General surgery physical examination

Done by Dr.Salem Mohammad AL-ma’aiteh - Orthopedic surgeon

Thyroid Examination
 Introduction:
 Wash hands, Introduce self, ask Patients name & DOB & what they like to be called, Explain
examination and get consent, Expose patient’s neck.

 General Inspection:
 Patient: stable, posture, anxious/ nervous, hot/ cold, facial complexion (myxoedema, flushed),
obvious muscle wasting, BMI, obvious swellings, dry hair/ waxy skin, Around bed.

 Hands:
 Fine tremor: patient holds arms and hands stretched out, fingers straight and separated. Can see
easily if you place a sheet of paper on top of hands.
 Nails: thyroid acropachy, onycholysis.
 Palms: moist&sweaty/ cold&dry, plamar erythema (thyrotoxicosis).
 Pulse (tachycardia and AF in thyrotoxicosis).

 Face
 Generally: waxy pale skin, hair loss (especially outer 1/3 eyebrows), myxedema (hypothyroidism).
 Eyes: lid retraction (upper eye lid), exophthalmos (sclera above and below iris), proptosis (forward
protrusion of eye; look from above and side).
 Extra-ocular muscles: H-test and ask about diplopia (ophthalmoplegia = Grave’s), lid lag.

 Neck:
 Inspection (from front): swellings, scars, swallow, stick out tongue (thyroglossal cyst moves on
tongue protrusion), hands above head (Pemberton’s sign = retrosternal goitre compresses SVC
and results in venous congestion).
 Palpation 1 (from behind): thyroid gland (over 2nd, 3rd, 4th tracheal cartilages) + while patient
swallows and sticks out tongue.
 Palpation 2 (from behind): full cervical lymph node exam.
 Percussion over sternum: for retrosternal goiter.
 Auscultation: thyroid bruit over each lobe.

 Finally:
 Proximal myopathy (patient stand up with arms crossed; shrug shoulders against resistance).
 Reflexes (increased in hyperthyroidism, decreased in hypothyroidism).
 Look for pretibial myxoedema* (Grave’s).

 To complete:
 Thank patient, Summarise and suggest further investigations you would do after a full history (e.g.
TSH, thyroid USS)
Lump examination:
 WIIPPPE: Wash your hands, Introduce yourself, Identity of patient (confirm), Permission (consent
and explain examination), Pain, Privacy, Exposure.
 History: Symptomatic, duration, progression, persistence, multiplicity.

 Examination:
 Site: Exact anatomical using distance measured from bony point.
 Size: 3D: width, length and depth (height).
 Shape: Spherical, elliptical.
 Surface: smooth (Slippery) or rough; flat or raised; regular or irregular, well or ill defined edge,
overlying skin, inflamed, ulceration, discharging sinuses (punctum).

 Consistency: hard (like your chin), firm (rubbery or spongy, Fluid-filled, like your nose) or soft
(like your earlobe).
 Pulsatility: Always let your hand rest still for few seconds on every lump to discover if it is
pulsating, Expansile pulsation (outward–upward), Transmitted pulsation (upward only) .

 Compressibility: disappear on pressure and reappear on release ex. vascular malformation and
fluid collection.
 Reducibility: reappear only on application of another force: cough.

 Fluctuation: the 2 fingers moved apart when middle area pressed, indicates a fluid- filled lump,
confirmed by eliciting a ‘fluid thrill’: Tapping a large fluid-filled swelling causes a pressure wave
which can be felt on the other side of the lump.

 Mobility: Fixation to skin (pinching the skin puckering or tethering), Mobility (try to move the
lump in 2 planes, lie superficial to a muscle), tested for mobility with the underlying muscles both
relaxed and contracted, If a previously mobile lump becomes fixed on contraction of the
underlying muscles it is likely that the lesion has infiltrated the muscle layer.

 Transillumination: Requires a bright pinpoint light source and darkened room, the light shoud be
placed on one side of the lump not directly on top of it. Indicates presence of clear fluid.

 Percussion: Dullness: Solid+fluid filled lumps, Resonance: Gas-filled lumps.

 Auscultation: bruits, murmurs & bowel sounds.
 Temperature.
 Tenderness.
 Specific examination of the lymph nodes which drain the site of the lump.
Breast Examination
 Wash hands, Introduce self, ask Patients name & DOB & what they like to be called, Explain
examination and get consent, Get chaperone, Expose patient (sitting first, then at 30˚).

 General inspection:
 Patient: age, cachexia.

 Look with patient sitting:

 Look for: asymmetry, local swelling, skin changes (erythema, dimpling, peau d’orange, scars),
nipple changes (Paget’s disease of the breast, inversion).
 In 4 positions:
 Arms relaxed.
 Hands rested on thighs.
 Hands actively pressed into hips (tenses pectorals).
 Hands behind head (to expose whole breast and accentuate dimpling).
 Also lift the breast to look in the submammary fold.

 Feel with patient lying:

 Position patient at 30 degrees. The patient’s hand on the side of the breast being examined
should be placed behind the patients head. Check pain first and start on normal side.
 Examine using both hands, massaging breast with your hand flat to skin. Use whole of all 4 fingers.
 Move your hands in step-wise increments around breast in a systematic manor (e.g. a spiral
motion from outside in).
 Examine the axillary tail between your first two fingers and thumb.
 Describe any lump (SSSCCCTTT): Site, Size, Shape, Consistency, Contours, Colour,
Tenderness, Temperature, (Transillumination).
 Ask the patient to gently massage each nipple to attempt to express any discharge.

 Lymph nodes:
 Put on gloves. Lymph nodes are palpated while lying first, then while sitting.
 Axillary lymph nodes: e.g to examine the right: ask the patient to hold your right biceps while
you support the weight of their right arm at their elbow with your right hand. Now place your left
arm over your right and place your left hand into their axilla. Now palpate the apical, lateral,
medial, anterior and posterior lymph node groups by pressing the soft tissues (hard) and rolling
them over the underlying harder tissues.
 Supraclavicular lymph nodes: feel with your fingertips pressed into the supraclavicular fossae
from the front.

 Summary
 Thank patient and cover them.
 Summarise and suggest further investigations you would do after a full history.
 Triple assessment:
 History & Examination.
 Imaging (ultrasound if <35y or mammogram if >35y).
 Tissue sampling (FNA if cystic or core biopsy if solid).
Respiratory Exam
 Introduction: Wash hands, introduce self, ask Patients name & DOB & what they like to be
called, Explain examination and get consent, Expose and sit patient at 45⁰.

 General Inspection:
 Patient wellbeing: stable, alert, comfortable, breathless, cachexic (cancer, emphysema),
Cushingoid (steroid use).
 General breathing: use of accessory muscles (COPD, pleural effusion, pneumothorax, severe
asthma), puffing through pursed lips (prevents bronchial wall collapse by keeping lung pressure
high in severe airway obstruction/emphysema).
 Noises: patients’ speech normal? (obstruction, recurrent laryngeal nerve palsy), stridor (large
airway obstruction e.g. mediastinal masses, bronchial carcinoma, retrosternal thyroid), wheeze,
cough (dry/bovine/productive), prolonged expiratory phase (asthma, COPD), clicks
(bronchiectasis), gurgling (airway secretions).
 Around the bed: oxygen, medication (metered dose inhalers, nebulisers), sputum pots (look at
sputum), cigarettes.

 Hands:
 Fine tremor (Beta-2 agonists); flaming tremor (CO2 retention in type 2 respiratory failure).
 Perfusion: peripheral cyanosis, capillary refill (>2s in hypoperfusion), sweaty/warm/clammy (CO2
retention), small muscle wasting (Pancoast tumour).
 Nails: clubbing (idiopathic pulmonary fibrosis, lung cancer, CF, bronchiectasis, sarcoidosis/TB),
tar stains (smoker).

 Pulse and Respiratory Rate:

 Pulse: rate and rhythm (tachycardia may indicate: hypoxia in severe asthma or COPD; PE;
infection), bounding pulse (CO2 retention).
 Count respiratory rate (while patient still thinks you are feeling pulse): tachypnoea (fever; severe
lung disease; hyperventilation), bradypnoea (sedation).

 Head and Neck:

 Face: Cushingoid (steroid use), plethoric (CO2 retention), telangiectasia/microstomia (systemic
sclerosis), butterfly rash (SLE), lupus pernio (sarcoid), lupus vulgaris (TB).
 Eyes: conjunctival pallor (anaemia or chronic disease), Horner’s syndrome (ptosis, miosis,
anhidrosis).
 Mouth: central cyanosis under tongue (hypoxia).
 Neck: JVP height (↑ in cor pulmonale), tracheal tug, tracheal deviation (pneumothorax pushes to
contralateral side; collapsed lung pulls to ipsilateral side; mass), notch-cricoid distance (<3 fingers
= lungs hyperinflation).

 Chest:
 Front first…
 Inspection:
 Chest wall: scars, skin changes, trauma, deformities (pectus carinatum e.g. in childhood asthma
or rickets; pectus excavatum e.g. in Marfan’s syndrome; barrel chest in emphysema or COPD),
kyphosis/scoliosis (restrict chest movements), radiotherapy tattoos.
 Chest wall movements: mainly upwards (emphysema), asymmetrical (fibrosis, collapsed lung,
pneumonectomy, pleural effusion, pneumothorax).
 Breathing: in-drawing of intercostal muscles (generalised is hyperinflation; localised is bronchial
obstruction), powerful expirations (asthma; chronic bronchitis), hyperexpanded chest (COPD).
 Palpation: supramammary and inframammary chest wall expansion (grip very hard around rib
cage with thumbs in air almost touching in expiration and watch thumbs move away from each
other during inspiration); feel for RV heave and palpable P2 (pulmonary hypertension).
 Percussion: compare left with right (start supraclavicluar, then on clavicles, then down to axilla)
(normally resonant; dull = consolidation or collapse; stony dull = pleural effusion; hyperresonant =
increased air space in emphysema, bronchitis, pneumothorax) N.B. Liver starts at 5th intercostal
space.

 Auscultation:
 Standard auscultation: patient breaths in and out deeply. Compare sides, starting in
supraclavicular area & ending in axillae. Decreased air entry = emphysema, pneumothorax,
pleural effusion, collapse. Added sounds: Pleural rub= pulmonary infarction, pneumonia, pleural
malignancy. Wheeze= asthma, COPD. Crackles: coarse (bronchiectasis or consolidation); fine
inspiratory at bases (pulmonary oedema); fine endinspiratory (pulmonary fibrosis).
 Whispering pectoriloquy: ask patient to whisper 99 (increased resonance = consolidation;
decreased resonance = effusion/pneumothorax).
 Listen for loud P2 i.e. loud second heart sound over pulmonary area (pulmonary hypertension).
 Now patient sit over bedside with crossed arms and percuss, auscultate and do vocal resonance
again on back (you must do it on front and back).

 Finally:
 Cervical lymph nodes (infection, carcinoma, lymphoma, sarcoidosis) (while patient still sitting)
 Calves: oedema (cor pulmonale), feel calves (swollen/tender = DVT)
 To Complete exam: Thank patient and cover them, “To complete my exam, I would like to see an
observations chart and do a peak flow”. Summarise and suggest further investigations you would
do after a full history.
Tension pneumothorax Hemothorax Cardiac tamponade
Breath sound Ipsilaterally decrease Ipsilaterally decrease normal
more than contralaterally
Percussion note hyperresonant dull normal
Tracheal location Contralaterally shifted Midline or shifted midline
Neck veins distended flat distended
Heart sound normal normal muffled
Abdominal Examination
 Introduction: Wash hands, Introduce self, ask Patients name & DOB & what they like to be
called, Explain examination and get consent, Expose and lie patient flat.

 General Inspection:
 Patient: stable, pain/discomfort, jaundice, pallor, muscle wasting/cachexia.
 Around bed: vomit bowels etc

 Hands:
 Flapping tremor (hepatic encephalopathy).
 Nails: leukonychia (hypoalbuminemia in liver cirrhosis), koilonychia (iron deficiency anaemia),
Clubbing:
 RS 70%: Lung cancer (non-small cell), cystic fibrosis, idiopathic pulmonary fibrosis, Sarcoidosis, lung
abscess, bronchiectasis, tuberculosis, empyema, Mesothelioma, Arteriovenous fistula, thymoma.
 CVS: cyanotic congenital heart disease (tetralogy of Fallot), infective endocarditis, atrial myxoma.
 GI: Malabsorption (Celiac), Crohn's & ulcerative colitis, Cirrhosis, GIT cancer (lymphoma, GIST).
 Others: Graves' disease (thyroid acropachy), Familial & hereditary, axillary artery aneurysm (unilateral
clubbing), Hypertrophic pulmonary osteoarthropathy, Sickle cell d., thalassemia, trauma, pregnancy).
 Palms: palmar erythema (hyperdynamic circulation due to ↑oestrogen levels in liver disease/
pregnancy), Dupuytren’s contracture (familial, liver disease), fingertip capillary glucose monitoring
marks (diabetes).

 Head:
 Eyes: sclera for jaundice (liver disease), conjunctival pallor (anaemia e.g. bleeding,
malabsorption), periorbital xanthelasma (hyperlipidaemia in cholestasis).
 Mouth: glossitis/stomatitis (iron/ B12 deficiency anaemia), aphthous ulcers (IBD), breath odor
(e.g. faeculent in obstruction; ketotic in ketoacidosis; alcohol).

 Neck and torso:

 Ask patient to sit forwards:
 Neck: feel for lymphadenopathy from behind – especially Virchow's node (gastric malignancy).
 Back inspection: spider naevi (>5 significant), skin lesions (immunosuppression).
 Ask patient to relax back:
 Chest inspection: spider naevi (>5 significant), gynaecomastia, loss of axillary hair (all due to
↑oestrogen levels in liver disease/ pregnancy).

 Abdomen:
 Inspection: distension (Fluid, Flatus, Fat, Foetus, Faeces), incisional hernias (ask patient to
cough), scars, striae (pregnancy, Cushing’s), spider naevi, movement with respiration (absent in
peritonitis), obvious pulsations, distended portal-systemic anastomoses (portal hypertension).
 Palpation: ask if any pain (start away from painful areas):
 Superficial palpation: crouch to patient’s level and roll fingers of one hand over the 9 regions
while watching the patient’s face. Check for: tenderness, guarding (peritonitis), rebound
tenderness (peritonitis).
 Deep palpation: palpate deeply in each of the 4 quadrants with both hands – the upper hand to
exert pressure, the lower hand to feel (you can be standing). Check for: masses, deep tenderness
and, if relevant, Rovsing’s sign (appendicitis) and Murphy’s sign (cholecystitis).
 Liver palpation: start from RIF & palpate in increments towards right costal margin (push in on
each inspiration), hepatomegaly: metastasis/HCC, cirrhosis, hepatitis, RVF, leukemia/ lymphoma.
 Spleen palpation: start from the RIF and palpate in increments towards left costal margin (push
in on each inspiration). It can be felt better if patient rolls onto their right side with tucked legs
(splenomegaly = lymphoma/ leukaemia, myelofibrosis, malaria, portal hypertension, haemolysis)
Spleen vs kidney: can’t get above it spleen, spleen notched, spleen not ballotable, spleen moves
down on inspiration.
 Kidney palpation: one hand anterior, one posterior. Ask patient to expire and press up into renal
angle with posterior hand and press down with your anterior hand – as patient breaths in you may
feel it between your hands. Ballot the kidney by flexing the metacarpophalangeal joints of your
posterior hand. Do ‘flick, flick, stop’ and repeat as necessary.
 AAA palpation: press down with finger tips (one hand each side) in the horizontal plane of the
umbilicus – start laterally and move medially (pulsatile mass can be normal, expansile mass is
AAA).

 Percussion:
 General percussion qualities if relevant (percussion tenderness = peritonitis; tympanic = flatus).
 Liver: start from the RIF, percuss upwards and find upper and lower borders (should become dull
over liver).
 Spleen: percuss upward towards spleen from RIF (dull percussion note of the spleen is only
heard when it is enlarged). Percuss up to Traube’s space which is just above left costal margin in
mid-clavicular line (if resonant = no splenomegaly).
 Flank: tap all the way across abdomen horizontally each way from centre. The flank should be
resonant; if a dull percussion note is heard in flanks, demonstrate shifting dullness (patient roll to
side and percuss all way across again) ± fluid thrill (patients hand hard on abdomen mid-line and
tap one side and feel other) (ascites).

 Auscultation:
 Listen for bowel sounds at ileocaecal valve in RLQ until heard, up to 1min (tinkling = obstruction;
absent = paralytic ileus/peritonitis).
 Aortic/renal bruits (1cm superior and lateral to umbilicus bilaterally).

 Finally: Check for ankle oedema (hypoalbuminaemia).

 To Complete Exam: Thank patient and cover them, “To complete my exam, I would examine the
external herneal orifices, the external genitalia and do a digital rectal examination”. Summarise
and suggest further investigations you would do after a full history.
Inguinal Hernia Examination
 Introduction: Wash hands, Introduce self, ask Patients name & DOB & what they like to be
called, Explain examination and get consent, Get a chaperone, Expose patient from waist down
and ask them to stand up, Apply gloves.

 General Inspection:
 Patient: stable, pain/ discomfort, pallor, muscle wasting/ cachexia.
 Around bed: vomit bowels.

 Inspection:
 From front…
 Lumps: size, shape, position; scrotal extension.
 Observe cough impulse.

 Palpation:
 Scrotal contents: feel from front. If any lump, determine if you can get above it.
 Lump/inguinal area (do both sides): feel from side with one hand on patient’s back, and feel the
lump/inguinal ligament region with the other.
 Describe lump (SSSCCCTTT): Site, Size, Shape, Consistency, Contours, Colour, Tenderness,
Temperature, (Transillumination).
 Feel cough impulse (do both sides): compress lump/ inguinal areas firmly. Patient turns head to
opposite side and coughs. If swelling becomes tense and expands, there is a positive cough
impulse.
 Reducibility:
 Locate the deep inguinal ring (midway between ASIS and pubic tubercle).
 Press firmly on the lump and, starting inferiorly, try and lift it up and compress it towards the deep
inguinal ring.
 Once it is reduced, slide your fingers up and maintain pressure over the deep inguinal ring o Ask
patient to cough.
 If hernia reappears, it is a direct hernia; if not, it is an indirect hernia.
 Release and watch hernia reappear (indirect will slide down obliquely; direct will project forwards)
If you cannot reduce it, try again with patient lying.

 Percussion and Auscultation:

 Percuss and auscultate lump: this may reveal if bowel is present in hernia.

 Finally:
 Examine abdomen: look for anything that can cause increased intra-abdominal pressure.
 To Complete exam: Thank patient and cover them, “To complete my exam, I would do a full
abdominal examination and also do a cardiorespiratory assessment to determine the patient’s
fitness for operative reduction”. Summarise and suggest further investigations you would do after
a full history.
Stoma exam:
 Patient: Looks well, No acute abdomen.
 Abdomen: Signs of acute abdomen, Scar from stoma formation operation.
 Stoma:
 Site, Surrounding skin, Opening:
 Spout (iliostomy) or flush with skin (colostomy).
 Loop (2 openings) or end (1 opening).
 Contents: liquid faeces (iliostomy), solid faeces (colostomy) or urine (urostomy).
 Patient cough: look for signs of herniation.
 Palpate:
 Abdomen, Around stoma: also get patient to cough while feeling over stoma (herniation).
 Types of stoma:

 Colostomy:
o End colostomy: all of distal bowel removed, so proximal opening brought to surface. Uses: A-P
resection of low rectal tumours (anus is removed so can’t re-anastomose) or Hartman’s
procedure.
o Loop colostomy: two holes made in a central part of intact large bowel and brought to the
surface to form a stoma. This is performed to stop faeces passing through distal bowel to protect a
distal anastamosis while bowel sutures heal. Usually reversed after 6 weeks. Uses: to protect
anastamosis after a segment of bowel removed e.g. tumour resection.
o Barrel colostomy: a segment of bowel removed and both ends brought to the surface to form a
stoma. Uses: sigmoid volvulus.
 Iliostomy:
o End iliostomy: whole colon removed. Uses: UC, FAP, Hirschsprung's disease.
o Loop iliostomy: as loop colostomy.
 Urostomy:
o Ileal conduit: short segment of ileum removed to act as baldder. One end sutured to skin, other
end sutured to ureters. Uses: cystectomy for bladder carcinoma.
 Complications of stoma:
 Early: high output stoma (→dehydration, hypokalaemia), retraction, bowel obstruction, ischaemia
of stoma.
 Late: parastomal hernia, prolapse, fistulae, psychological complications, skin dermatitis, fistulae
formation.
 Stoma care:
 Stoma nurse is best to help. Most bags have an emptying tap. These are emptied when 2/3 full,
irrigated with water daily, and changed every 2-4 days.
 Some bags are temporary and are changed whenever they are full
 Diet: take lots of fluids, small amounts of fibre for first 2 months. Avoid: nuts, coconuts, sweetcorn,
celery (cause blockage); broccoli, beans, fizzy drinks (cause flatulence).
 Bag can be left on in the shower.
Digital Rectal Exam
 Introduction:
 Wash hands, introduce self, ask Patients name & DOB & what they like to be called, explain
examination and get consent.
 Get chaperone.
 Explain procedure is intimate but explain why it is necessary.
 Explain what you want the patient to do “undress from the waist down, then lie on your left side
then bring your knees up to your chest”.
 Give them a sheet to cover up until you are ready.
 Use the patients name and comfort them.
 Explaining what you are doing and checking they are OK throughout.

 Gather equipment:
 Gloves: put on, Lubricant, Gauze.

 Inspection:
 Part the buttocks and look for any blood, rashes, fistulae, fissures, excoriations and warts.
 Ask the patient to bear down and look for any rectal prolapse.
 Ask the patient to squeeze their bottom and look for anal sphincter competency.

 Examination:
 Lubricate gloved finger and approach the anus from posteriorly. Pause when the finger is over the
anus and wait until the sphincter relaxes.
 Advance finger into anus:
 Comment on consistency of any faeces.
 Ask the patient to bear down (brings high rectal lesions lower).
 Ask the patient to squeeze your finger (tests anal tone).
 Do a 360˚ sweep feeling for any masses or wall thickenings.
 Feel the 2 lobes of prostate gland & comment on any masses, symmetry, consistency and size.
 Remove finger and wipe on cotton wool gauze - determine if there is any faeces and any mucus
or blood. Clean the anus.

 To complete: Thank patient and cover patient, Document procedure finding and that a chaperone
was present and who it was. Summarise and suggest further investigations you would do after a
full history e.g. PSA, Rectal USS.
Testicular Examination
 Introduction: Wash hands, Introduce self, ask Patients name & DOB & what they like to be
called, Explain examination and get consent, Get a chaperone, Expose patient from waist down,
have patient stood up, Apply gloves.

 General Inspection:
 Patient: stable, pain/ discomfort, cachexia, body hair loss, gynaecomastia. Around bed.
 Inspection From front but ensure you also lift scrotum to inspect posteriorly:
 Skin: erythema, rashes, excoriations, scars, ulcers.
 Testes: level (left usually lower), swelling, oedema, masses.
 Inspect penis and retract foreskin.

 Palpation:
 Perform with patient standing then lying. Support the testes with left hand and feel with index
finger and thumb of right hand.
 Testes: feel inferior, middle and superior parts of testes. Note size, consistency, any
lumps/masses. Describe lump (SSSCCCTTT): Site, Size, Shape, Consistency, Contours, Colour,
Tenderness, Temperature, Transillumination.
 Epididymis: feel around the posterior aspect of each testis for epididymis (epididymitis).
 Spermatic cord: feel neck of scrotum (superior to testes) with thumb anteriorly and index finger
posteriorly (feels like string) Examine inguinal lymph nodes.
 Reflexes:
o Phren’s test: if testicular pain is relieved by elevating testes it’s epididymitis; if not, it’s testicular
tortion.
o Cremateric reflex: stroke inside of leg and watch scrotal skin tighten.

 Finally:
 Feel supraclavicular lymph nodes: testicular cancer metastasises here (not inguinal nodes).
 To Complete exam: Thank patient and cover them, “To complete my exam, I would do a full
abdominal examination and hernia examination”. Summarise and suggest further investigations
you would do after a full history.
Peripheral Arterial Exam
 Introduction: Wash hands, introduce self, and ask Patients name & DOB & what they like to be
called, explain examination and get consent. Lie patient flat and expose legs.
 General Inspection:
 Patient: stable, pain/ discomfort, face, position.
 Risk factors: age, body habitus.
 Around bed: oxygen, mobility aids, cigarettes, medicine
 Upper Limbs:
 Expose patient’s arms…
 Inspection: skin colour changes (pink, pale, matted); ischaemia changes (gangrene); tar stains in
fingers; tendon xanthomata
 Palpation: Temperature, Capillary refill, Pulses: radial (including radio-radial & radio-femoral
delay), brachial, and blood pressure in both arms (>10mmHg difference significant).
 Radial artery: felt just lateral to tendon of flexor carpi radialis against styloid process of radius.
Palpable radial pulse indicate a systolic blood pressure greater than 80 mmhg.
 Brachial artery: elbow is slightly flexed and supported by your left hand, examine by right thumb,
medial to tendon of biceps muscle against lower end humerous.
 Face:
 Eyes: corneal arcus, xanthalasma.
 Mouth: central cyanosis.
 Carotid pulse character and bruits:
 Common carotid artery: felt against transverse process of C6. Put your thumb on carotid artery
at level of cricoid cartilage medial to sternomastoid & ask patient to look to same side. Or stand
behind patient & feel carotid with your middle 3 fingers.
 Abdomen:
 Body habitus, scars.
 Aortic pulse: inspect for pulsation, palpate, auscultate (AAA) (NB. it is important to feel this even
if the focus of the examination is the legs).
 Femoral pulse: palpate both at once, auscultate. At mid-inguinal point "in groin region halfway
between symphysis pubis and ASIS.
 Lower Limbs (MAIN PART):
 Check if pain in legs. Examine with patient standing fully, then laying supine.
 Inspection (especially feet):
 Skin colour changes (pink, pale, matted).
 Ischaemia changes: especially between toes and heels.
 Trophic changes (shiny skin, hair loss, thin skin, and ulcers - check pressure areas).
 Muscle wasting, Ankle oedema.
 Scars (e.g. CABG venous grafting, femoral-popliteal bypass).
 Also take elements of diabetic foot exam inspection
 Palpation:
 Temperature: along length of leg. Capillary refill. Pulses: starting proximally (popliteal, posterior
tibial, dorsalis pedis); squeeze calves (tenderness= critical ischaemia); sensation.
 Leg circumference: assessed by measuring the circumference of the leg 10 cm below the tibial
tuberosity and 10 to 15 cm above the upper edge of the patella. If there is a difference of >3 cm
between the extremities to be significant.
o Popliteal artery: felt in middle of popliteal fossa while patient lies supine with knee slightly flexed,
place both thumbs on patella & place fingers of both hands firmly into popliteal fossa.
o Anterior tibial artery: midpoint between two malleoli anteriorly, lateral to tendon of extensor
hallucis longus. Posterior tibial artery: 2 cm behind & below medial malleolus.
o Dorsalis: felt lateral to extensor hallucis longus tendon against navicular bone. Absent in sever
lower limb ischemia & in 5% of normal subjects.
 Buerger’s angle and filling/ reperfusion time:
o Check if pain in leg, With patient lying supine, lift their leg until heel becomes pale then hold for
30s (if it does not become pale, test is normal; if it becomes pale, this angle is Buerger’s angle).
o Now ask patient to sit up and hang their legs over the edge of the bed. Watch their feet for 2-3min.
o Pallor followed by reactive hyperaemia (rubor) on dependency, is a positive test and implies
significant peripheral arterial disease.
 To Complete Exam: Thank patient and cover them, “I would complete my exam by performing a
full cardiovascular exam, testing sensation and using Doppler ultrasound for pulses”. Summarise
and suggest further investigations you would do after a full history (e.g. ABPI, duplex USS,
angiography, bloods, ulcer swabs, ECG, CXR, HbA1C...).
 Measure The Ankle Brachial Index (ABI):
 Ankle to Brachial Index (ABI); simply, the ratio of the systolic blood pressure at the ankle to the
systolic blood pressure at the arm (brachial artery); ankle pressure taken with Doppler.
 ABI= higher of Ankle systolic pressure (Posterior tibial “PT” or dorsalis perdis “DP”)/ higher arm
systolic pressure (left or right arm)
 Calcified arteries ≥1.4. Normal ABI: ≥1.0. Claudicator ABI: <0.6. Rest pain ABI: <0.4.

Ulcer Examination:
 Introduction, consent, appearance, privacy and exposure.
 Inspection:
 Site, Size, Shape, Edge, Depth, Floor (can be seen, Discharge), Margin
(Surrounding skin), Inspecting for other ulcers (web spaces and pressure
areas), Signs of ischemia and edema, Deformities, amputations and
gangrene.
 Palpation:
 Tenderness, Temperature, Crepitus, Base (can be palpated), Mobility of ulcer.
 Vascular examination: (Capillary refill, Pulses, other tests (Burger test,
ABI)).
 Neurological examination: (Fine touch, vibration sense, proprioception).
 Regional lymph nodes examination.
 Relevant diagnostic tests (Doppler us, angiography....)
 Management:
 Primary treatment involves:
 No predisposing factors: debridement & repair of defect, on assumption that recurrence will not
occur once normal function and sensibility returns.
 In paraplegic patient recurrence is likely, so management involve multidisciplinary approach.
 Skin care, dressings, optimising nutrition; correcting anaemia; preventing infection.
 Relieving pressure (special mattress; dispersion cushions or foams, use of low air-loss &
airfluidised beds, nursing care; relief of muscle spasm & contractures).
 The bed-bound patient should be turned every 2 h,
 The wheelchair-bound patient being taught to lift themselves off their seat for 10 s every 10 min.
 Surgery involves:
 Debridement to promote healing & plastic surgery to reconstruct defect (skin flaps), use of VAC,
urinary/faecal diversion.
Diabetic Foot / Foot Ulcer Examination
 Introduction: Wash hands, introduce self, ask Patients name & DOB & what they like to be
called, Explain examination and get consent, Expose feet.
 Inspection:
 General: gait, shoes (flat heel, pattern of wear).
 Skin: vascular insufficiency (hair, pallor), rubor/corns/callous at pressure points, texture, fissures,
skin breaks/lesions/ulcers, diabetic dermopathy, infection (swelling, erythema, gangrene,
cellulitis), oedema, venous eczema/lipodermatosclerosis.
 Nails: dystrophic, ingrown.
 Webspaces: cracked, infected, ulcers, maceration.
 Deformity: claw toes, bony prominency, Charcot’s joints (joint swelling, collapse of medial
longitudinal arch – due to “loss protective pain sensation”).
 Describe any ulcer: size and site, characteristics (shape, edge, colour), secondary features.
 Palpation (Arteriopathy):
 Temperature: use dorsum of each hand to feel up legs.
 Pulses: femoral, popliteal, pos tibial, dorsalis pedis. Capillary refill.
 Palpation (Neuropathy):
 Sensory: show patient how each feels on sternum before and get them to close their eyes:
 Monofilament - use monofilament fully out and use enough force to make it bend. Touch foot in
multiple places.
 128Hz Tuning fork - use fingers to twang end with prongs and hold circular base on the patient’s
joint. Start over big toe joint first and move proximally if patient can’t feel it. Ask patient to tell you
when they feel a vibration, and ask them to say when it stops (manually stop it)
 Proprioception - hold distil phalanx of big toe with a finger each side (while stabilising proximal
phalanx with other hand). Ask the patient to look and show them the up and down positions. Now,
ask them to close their eyes and wiggle up and down a few times, then stop and ask patient if it’s
up or down. If no proprioception, move to proximal joints until they can.
 Motor: muscle wasting, pes planus, pes cavus, Charcot joints.
 Reflexes: ankle jerk. Autonomic: sweaty, dry cracked skin.
 To Complete exam: Thank patient and cover them, “To complete my exam, I would examine do a
full neurovascular examination and educate the patient”. Summarise and suggest further
investigations you would do after a full history:
 ABPI, Doppler arterial pulses, Blood glucose, HbA1C.