gradually increased in size over the last 2 weeks but
remained painless.
The age of menarche was at 12 years, the patient has 2 children, no breast
feeding were done, she uses oral contraceptive pills since 5 years and she
has no family history of breast cancer.
2 days ago the patient went to a private doctor which examined her and
referred her to the hospital for surgical biopsy.
The patient was admitted to the hospital yesterday, blood investigation were
done and she is currently waiting for biopsy.

Example 2: Breast abscess:

Chief Complaint: breast swelling (mass) for 5 days duration.

HPI:
Pre-Op: Patient’s condition started 5 days ago as sudden onset of breast
swelling, the swelling is located in the left breast, moderate in size associated
with pain throbbing in nature, severe and continuous, aggravated by touching
but no relieving factors and no radiation. There’s also fever, high grade and
continuous. The swelling gradually increased in size and pain increased in
severity.
The patient took some oral medications and antipyretics but did not relieve the
condition.
Yesterday, the patient went to a private doctor which examined her,
diagnosed her with breast abscess and referred her to hospital for admission.
In the hospital, blood investigations were done.

Op Hx: The patient was admitted to the operating room yesterday at 8:00 PM
for abscess drainage. The procedure was done under general anesthesia. No
known complications. The patient was discharged from operation room at
8:30 PM and she regained partial consciousness at 8:30 PM and full
consciousness at 9:30 PM.
Post-op Hx: “Similar to other cases”

Hernia
History taking:

Chief complaint: e.g. swelling in the right groin.

History of present illness:
1) Analysis of mass:
- Time and mode of discovery: when and how did the patient discover the
mass?
- Site.
- Size: approximate size.
- Painful or painless.
- Aggravating or relieving factors (coughing, laughing, standing, lying down).
- Associated symptoms: ask about the GIT symptoms.
- Changes in the mass from discovery until now (e.g. increased in the size,
became painful).
2) Reaction: where did the patient go, and what investigations were done?
3) Condition of the patient now.

Example:

Chief complaint: right groin swelling for 1 year duration.

HPI:
Patient’s condition started 1 year ago when he accidently discovered a small
swelling in the right groin while he was showering. The swelling is painless.
Increases in size by coughing or laughing and decreases in size while lying
down. There are no associated symptoms such nausea, vomiting, anorexia,
fever, abdominal pain, abdominal distension, changes in bowel habit or color
of stool, jaundice.
The swelling gradually increased in size over the last year.
The patient visited a private doctor which examined him and referred him to
the hospital for admission.
In the hospital, blood investigations were done and the patient is waiting for
surgery.

Thyroid Swelling
History taking:

Chief complaint: e.g. neck swelling for ## duration.

History of present illness:
1) Analysis of mass:
- Time and mode of discovery: when and how did the patient discover the
swelling?
- Site.
- Size: approximate size.
- Painful or painless.
- Aggravating or relieving factors.
- Associated symptoms: ask about:
- Local symptoms: shortness of breath (pressure on trachea), difficulty
swallowing (pressure on esophagus), and hoarseness of voices (pressure
or invasion of recurrent laryngeal nerve).
- Symptoms of hyperthyroidism: palpitation, weight loss, increased appetite,
change in bowel motion toward diarrhea, heat intolerance, sweating,
nervousness, anxiety, insomnia, menstrual changes (oligomenorrhea or
amenorrhea), proximal muscle weakness (some consider it a sign rather
than a symptom; ask about ability to comb the hair and stand from sitting
position), tremor (also a sign).
- Symptoms of hypothyroidism: fatigue, cold intolerance, change in bowel
motion toward constipation, apathy, excessive sleeping, weight gain,
decreased appetite, menstrual changes (heavy period: menorrhagia)
- Changes in the mass from discovery until now (e.g. increased in the size,
became painful).

2) Reaction: where did the patient go, and what investigations were done?
3) Condition of the patient now.

Example:
Chief complaint: neck swelling for 1 month duration
HPI:
Patient’s condition started 1 month ago when she accidently discovered a
small swelling in the frontal aspect of the neck on the right side while she was
looking at herself in the mirror. The swelling is painless. No specific factors
that increase or decrease the swelling. There are no associated symptoms
such as shortness of breath, difficulty swallowing, hoarseness of voice,
palpitation, changes in the weight, changes in the appetite, changes in bowel
motion, changes in the menstruation, heat or cold intolerance, fatigue, sleep
disturbances, nervousness.
The swelling gradually increased in size over the last month.
The patient visited a private doctor which examined her and referred to the
hospital for admission for surgical biopsy.
In the hospital, blood investigations were done and the patient is waiting for
surgery.

Operative Hx
History taking:

Ask about the following:

- Name & reason of the operation.
- Time of admission to operating theater.
- Type of anesthesia.
- Blood transfusion.
- Known complications (note  some doctors would not agree on asking
this question because the patient is unconscious and unaware of the
complications).
- Time of discharge from operating theater.
- Time of regaining consciousness.

Example:
Op Hx: The patient was admitted to the operating theater at 9:00 AM for
elective cholecystectomy. The operation was done under general anesthesia.
There were no known complications & no blood transfusion. The patient was
discharged from the operating theater at 10:30 AM. She regained partial
consciousness at 10:30 AM and full consciousness at 11:30 AM.
Post-op Hx
History taking:

Ask about the following points and repeat them every day starting from
day 0 (day of operation):
- Fever (review the causes of post-op fever, below).
- Nausea and vomiting (causes: pain, opioids analgesics, paralytic ileus,
and anesthesia).
- Oral intake: solid and liquid.
- Cough/sputum (causes: anesthesia, chest infection).
- Dyspnea.
- Chest pain.
- Pain at site of operation: excessive pain maybe caused by wound
infection.
- Wound discharge or bleeding.
- Passage of flatus or stool (indicates the return of GIT function).
- Passage of urine.
- Mobility (i.e. does the patient get up and start walking? prolonged
immobility is bad  DVT).
- Pain in the legs (may indicate DVT).
- Tubes & Drains: e.g. Foley catheter, nasogastric tube (NG tube), surgical
drain.
- Treatment received: Drugs & IV fluids.

Example:
Post-op Hx:
- Day 0: the patient had cough, sputum, mild pain at the the site of
operation. But there was no fever, no nausea or vomiting, no oral intake,
no chest pain, no shortness of breath. She passed urine but hasn't passed
flatus or stool. No leg pain & hasn't started mobilizing yet. She received IV
fluids & IV medications.

- Day 1: No fever, no nausea or vomiting, no cough, no chest pain or

dyspnea, she passed flatus and stool & oral intake was resumed in the
form of liquid & soft food (e.g. orange juice & biscuit). The pain is
 decreased at the site of operation. The patient started walking in the ward
and going to bathroom. She received IV fluids & IV medications.

- Day 2: no fever, no nausea or vomiting, no cough, no chest pain or

shortness of breath, mild pain at operation wound, normal oral intake,
normal passage of stool and urine, no leg pain and normal mobility.

Notes
Criteria of colicky pain:
- Intermittent.
- Hollow viscus
- Smooth muscles
- Peristalsis.
- Distal obstruction.

Seen in the following organs: bowel, ureters, fallopian tubes, biliary tree, &
salivary glands ducts.

Causes of post-op vomiting:

- Pain: stimulation of chemoreceptor trigger zone.
- Drugs: narcotics; morphine. Prescribe an antiemetic with the narcotics.
- Effect of anesthesia.
- Paralytic ileus.

Note  The term acute abdominal pain generally refers to previously

undiagnosed pain that arises suddenly and is of less than 7 days' (usually less
than 48 hours') duration.

Ballotable organs:
- Kidney.
- Gravid uterus.
- Ovarian cyst.

Note  Auscultation for bowel sounds: 5 cm below & right to umbilicus &
wait for 2 minutes. Normal bowel sounds 8\minutes.
Note  Renal angle tenderness examination by thumb & fist.
Note  Shifting dullness: wait 30-60 seconds before turning the patient.

Post-op return of GI function:

- Small bowel: 12-24h.
- Stomach: 24-48h.
- Large bowel: 48-72h.

Causes of post-op fever:

Days 0, 1 & 2:
- Reactionary fever: anesthesia, tissue damage & absorption of blood &
inflammatory mediators.
- Atelectasis.
- Infection: clostridial infection.

Days 3, 4 & 5:
- Cellulitis & wound infection.
- UTI.
- Pneumonia.
- Thrombophlebitis.

Days 6, 7 & 8:
- DVT.
- Abscess.

Note  Drug fever & transfusion reaction can occur at any time.

Physical Exam

General Examination
- Introduce yourself.
- Obtain the identity of the patient.
- Explain to the patient what you're going to do.
- Do proper position (Sitting position), exposure, hands warming &
disinfection.

General look:
- Age group: child, young age, middle age, old age.
- Sex: male or female.
- Posture: sitting on the bed, lying on the bed.
- Comfortable or in pain.
- Dyspnic or not.
- Medical devices: IV cannula, IV fluid, oxygen cylinder.

Conscious level: conscious, alert and oriented (to person, to place, and to
time).

JACCOL (Jaundice, Anemia, Cyanosis, Clubbing, Oedema,

Lymph nodes):
- Jaundice: take the patient near the window and examine the upper sclera
under the sun light while asking patient to look down to expose the upper
sclera. Other site for jaundice exam: under the tongue.
- Pallor (Anemia): Sites of examination: conjunctiva, oral mucosa, palm of
the hand.
- Cyanosis: Central  lips. Peripheral  tip of the nose (some consider it
central), tip of fingers.
- Clubbing: when the angle between the nail bed and the nail plate becomes
more than 165 degree.
- Oedema: apply pressure over the shin of tibia at about 10 cm above
medial malleolus for about 30-60 seconds and then look for indentation.
Should be done bilaterally at the same time.
- Lymph node: some consider only the cervical nodes exam are part of the
general exam:
1) Cervical lymph nodes (most important):
- Superficial group  submental, submandibular, pre-auricular, post-
auricular and occipital.
- Deep group  along the internal jugular vein and the supraclavicular
nodes.
1) Axillary lymph nodes: 6 groups: anterior group (pectoral), posterior
group (subscapular), lateral group (humeral), central group,
interpectoral group and apical group (subclavicular).
 2) Inguinal lymph nodes: horizontal group  along inguinal ligament.
Vertical group  along long saphenous and femoral veins.

Vital signs:
- Pulse rate (PR): rate (measure for 15 seconds and multiply by four),
rhythm (regular or irregular), volume (normal, low, high), state of vessel
wall, (normal, sclerosed).
- Blood pressure (BP): measure with patient in sitting position and the arm is
at the heart level.
- Respiratory rate (RR): count the respiratory rate by looking at the chest
movement while pretending to measure the pulse.
- Temp: oral temperature is the standard, measure by placing the
thermometer under the tongue for 1-2 minutes. Axillary temp is 0.5 degree
C less than the oral temp. Rectal temp measurement is done in children
and it's 0.5 degree C more than the oral temp.

Example of presenting after doing the general exam:

- Middle age male, sitting on the bed, looking comfortable and not dyspic.
There is an IV cannula in the dorsum of his right hand with IV fluid drip
running.
- He is conscious, alert and oriented.
- Mild pallor, but no jaundice, no central or peripheral cyanosis, no fingers
clubbing, no leg edema, no lymphadenopathy.
- Vital signs:
PR: 76 bpm, regular, normal volume and normal vessel wall.
BP: 125/75 mmHg, in the right arm in sitting position.
RR: 14 breath/minute.
Temp: 36.8 C oral.

Abdominal Examination
- Introduce yourself.
- Obtain the identity of the patient.
- Explain to the patient what you're going to do.
- Do proper position (Supine position), exposure (From nipples to mid-
thighs), hands warming & disinfection.
Inspection:
Stand at the feet of the patient and look for:
1) Symmetry.
2) Shape of the abdomen: flat, scaphoid or distended.
3) Movement with respiration: absence of movement with respiration may
indicate peritonitis.

Kneel beside the patient and look for:

4) Epigastric pulsation: maybe normal in thin patient. Differential
diagnosis: abdominal aortic aneurysm (AAA), pancreatic or gastric
tumor overlying the abdominal aorta, vascular tumor in left liver lobe &
RV pulsation.
5) Visible peristalsis: look for 2 minutes. If visible, it may indicate bowel
obstruction.
6) Visible masses.

Stand beside the patient and look for:

7) Umbilicus: shape (inverted, flat or everted), position (normally midway
between xiphosternum and symphysis pubis), discharge, swelling,
redness.
8) Surgical scars: give clue about previous operations.
9) Hair distribution: hair loss in male may indicate chronic liver disease.
10) Dilated veins: may indicate chronic liver disease or inferior vena cava
obstruction.
11) Striae: may indicate previous pregnancy (striae albicans  white in
color), current pregnancy (striae gravidarum  brown in color) or
steroid abuse.
12) Hernial orifices: look for visible cough impulse by asking the patient to
cough while looking at groins and umbilical area.

Palpation:
Before palpating, always ask the patient about abdominal pain and full
bladder.
- Superficial and deep palpation: looking for rigidity (involuntary contraction
of abdominal wall muscles), guarding (voluntary muscle contraction),
tenderness, masses.
- Palpation for organomegaly:
1) Liver: palpate for the lower edge starting from right iliac fossa and
ascend upward while asking the patient to take deep breathes.
Normally, the liver is impalpable except in thin patients. Then, percuss
for the upper edge, starting from right 2nd intercostal space at
 midclavicular line and move downward. Normally the upper edge
reaches the 5th or 6th intercostal space.
2) Spleen: starting from right iliac fossa and move toward the spleen while
asking the patient to take deep breathes. Then percuss over the
spleen. Normally, the spleen is impalpable below the costal margin.
The spleen should be 2-3 times its size to be palpable below the costal
margin. “Read about the differentiating points between the spleen and
the left kidney”.
3) Kidneys: palpated by 2 methods: bimanual and ballottement method.
- Bimanual method: apply pressure on the kidneys by the two hands.
- Ballottement method (done only in palpable kidney): push the
kidney by one hand (displacing hand) toward the other hand
(watching hand).
4) Bladder: palpate by the ulnar (medial) border of the left hand starting
above the umbilicus and gradually move downward.

Percussion:
1) Ascites (fluid in the peritoneal cavity): 2 methods:
- Shifting dullness: done for smaller amount of fluid (>500 cc):
percussion of the abdomen starting from the umbilicus and move
laterally until the percussion note becomes dullness. Then turn the
patient to lateral decubitus position (on his side), wait for 30-60
seconds and then percuss again. If the percussion note changed
from dullness to tympanic then ascites is present.
- Transmitted thrills: done for larger amount of ascites (>1000 cc):
percuss on one side of the abdomen by the right hand while placing
the left hand on the other side for detecting the thrills transmitted
through the ascitic fluid. Note  Ask the patient or an assistant to
place his hand with the ulnar surface on the center of the abdomen
to prevent transmission of the thrills through the fatty tissue.
2) Percuss the entire abdomen.

Auscultation:
Auscultate the following structure by the diaphragm of the stethoscope:
1) Bowel sounds: place the diaphragm of the stethoscope over the right
iliac fossa, 5 cm (2 inches) below and lateral to the umbilicus and listen
for 2 minutes. Normal bowel sound are present as gurgling which
occurs at rate of 8-10/minute.
2) Renal artery bruit: place the stethoscope above and lateral to the
umbilicus and listen for bruits which may present in renal artery
stenosis.
Others:
 3) Bruit over the liver  vascular tumor in the liver.
4) Venous hum over the spleen  portal hypertension.
5) Bruit over the abdominal aorta  abdominal aortic aneurysm.

IMPORTANT NOTE: After finishing the abdominal examination, always say to

the examiner "now i should examine: the inguinal lymph nodes, the external
genitalia, PR exam, left supraclaviular lymph node (virchow's node) and the
back.

Left supraclavicular lymph node exam: Ask the patient to shrug his
shoulders and then palpate the lymph node. If enlarged, it may indicate intra-
abdominal malignancy such as gastric or pancreatic cancer.

Back exam:
Inspection: for scars, discoloration, swellings, hair loss, wounds, and ulcers.
Palpation:
1) Spine: palpate the spine for tenderness  spinal metastasis (tumor
secondaries).
2) Sacral edema: apply pressure on the sacral area with the thumb and
look for indentation.
3) Renal angle tenderness: apply pressure by the thumb over the renal
angle. If no tenderness, then hit the area gently with closed fist. Renal
angle is located at the junction of 12th rib and erector spinae muscle
(paraspinalis).

Thyroid examination
Consists of examination of thyroid proper & thyroid status:

- Introduce yourself.
- Obtain the identity of the patient.
- Explain to the patient what you're going to do.
- Do proper position (Sitting position), exposure (Neck & upper chest),
hands warming & disinfection.

Thyroid proper:
Inspection: (from front)
- Site, shape & size
- State of overlying skin (discoloration, ulceration, other masses, dilated
veins, & scars).
- Water swallowing, protrusion of the tongue, & elevation of the hands
upward (Pemberton's sign).

Palpation:
- Form front: 3Ts  temperature, tenderness & tracheal position (1 finger or
3 fingers technique).
- From behind: palpate the thyroid gland starting from the normal side then
the affected side & assess the features of the mass. Ask the patient to
swallow to assess movement with swallowing & retrosternal extension,
palpate carotid pulsation for displacement or obliteration (Berry sign), &
palpate cervical lymph nodes.

Percussion: (from front) over clavicles, sternum & upper chest. If dullness
 retrosternal goiter.

Auscultation: (from front) diaphragm of the stethoscope over the upper

lobes. If bruit  Graves’ disease or anaplastic cancer.

Others (not part of the examination sequence):

- Lahey's method for palpation of deep surface of the thyroid: to palpate the
left lobe, push the thyroid toward the left by the left hand to move the
thyroid from the tracheoesophageal groove & then palpate the deep
surface by the right hand.
- Crile's method for palpation of small nodules: keep the thumb on the lobe
to be examined & ask the patient to swallow, feel for small nodules on the
surface as the gland moves up & down.
- Kocher's test: bilateral compression of goiter leads to stridor.
- Gifford's sign: used to differentiate between intra-orbital mass and
thyrotoxicosis in unilateral exophthalmos. The inversion of upper eyelid is
possible in intra-orbital mass but impossible in thyrotoxicosis.

Thyroid status:
General look:
- Signs of weight loss or gain
- Agitation, restlessness or apathy and lethargy
- Clothes appropriate to the weather or not.
- The facial appearance and expression.
- Loss of the eyebrows  hypothyroidism.
- Carotene pigmentation of the face  hypothyroidism.
Eyes:
1) Lid retraction (Dalrymple`s sign): in primary gaze, the upper limbus and/or
the upper sclera are visible.
2) Infrequent blinking (Stellwag's sign).
3) Corneal ulceration (exposure keratopathy).
4) Cheimosis.
5) Ophthalmoplegia: test eyes movement in all cardinal positions of gaze.
Look specifically for impairment of movement in upper & lateral direction
due to restriction of superior rectus, lateral rectus & inferior oblique
muscles.
6) Lid lag (Von Graefe's sign): fix the patient's head with the left hand to
prevent neck movement, move a finger or pen up & down with a variable
velocity, at a distance of 40-50 cm & ask the patient to follow it with the
eyes. Note the lag of upper eyelid in downgaze which results in exposure
of larger portion of upper sclera. The lid lag may not occur unless the
muscles are fatigued by frequent movement up & down.
7) Exophthalmos: the lower sclera is visible between the inferior limbus &
lower eyelid. Assess the severity by:
- Naffziger's method (mild): stand behind the sitting patient & tilt the head
slightly backward & observe the protrusion of eyeball beyond the plane
of supraciliary ridge.
- Joffroy's sign (moderate): tilt the head slightly downward, ask the
patient to look upward & note the absence of the wrinkles on the
forehead.
- Mobius sign (severe): inability to maintain convergence of the eyes.
8) Opthalmoscopic examination.

Upper limbs:
1) Fine tremor: Ask the patient to raise the upper limbs forward, fan the
fingers, close the eyes. Then put a paper over the hands and look for
tremor.
Note  other method to examine for tremor: Ask the patient to protrude
the tongue without making it touching the lips or teeth.
2) Fingernails: clubbing, acropachy, onycholysis.
3) Palm of the hand: palmer erythema, muscle wasting, sweating,
dupuytren's contracture.
4) Dorsum of the hand: vitiligo, bruises & muscle wasting.
5) Radial pulse: sleeping or resting tachycardia, irregular pulse (AF or ectopic
beats), high volume & collapsing pulse (water-hammer).
6) Blood pressure.
7) Reflexes.
8) Muscles power.

Lower limbs:
1) Pretibial myxedema: thickened hyperpigmented skin with coarse hair over
the tibia.
2) Vitiligo.
3) Clubbing
4) Ankle jerk (delayed relaxation in hypothyroidism).

Proximal myopathy: Ask the seated patient to stand up without upper

limbs support or ask the patient to sit on the ground & then to stand up.

Hernia Examination
- Introduce yourself.
- Obtain the identity of the patient.
- Explain to the patient what you're going to do.
- Do proper position (Standing position), exposure (from the waist
downward), hands warming & disinfection.

Inspection:
- Site, shape, site & overlying skin condition.
- Ask the patient to cough & look for visible cough impulse on each side
separately.
- Inspect the scrotum for enlargement & shifting of the raphe. Then ask the
patient to elevate his scrotum to look for retroscrotal lesions.

Palpation:
- Temperature & tenderness.
- Can or cannot get above the swelling.
- Assess the features of mass.
- Ask the patient about to reduce the mass.
- Finger occlusion test & palpable cough impulse.
- Zieman's test.
Percussion

Auscultation: for bowel sounds.

Others: Abdominal, PR, & chest examination.

Mass Examination
- Introduce yourself.
- Obtain the identity of the patient.
- Explain to the patient what you're going to do.
- Do proper position, exposure, hands warming & disinfection.

Inspection: site, size, shape & skin condition.

Palpation: tenderness, temperature, consistency, edge, surface,

compressibility, thrills, pulsation.

Ulcer Examination
- Introduce yourself.
- Obtain the identity of the patient.
- Explain to the patient what you're going to do.
- Do proper position, exposure, hands warming & disinfection.

Inspection: site, size, shape, edge, depth, floor, discharge & skin condition.

Palpation: temperature, tenderness, ulcer base (fixity, induration), vascular

exam, neurological exam & lymph nodes.