= = `äáåáÅ~ä=bñ~ãáå~íáçå= få= pìêÖÉêó= by Peshraw Karim
.
Shanyar Qadir
© 2014
.
Shvan Omar
Index
Chapter
Page
Chapter 1: Examination of a Swelling…………………………………………………
4
Chapter 2: Examination of an Ulcer…………………………………………………...
8
Chapter 3: Examination of Scrotal Swelling…………………………………………..
10
Chapter 4: Examination of an Inguino-Scrotal Swelling……………………………… 12 Chapter 5: Examination of Intra-Abdominal Lump………………………………….... 15 Chapter 6: Examination of a Breast Lump…………………………………………….
22
Chapter 7: Examination of a Thyroid Swelling………………………………………..
27
Chapter 8: Examination of Peripheral Vascular Disease (PVD)………………………
31
Chapter 9: Examination of Varicose Veins……………………………………………
36
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Note: Although this booklet is intended to be used as a stand-alone resource, the procedures are better understood if you use this booklet with the accompanying Indian Videos. After all, this is a transcript of those videos. Thanks
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Chapter 1: Examination of a Swelling
Inspection Site: exact anatomic position Number: single or multiple Shape: spherical, oval, kidney-shaped or irregular Size: measure exact size in cm using a tape measure (measure longitudinal and transverse axis and if possible the depth) Surface: • •
The color: red in hemangioma, black in melanoma The surface is smooth or irregular
Overlying skin: is it normal? Inflamed? Or ulcerated? • • • • •
Shiny, smooth skin with prominent veins suggest sarcoma Black punctum over skin of a swelling is diagnostic of sebaceous cyst Redness of overlying skin indicates inflammation Presence of scar of previous surgery suggests that the swelling is recurrent one An edematous skin with multiple peels like an orange peel (termed as Peau d’Orange) appearance suggests an infiltrating malignant lump blocking cutaneous lymphatics.
Movement (pulsation): can be seen in aortic aneurysm
Site related signs: •
• •
If the swelling is over the abdomen or chest or spinal canal ask the patient to cough for an impulse on coughing. A visible increase in the size of the swelling synchronous with the cough is termed as impulse on coughing) If the swelling is in the limb inspect the distal limb for any pressure effects, like edema or nerve palsy If the swelling is in the neck, look for movement on deglutition
Review Inspection 1. Site & number 2. Shape & size 3. Surface & skin over the swelling 4. Pulsatility 5. Site related signs
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Palpation Temperature: with dorsum of your fingers compare temperature of the swelling with normal skin. Local rise in temperature could be due to: • • •
Cellulitis and abscess Sarcoma Vascular swelling
Tenderness: usually indicates inflammation Confirm size & shape Surface: is it smooth, lobular, nodular or irregular
Edge: palpate with tips of your fingers and note whether it is: • • • •
Well-defined and regular (mostly in benign swelling) Well-defined and irregular (mostly in malignant swelling) Diffuse and ill-defined (inflammatory swelling like cellulitis) Slipping edge (characteristic for lipoma)
Consistency: could be soft, cystic, firm, hard, bony hard or variable. If the swelling is soft or cystic look for the following signs: Sign of moulding (indentation): press a finger over the swelling for 1-2 seconds then remove it, if the swelling remains indented this indicates positive moulding sign. Sign of moulding is positive in: • • •
Sebacous cyst Dermoid cyst Colonic mass with fecal matter
Fluctuation: transmission of an impulse in two directions at right angles to each other. It implies presence of fluid in the swelling Trans-illumination: demonstration of transmission of light through a swelling. It indicates presence of clear fluid in the swelling. Transillumination is positive in: • • • • •
Cystic hygroma Epididymal cyst Meningocele with thin skin Ranula Congenital hydrocele
5
Impulse on coughing: if swelling is likely to be communicating with peritoneal, pleural cavity or spinal canal ask the patient to cough, if the swelling increases in size or becomes tense (when you grasp it) it indicates positive impulse or coughing. Reducibility: try to reduce or return the swelling to its normal cavity, it could be positive in: • • • •
Hernias Meningocele Varicocele Saphena varix
Compressibility: when the swelling is compressed it reduces in size but on releasing the pressure it returns to its original size without straining or coughing. This is characteristic of hemangioma. Pulsatility: seen in aortic aneurysm. Place four fingers over the swelling as far apart as possible and note the finger movement, if the fingers move upward and apart from each other this indicates an expansile pulsation as seen in aortic aneurysm. But if the fingers are raised vertically without moving apart from each other it is a transmitted pulsation, seen when a mass sits over an artery as stomach malignancies sitting over the aorta. Fixity: test fixity to skin, subcutaneous tissue, muscles & tendons, bone • • • • • • •
If it is fixed to the skin, the skin over it cannot be pinched off If the skin can be pinched off over the swelling this indicates that the swelling is under the skin Ask the patient to contract the underlying muscle: If the swelling is in the subcutaneous tissue above the muscle the swelling becomes more prominent and mobile in all directions. If the swelling is within the muscle itself it becomes fixed and immobile If the swelling is deep to the muscle it becomes less prominent and difficult to palpate. If the swelling is fixed to above it becomes totally immobile irrespective to muscle contraction.
Review Palpation • Temperature and tenderness • Confirm the size and shape • Palpate surface and edges • Note the consistency • If soft or cystic, do specific tests • Fixity to other structures
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Percussion Tympanic note indicates presence of gas in: • • •
Entertocele Pharyngocele Hydatid thrill in hydatid cyst
Auscultation •
Pulsation can be heard in vascular swelling or in swelling with rich vascularity
Focal examination 1. Examination of lymph nodes Palpate the regional lymph nodes, if they are enlarged then palpate the next group draining the previous ones for any enlargement.
2. Pressure effect on • • • •
Bone: erosion Artery: weak distal pulse Vein: edema and dilated veins Nerve: paresthesia and wasting
3. Joints above and below: look whether their movement is affected or not.
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Chapter 2: Examination of an Ulcer
Inspection 1) Size and shape of the ulcer (using a tape measure) 2) Number (single or multiple) 3) Location of the ulcer: • • •
Rodent ulcer → nose Tuberculous ulcer → neck Bedsore ulcer→ sacrum
• • •
Ischemic ulcer → dorsum of foot and toe Varicose ulcer → medial aspect of lower third of the leg Trophic ulcer → weight-bearing area (e.g. heel of the feet)
4) Margin and Edge of ulcer •
•
Margin is the border or transitional zone of skin around an ulcer. Types: o Healing margin (outer white – central blue – inner red) o Inflamed margin (red, irregular margin with inflamed surrounding skin) o Fibrosed margin (thickened white) Edge is the mode of union between the floor and the margin of ulcer. Types: o Sloping edge → healing ulcer o Undermined edge → tuberculous ulcer o Punched edge → trophic ulcer o Everted edge→ malignant ulcer o Raised edge → rodent ulcer
5) Floor of ulcer: is the exposed surface of the ulcer, we look for • • •
Type of Granulation tissue Amount of Slough (necrotic soft tissue not yet separated from living tissue) Nature of Discharge
6) Surrounding skin: if ulcer is spreading & infected, surrounding skin is shiny, red, and edematous due to cellulitis • • • •
Dark pigmentation & eczema → varicose ulcer Scars and puckering of skin → tuberculous ulcer Hypopigmentation → non-healing ulcer Large scar→ Marjolin’s ulcer
Review Inspection 1. Size & Shape 2. Number 3. Location 4. Margin & Edge 5. Floor 6. Surrounding skin
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Palpation 1) Surrounding skin: for temperature & tenderness 2) Ulcer: edge, floor, base •
Edge o Soft: healing ulcer o Firm: non-healing ulcer o Hard: malignant ulcer
•
Base (tissue on which the ulcer rests): o Consistency o Underlying structures (muscle, fascia or bone?)
•
Floor: o Granulation tissue: bleeding on touch? Healthy granulation tissue may show pinpoint hemorrhagic spots, while malignant ulcer may bleed profusely o Slough: attached loosely or firmly?
3) Test the fixity of the ulcer to the structures in its base Review Paplation 1. Surrounding skin 2. Ulcer: edge, floor, base 3. Test the fixity
Focal Examination 1. Lymph nodes • • •
Hard, discrete, non-tender → malignant ulcer Soft, tender → infective Non-tender, matted → tuberculous ulcer
2. State of arteries, veins, nerves • • • •
If ulcer in lower limb: ask patient to stand and look for varicose veins, varicosities, also test for DVT by calf tenderness (Moses sign) and Homan's sign (pain on passive dorsiflexion of foot). For any ulcer palpate arteries to rule out vascular disease & arterial insufficiency Test sensation of skin surrounding ulcer by sharp pin In trophic ulcer we should o Map area of anesthesia o Search features of Leprosy o Neurologic exam
3. Examine joint around ulcer for active and passive movement
Systemic Examination •
CVS: for CHF which delays ulcer healing,
R.S: for TB & secondaries,
A.S: for splenomegaly
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Chapter 3: Examination of Scrotal Swelling
Inspection Inspection of a scrotal or inguino-scrotal swelling should always be done in standing position. Otherwise direct hernias, varicoceles and full extent of hernias will be missed. 1: • • •
Unilateral or Bilateral? Scrotal or Inguino-scrotal? (Only in the scrotum? Or does it extend to the inguinal region?) Relation to Testis (Can the testis be seen separately? or is it incorporate into the swelling?), Epididymis, Cord, and Penis (is it pushed to the opposite side? Is it buried in the swelling?
•
Shape and Surface [globular, retard, or irregular]: scrotal swellings (testicular, epididymal and hydroceles) are globular. Hydrocele has a characteristic constriction around its central portion, this is diagnostic of a tunica vaginalis hydrocele. Size (in cms): measure the size in all three dimensions
2:
• 3: •
Overlying skin: o Rugosities: normal scrotal skin has rugosities that may become diminished in a hydrocele. Edematous skin is firm and non-tender on palpation, a feature of filarial elephantiasis (Ram’s Horn penis is also seen). o Redness, edema: features of scrotal wall cellulitis or acute epididymo-orchitis. o Excoriation, vesicles: seen in urinary extravasation. o Blackening: a feature of Fournier’s Gangrene (an idiopathic gangrene of scrotal skin secondary to infection and cellulitis). o Ulcers, sinuses, scars: seen in tuberculous epididymitis.
It is important inspect the posterior surface of the scrotum or you may miss a posterior sinus or ulcer. Lastly, ask the patient to cough and look for visible expansile impulse in the swelling and over both inguinal canals. Review Inspection 1. • Unilateral or Bilateral? • Scrotal or Inguino-scrotal? • Relation to Testis, Epididymis, Cord, & Penis.
2. • • •
Shape Surface Size (in cms)
3.Overlying skin: • Rugosities • Redness, edema • Excoriation, vesicles • Blackening • Ulcers, sinuses, scars
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Palpation Temperature and Tenderness
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Chapter 4: Examination of an Inguino-Scrotal Swelling Inguino-scrotal swellings extend from scrotum to inguinal region and include: Inguinal hernias, Congenital hydroceles, Varicoceles, Cord swelling.
Inspection The patient should be in standing position, stripped below the waist: • •
To inspect the full extent of the hernia To inspect direct hernias and varicocele that may not be seen in lying down position
1) Shape of the swelling • •
Indirect hernias are usually pyriform in shape Direct hernias are usually globular in shape
Location of the swelling and see whether it is unilateral or bilateral Measure exact size in cm, the size should be measured when the hernia is fully extended by asking the patient to cough 2) Overlying skin: • • • •
Look for redness, edema, scar or discoloration Redness, edematous & shiny skin suggest acute strangulated hernia Scar of previous surgery indicates recurrent hernia Observe the swelling closely for visible peristalsis: maybe seen in enterocele
3) Cough impulse test: • •
Positive cough impulse: diagnostic of an inguinal hernia Hernia with no expansile impulse (negative cough impulse): 1. Omentocele with adhesion 2. Obstructed hernia 3. Strangulated hernia
4) Position of the penis: • •
A hernia usually pushes the penis to the opposite side A very large hernia will bury the penis in the scrotal skin
Review Inspection 1. • Shape, location • Unilateral or bilateral • Exact size (cms)
2. Skin overlying the swelling • Redness, edema • Scar • Discoloration • Peristalsis
3. Inpulse on coughing 4. Position of the penis
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Palpation 1) Temperature & Tenderness 2) Reach the top of the swelling: Palpate the cord structures between the thumb in front and other fingers behind, if it is not possible to reach the top of the swelling in the scrotum this indicates inguino-scrotal swelling 3) Relation of pubic tubercle: Palpate the pubic tubercle and see its relation with the swelling; an inguinal hernia is medial to the pubic tubercle and above the inguinal ligament, while femoral hernia is lateral to pubic tubercle and below inguinal ligament. 4) Relation to the testis: Palpate the testis and see whether the swelling stops above it or incorporates the testis into it: • •
Acquired hernia always stops above the testis Congenital hernia includes the testis within its sac
Look whether the testis can be reduced to the abdomen along with other contents of the sac or not. If the testis is absent and scrotum is empty then it is a case of undescended testis. 5) Consistency: • • • •
Softy & elastic: enterocele Firm & doughy: omentocele Tense & tender: strangulated hernia Bag of worms feel: varicocele
6) Impulse on coughing: ask the patient to turn his head to opposite side and cough forcefully, keep your hand on the swelling and feel for an expansile impulse on coughing, that is the swelling increases in size and feels more tense during act of coughing If the hernia is small and not visible keep your hand over the inguinal canal from deep to superficial ring and then ask the patient to cough and feel the impulse. Zieman’s technique: used to differentiate indirect and direct inguinal and femoral hernias from each other. Stand on the side of hernia then reduce the hernia and place three fingers: index finger over the internal ring, middle finger over the external ring, ring finger over the femoral ring. Then ask the patient to close the nose and mouth on blow, an impulse is felt by: • • •
Index finger in indirect inguinal hernia Middle finger in direct inguinal hernia Ring finger in femoral hernia
7) Test Reducibility
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8) Internal ring occlusion test: Reduce the hernia and place a finger over the deep inguinal ring (1.25 cm above mid-inguinal point), then ask the patient to cough, if the hernia is indirect it will not bulge out on occluding deep inguinal ring (this is a positive occlusion test) but if the hernia is direct it will bulge out medial to the occluded ring at the time of coughing (negative internal ring occlusion test) 9) Do invagination test, which gives us information about the following: 1. 2. 3. 4.
Size of the superficial (external) inguinal ring Direction of the hernia tract Direction of the expansile impulse Sphincteric strength of conjoint tendon
Invagination test contra-indications: 1. If the external inguinal ring is small 2. In a child Review Palpation 1. Temperature & Tenderness 2. Reach the top of the swelling 3. Relation to Pubic Tubercle 4. Relation to Testis 5. Note the Consistency
6. 7. 8. 9.
Test Reducibility Test for Cough Impulse Perform Internal Ring Occlusion Test Perform Invagination Test
Percussion Ask the patient to cough to distend the swelling then percuss gently: • •
Resonant note: enterocele Dull note : All other swellings
Auscultation Peristalsis may be heard in enterocele, otherwise auscultation isn’t of any diagnostic use in this case. Examine the opposite side: Palpate testis, epididymis & spermatic cord of the opposite side to confirm that they are normal Look for a possible cause: 1. 2. 3. 4. 5.
Tone of abdominal wall muscles Scars, ascites Urethra for stricture PR for enlarged prostate Respiratory system for chronic bronchitis, TB
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Chapter 5: Examination of Intra-Abdominal Lump
Inspection • •
Position: lying down supine, relaxed, with the legs semi-flexed. Exposure: expose the abdomen from the nipple to the mid-thigh
Note the contour of the abdomen To inspect the contour, imagine a line from the tip of the xiphoid process to the symphysis pubis: • • •
Scaphoid: if the abdomen lies below this line and is concave Normal (flat): if it is along this plane Distended (protuberant): if abdomen lies above this plane or convex
If the abdomen is distended note if it is uniform or asymmetrical by comparing both sides to each other Now inspect the abdomen for: • • •
Redness, scars Striae, Branding marks Nodule, Distended veins
Redness • • • • • •
Redness over a lump suggests local inflammation Redness of skin around the umbilicus in an acute abdomen suggests acute hemorrhagic pancreatitis (Cullen’s sign) Branding marks usually suggest chronic or long-standing pain Hard subcutaneous nodules suggest secondary spread of the malignancy to the skin (e.g. in carcinoma of stomach) Dilated veins around the umbilicus with centrifugal flow suggest portal hypertension (caput medusae) Vertical femoro-axillary veins are seen in venacaval obstruction
Scars • • • • • •
If there is a scar of previous operation ask about the nature of the operation A scar at McBurney’s point is of appendectomy A scar below the right costal margin suggests cholecystectomy A scar in suprapubic (lower midline) region suggests suprapubic cystolithotomy or prostatectomy A scar in the loin region suggests a kidney operation Notice the widening of the scar in the central part, ragged white scar suggests wound infection after operation
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After inspecting the skin inspect the umbilicus for: • • •
Is it in the center? Is it stretched / everted? Is there a hernia?
1) Location of umbilicus • • •
Normally it is in the midline, midway between the tip of xiphoid process and the top of symphysis pubis It is displaces upwards by lumps arising from pelvis In ascites the distance between the xiphoid and umbilicus is more than distance between umbilicus and symphysis pubis (Tanyol’s sign)
2) Shape of umbilicus: In ascites it maybe transversely stretched (laughing umbilicus) 3) Hernia: In umbilical hernia the umbilicus is everted, we ask the patient to cough to see if there is an expansile impulse indicating an umbilical or para-umbilical hernia.
Now we look for abdominal movements 1. Movements during respiration 2. Visible peristalsis 3. Visible pulsations 1) Movements •
• • • •
Note abdominal movement during respiration and compare it with chest expansion o If thoracic movements are more prominent, it is thoraco-abdominal breathing (common in males) o If abdominal movements are more prominent, it is termed as abdomino-thoracic breathing (common in females) In peritonitis the abdomen doesn’t move during respiration In localized peritonitis only the affected portion maybe immobile If there is a visible lump (particularly if it is in the upper abdomen) observe whether it moves up and down with each respiration Lumps that don’t move with respiration: o Retroperitoneal lumps o Intra-abdominal lumps not connected to the diaphragm
2) Look for visible peristalsis: If the peristaltic movement in the epigastrium moving from left to right (this is a characteristic movement of pyloric stenosis) Step-ladder pattern of peristalsis showing multiple distended loops rising towards the center, is typical of low ileal obstruction.
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3) Visible pulsations • •
•
Aneurysm of abdominal aorta is pulsatile If a lump is in the epigastrium and umbilical region which is overlying the abdominal aorta, it may transmit pulsations from abdominal aorta, the lump itself is not pulsatile, these pulsations will disappear in the knee-elbow position when then lump falls away from the aorta. In a thin patient pulsations of abdominal aorta maybe visible
After that ask the patient to stand up and check for scrotal swelling • • •
• • • • • •
An epigastric lump that is due to secondary metastasis to the para-aortic lymph nodes maybe caused by a right testicular tumor. Then inspect the hernia orifices; ask the patient to cough and look for a coughing pulse If a lump is arising from the pelvis or is very large, inspect the legs for edema. Then ask the patient to sit, and standing behind the patient; inspect the spine for any deformity, gibbus, kyphus, kyphosis or scoliosis. Inspect the para-spinal area for any para-spinal swelling or sinus Paraspinal scar or sinus is very suggestive of TB of spine Then inspect the renal angle for fullness Then check the left supraclavicular region for a swelling due to enlarged lymph nodes Left supra clavicular lymph nodes can be enlarged due to secondary deposits from the malignancy of stomach, colon or testis (Troisier’s sign) The lymph nodes themselves are termed as Virchow’s lymph nodes
Remember to inspect the four extra-abdominal sites: 1. 2. 3. 4.
Scrotum: while standing Hernial orifices: while standing Spine: from the backside (para-spinal regions, renal angles) Virchow’s nodes: Left supra-clavicular nodes
Review Inspection • Note the contour (Scaphoid, Normal, Distended) • Look for localized bulge o Note the effect of raising the neck- Does it become more prominent or less? • Note the skin over the abdomen o Redness, Scars o Striae, Branding marks o Nodule, distended veins • Note the Umbilicus o Is it in the center? o Is it stretched/everted? o Is there a hernia? • Look for movements o Movement during respiration o Visible peristalsis o Visible pulsations • Inspect the other sites (Scrotum, Hernial orifices, Spine, Virchow’s nodes)
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Palpation • • •
Warm your hands by rubbing them together Note the temperature over the site of the lump and compare it with normal and note if there is any local rise in temperature suggestive of acute inflammation in the lump Palpate gently with a flat hand (superficial palpation) for: o Tone of abdominal wall muscles o Tenderness (demarcate the exact location) o Normal abdomen is soft, elastic and non-tender
Superficial palpation 1. 2. 3. 4. • • •
Warmth and tenderness Area of tenderness Guarding of rigidity Rebound tenderness
Guarding: contraction of abdominal muscles upon palpation Rigidity: the state of sustained contraction even if we don’t palpate (e.g. in acute peritonitis) Rebound tenderness: if there is a mild local tenderness check for rebound tenderness. Slowly press down your hand over the tender area and withdraw suddenly, if there is acute pain on withdrawal then it is rebound tenderness. Rebound tenderness indicates inflammation of parietal pleura due to an inflamed underlying organ. In intestinal obstruction rebound tenderness suggests strangulation.
Deep Palpation 1. Palpation of the lump 2. Palpation of the rest of the abdomen
1. Before doing palpation of the lump, you should determine: A. Intra- or extra-abdominal lump B. Size, shape, consistency, location A. Intra- or extra-abdominal: (keep your hand on the lower border of the swelling. If the swelling moves with respiration then it is intra-abdominal, if it doesn’t it can be parietal or intra-abdominal) Ask the patient to raise the neck: • •
If the swelling becomes less prominent and difficult to palpate then intra-abdominal If the swelling becomes more prominent and easier to palpate then extra-abdominal o If mobile then subcutaneous o If it becomes fixed on contracting the abdominal muscles then intramuscular
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B. Palpation in details: • •
•
Measure the size in cm Note its location in relation to: o Involved quadrant o Costal margin o Umbilicus o ASIS (Anterior Superior Iliac Spine) o Symphysis pubis Shape, surface, margin o Well-defined margin: neoplasm o Ill-defined margin: inflammatory swelling
C. Consistency: • • •
Soft, cystic, firm or hard Uniform or variable If cystic test fluctuation and fluid thrill
D. If in lumbar region palpate bimanually •
If it is in the right or left hypochondrium; check if it extends under the costal margin and whether fingers can be inserted between it and the costal margin.
E. Mobility • • • •
If the swelling is in the upper half of abdomen check movement with respiration Hold the swelling between fingers of both hands and try to move it horizontally and vertically If mobile then check restriction of movement in any direction (e.g. an ovarian cyst is mobile in all directions) If the swelling is in the flanks then palpate bimanually and check anteroposterior movement and balloatment (only renal lumps are balloatable).
F. Pulsatility • • • •
Put two index fingers on the edge of the swelling If the fingers move up and away from each other (expansile pulsation) then it is an aneurysm If the fingers only move upwards (transmitted pulsation) then it is a mass If in doubt put the patient in knee-elbow position, transmitted pulsation will disappear. An aneurysm will continue to pulsate.
2. Palpation of the rest of abdomen A. Palpate for liver, spleen and kidneys B. Note their relation to the lump
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Liver: Start palpating in the right iliac fossa along the mid-clavicular line with the fingers parallel to the liver border exerting moderate pressure during expiration. If palpable note the site, border, surface, consistency and tenderness Spleen: Start from right iliac fossa towards left costal margin with fingers parallel to the left costal margin. If palpable note its size in cm, then palpate the anterior border for the splenic notch and note that the fingers can’t be inserted into the costal margin. If not palpable turn the patient to his right side and do bimanual palpation. Kidney: Do bimanual palpation in both lumbar regions for renal lump. If abdomen is thin the lower pole of the right kidney maybe normally palpable
3. Palpate for tenderness over: •
Colon (in the flanks),
Lower intercostal spaces (in lower chest),
Renal angles
Check for the testicular tumor • • •
Note right testicular swelling in a patient with an epigastric lump Palpate hernial orifices for hernia (feel cough impulse) If lumps arises from the pelvis or from the retroperitoneal space or it is so large as to compress the inferior vena cava then examine the legs for edema (due to compression of the vein or obstruction of lymphatics)
Examine the back • • •
Palpate the spine for deformity and tenderness Look for renal angle tenderness Palpate the supraclavicular fossa (especially left) for Virchow’s lymph nodes
Review Palpation • Superficial o Warmth and Tenderness o Area of Tenderness (mark the exact location) o Guarding and Rigidity o Rebound tenderness • Deep o Palpate the lump Intra- or Extra- abdominal Size, shape, consistency, location If lumbar, bimanual palpation and balloatment Mobility Pulsatility o Rest of abdomen Palpate for liver, spleen and kidneys Note their relation to the lump Palpate for tenderness over colon, lower intercostal spaces and renal angles Palpate (Scrotum, Hernial orifices, Back-Spine, paraspinal, Left supraclavicular nodes)
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Percussion •
Percuss on the lump (solid = dull, retroperitoneal and deep = resonant) e.g. resonant note over a renal lump
•
If swelling in upper abdomen, note if dullness is continuous with liver or splenic dullness
•
Percuss for upper and lower border of liver and measure the liver span
•
Confirm mobility of diaphragm by tidal percussion
•
Percuss for spleen in the left 9th intercostal space from posterior axillary line forwards o
•
If spleen is enlarged the dullness will extend beyond the mid-axillary line
If a renal lump is suspected percuss posteriorly in the loin, just lateral to erector spinae muscle. Normally this area is resonant due to the presence of the colon. If kidney is enlarged then there will be a dull note but in other lumps like spleen the note remains resonant.
•
Percuss from umbilicus to the flanks to detect ascetic fluid. If there is dullness in the flanks try to demonstrate a shifting dullness. Keep the pleximeter finger just lateral to the border of the dullness and roll the patient over to the opposite side, wait for 20 seconds and percuss again. If the note becomes resonant, presence of free fluid in the abdomen is confirmed. Then turn the patient supine again and demonstrate that the note is dull once again. If the dullness extends to both flanks and suprapubic regions, it is termed horseshoe shaped dullness.
•
If there is a large ascites or a large cystic lump, percuss for fluid thrill.
•
If the lump is suspected to be a hydatid cyst, try to demonstrate a hydatid thrill or the after-thrill.
Auscultation • • • • •
Auscultate carefully over the abdomen for abnormal sound and peristalsis If the lump is pulsatile auscultate over it first for a bruit Auscultate over abdominal aorta and then on the renal arteries for bruit If the liver or spleen is enlarged, auscultate them for hepatic rub and splenic rub during deep inspiration Auscultate in the peri umbilical area and the right iliac fossa for peristalsis
Lastly do a PR and in females a PV exam
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Chapter 6: Examination of a Breast Lump
Inspection Expose the patient from the waist up. First do comparative inspection of both breasts and then inspect the affected breast. Position (for comparative inspection) 1. Sitting erect, with both arms by the side. 2. Sitting erect, with both arms raised above the head. 3. With the patient bending forwards. (In carcinoma, affected breast won’t fall freely & lags behind). Do Comparative Inspection for: 1. Visible lump or bulge (note the quadrant in which it is situated) 2. Compare the level of the nipples (the nipple will be at a higher level if it’s fixed by a malignancy, this is more pronounced when arms are above the head) If the breasts are identical, measure the vertical distance from the clavicle and horizontal distance from the midline (to know the exact displacement of the nipple) Auchincloss’s method: the visible signs of breast carcinoma become more prominent on raising the arms. In this position inspect the undersurface of the breasts; also inspect both axillae for swelling. Inspection of the affected breast (nipple and areola) Nipple 1) Nipple displacement: check to see if it is: • •
Towards the lump (carcinoma) Away from the lump (bening lump)
2) Nipple retraction: check to see if it is recent or congenital, it is usually associated with diminished size of areola. Recent retraction is highly suggestive of carcinoma. 3) Nipple discharge: (check underwear for color and amount of discharge) •
• •
Bright red discharge: o Carcinoma o Duct papilloma Blackish red discharge o Duct papilloma with obstructed duct Clear watery or greenish discharge o Fibroadenomas
•
•
Mily white discharge o Lactation o Galactocele o Mammary ductectasia o Galactorrhea Purulent discharge o Acute mastitis o Chronic abscess with ductectasia
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Areola • Cracks • Fissures • Eczema o Unilateral with destruction of the nipple: Padget’s o Bilateral and itching: allergic eczema
Overlying skin, inspection of: 1. Redness, shininess, edema (inflammatory) and dilated veins (suggest sarcoma rather than carcinoma) 2. Retraction and puckering 3. Peau d’Orange appearance (due to cutaneous lymphedema with pitting at the site of hair follicles where the skin is firmly attached) 4. Ulcers and nodules Lastly inspect the arm for edema REVIEW Inspection 1. Inspect both breasts simultaneously • For asymmetry and lump • For level of nipples 2. Inspect the nipple and areola • Nipple - For deviation, displacement - Retraction, cracks - Nipple discharge • Areola - For cracks, fissures - Eczema 3. Inspect the sign over the breast • For redness, shininess, edema and dilated veins • Retraction, puckering • Peau d’Orange appearance • Ulcers and skin nodules 4. Inspect the arm for lymphedema • Lympatic obstruction in axilla
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Palpation Let the patient lie supine on the examination table. Note the skin temperature over the lump comparing it to the normal breast. Then notice the consistency of the normal breast tissue on the normal side before palpating the affected breast. First palpate with a flat hand rolling and feeling the breast between the palmar surface of the fingers and the underlying chest wall to identify any breast lump. Then palpate between the fingers and the thumb to note the consistency of the breast tissue. Palpate the four quadrants of the breast and then the tissue beneath the areola and then the axillary tail. Once the lump is identified with a flat hand, palpate it between the fingers and the thumb to note its characteristics: 1. 2. 3. 4. 5.
Size of the lump (in cm) Shape Surface: smooth/irregular Edge: well-defined/ill-defined Consistency: soft, firm, hard or cystic
Now press from the periphery towards the nipple in a squeezing action in each of the quadrants and look for nipple discharge. If this fails to bring a nipple discharge, compress the breast tissue under the breast and the areola between the thumb and other fingers. Note: • •
Black discharge in duct papilloma. Milky discharge during lactation. In a newborn child, a milky discharge maybe expressed for the first few days due to the effect of maternal hormones on the child (Witch’s milk)
If the swelling is soft and cystic as in galactocele, chronic abscess, or cystic hygroma then test for fluctuation and trans-illumination. Trans-illumination should be carried out in a dark room with a powerful torch. Place the torch on the undersurface of the breast. Normal breast tissue is translucent. A cystic hygroma maybe transilluinant, but most other breast swellings are opaque and cast a negative shadow. Test fixity: • • • •
To the skin To the breast tissue To the pectoral fascia and muscle To the chest wall
1) Fixity to the skin •
If the skin is puckered, ulcerated or infiltrated then the lump is obviously fixed to the skin. If not, then slide the skin over the lump and test its mobility. Also, try to pinch the skin over the swelling. If the skin is not fixed to the lump, move the lump from side to side and see if the skin gets dimpled. If there is dimpling then the lump is tethered to the skin.
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2) Fixity to the breast tissue Stretch and fix the breast tissue over the lump with stretched thumb and middle fingers of the left hand. Now try to move the lump in all directions with the right hand. • •
Fibroadenoma is freely mobile and not fixed to the breast tissue. Often it is so freely mobile within the breast tissue that it is termed as a breast mouse. A malignant lump that is fixed to the breast tissue becomes immobile when the breast tissue is fixed by stretching.
3) Fixity to the Pectoralis major and Serratus anterior •
•
Ask the patient to place her hands on her waist. First test the mobility of the lump in the direction of the fibers of the Pectoralis major and at a right angle to it while the muscle is relaxed. Now ask the patient to press her hands firmly over the hip. Palpate the anterior fold of axilla to confirm that the Pectoralis major is contracted and taut. Move the lump again in the same two directions. Any restriction of mobility on contraction of Pectoralis muscle suggests the fixity of the lump to the Pectoralis muscle or fascia. If the lump is in the outer and lower quadrant, it lies on the Serratus anterior, so we test fixity to Serratus anterior. Let the patient stand at arm’s length from a wall with the palms resting on the wall. Test the mobility of the lump in horizontal and vertical directions. Now ask the patient to push against the wall with outstretched hands, this contacts the Serratus anterior. Now test the mobility again. Any restriction of mobility indicates fixity of the lump to the Serratus anterior. Now inspect the scapulae as the patient is pushing against the wall. If there is winging of the scapula on the affected side, it indicates paralysis of the Serratus anterior due to involvement of the long thoracic nerve.
4) Fixity to the chest wall •
If tumor is fixed & immobile even when Pectoralis major is relaxed then it’s fixed to the chest wall.
REVIEW Palpation: 1. Temperature and tenderness 2. Size, shape, surface and edge of the swelling 3. Consistency 4. If cystic: fluctuation and trans-illumination 5. Nipple discharge 6. Fixity to surrounding structures
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Examination of Lymph Nodes With the patient in sitting position ask her to keep the arm hanging loosely by the side. • • • • • •
• •
First palpate against the medial wall of the axilla (along the chest wall) for the central group of lymph nodes. Move the hand higher up for the apical group. Then palpate under the anterior axillary fold for pectoral group of lymph nodes and under the posterior axillary fold for the subscapular group. Now palpate the lateral wall of the axilla against the upper end of humerus for the brachial group of nodes. Then palpate below the clavicle in the deltopectoral groove for the deltopectoral (infraclavicular) group. Now stand behind the patient and palpate the base of the anterior triangle of the neck behind the middle of the clavicle. Lift the patient’s arm with the other hand to relax the muscles and the cervical fascia. This is the supraclavicular group of lymph nodes. Next palpate the opposite axilla in the same manner. If any one or more groups of lymph nodes are palpable note their site, number, consistency and mobility. If the lymph nodes are enlarged examine the arm, forearm and dorsum of the hand on the affected side for edema and compare it with the opposite arm. Edema of the arm indicates lymphatic obstruction in the axillar or axillary vein thrombosis.
Systemic Examination 1. 2. 3. 4.
Abdomen for hepatomegaly and free fluid Per-vaginal and Per-rectal examination Chest for effusion and consolidation Bony swellings and tenderness
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Chapter 7: Examination of a Thyroid Swelling Thyroid is located in front of the neck, with its 2 lobes on either side of the trachea connected by isthmus
Inspection Make the patient sit on stool with neck slightly hyperextended. Asking the patient to swallow makes the thyroid move prominent for inspection 1) Size, Shape and Situation (Midline, both sides of the midline, one side): measure by measuring tape 2) Location 3) Borders in relation to the sternomastoid muscle and the suprasternal notch 4) Surface • •
Smooth → simple goiter, single nodule Nodular, Bosselated → Multinodular goiter
5) Skin over thyroid • • • •
Redness and edema → suggestive of inflammation Scar of previous surgery Sinuses → thyroglossal fistula Dilated vein
6) Pulsation 7) Upward movement on deglutition and protrusion of tongue •
•
Thyroid swelling moves in deglutition but we have other condition where swelling moves in deglutition: o Thyroid o Thyroglossal cyst o Pre-tracheal Lymph Nodes o Subhyoid bursa o Extrinsic carcinoma of larynx But lipoma does NOT move during deglutition because it is not attached to the pre-tracheal fascia
If swelling is a nodule which is close to the midline we must test its upward movement on protrusion of the tongue. Thyroglossal cyst and Thyroglossal fistula move upwards with tongue protrusion.
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Palpation Methods for palpation: 1) Standard method: test temperature of swelling with back of fingers, then look for any tenderness 2) Lahey’s method → for palpation of the deep surface of thyroid 3) Crile’s method → for palpation of small nodules in the thyroid In palpation we look for 1) Size and shape 2) Borders: we check for a retrosternal goiter by palpating the tracheal rings in the suprasternal notch 3) Surface: smooth / bosselated 4) Consistency: nodules If entire gland or lobule is enlarged, note: • • •
Surface: smooth, bosselated Consistency: soft (colloid goiter), firm (multinodular goiter), hard (carcinoma, Riedel's thyroiditis) Retrosternal extension?: palpate the lower border during deglutition
If single nodule • • •
• •
Location: lobe or isthmus Size and Shape Consistency: soft, firm o Cyst in thyroid is firm o Solid swelling (adenoma) soft Is the rest of the thyroid gland palpable? Normally the rest of the gland is not palpable (solitary nodule), if it is palpable then it is considered a multinodular goiter with a single large nodule
5) Thrill: Put finger gently on the upper pole of each side to check for a thrill → if positive it is diagnostic of primary toxic goiter 6) Fixity: Test for fixity and mobility → fixity in any direction suggests + malignant infiltration or thyroiditis 7) Trachea: Deviation, Kocher’s test for scabbard trachea •
Kocher’s test: Ask patient to take heavy deep breath and open mouth and compress swelling from both sides, if there is hoarseness of voice (indicate narrowing of trachea). It is seen in carcinoma and multinodular goiter
8) Carotids: we check for Berry’s sign (for obliteration of carotid pulsation): in a benign goter, carotid pulse is well felt, though displaced backward. In malignant goiter, carotid pulse is weak or absent
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Percussion & Auscultation Percuss on manubrium sternii • •
Normal = Resonant Retrosternal Goiter = Dull
In auscultation: we auscultate over the swelling, paying more attention at the upper poles for a systolic bruit which is diagnostic for primary toxic goiter and it is due to increased vascularity. After examination of thyroid look for • • • •
Sign of thyrotoxicosis Sign of myxedema Sign of retrosternal extension Sign of metastasis
Sign of thyrotoxicosis 1) Eye signs → Looking for Exophthalmos • • •
Lid retraction (Dalrymple’s sign), Lid lag (Von Graefe’s sign) & Infrequent blinking (Stellwag’s sign) Actua l bulge (Naffziger’s method), and sclera seen inferiorly Absence of wrinkling and inability to converge: o No forehead wrinkles → Joffroy’s sign o Difficulty everting the upper eyelids in thyrotoxicosis → Gifford’s sign o Note convergence of eye by holding finger one meter from the eyes and ask patient to look, then slowly move finger towards midpoint of eyebrows of the patient, the patient can’t converge the eyes in exophthalmos (Mobius’s sign)
Progressive Exophthalmus: 1. 2. 3. 4.
Further bulging of eyeballs Conjuctival congestion and edema Corneal ulcers, diminished vision Ophthalmoplegia
2) Tremors: Fine tremor of out-stretched hands and protruded tongue (positive in thyrotoxic patient) 3) Tachycardia • • •
Radial pulse: count pulse rate in early morning at 4 am during sleep (Sleeping Pulse Rate) Palms & feet: warm and moist Legs: pretibial myxedema with thickened, hyperpigmented skin and coarse hair
4) Bruit, thrill
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Sign of myxedema • • • •
Edema of face and legs Hoarseness of voice Lethargy Delayed relaxation of deep reflexes
Sign of retrosternal extension (RSE) • • • •
Palpate tracheal rings: inability to palpate suggest RSE Percuss manubrium sterni: dull sound suggests RSE Thoracic outlet obstruction: Pembert’s sign Horner syndrome: ptosis, miosis, enophthalmus, absent cilio-spinal reflex and anhydrosis (in RSE or malignant goiter)
Sign of metastasis • • • • •
Hard cervical lymph nodes Hard nodules on skull Long bone metastasis Nodular liver & ascites Chest effusion/consolidation
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Chapter 8: Examination of Peripheral Vascular Disease (PVD) Presentation: gangrenous (already dead) or ischemic limb. If gangrene present, examine it first, then proceed to examination of the ischemic limb.
Inspection Gangrene: •
•
Dry gangrene: shows a dark discoloration with a shriveled and mummified appearance. There is a clear demarcation between the gangrenous & the normal limb. With time the dry gangrene will separate itself by the process of aseptic ulceration & the ulcer will be covered up by skin. Wet gangrene: shows black discoloration and the tissue is edematous & swollen. There is no clearcut demarcation between the gangrenous and the normal limb.
Proximal limb: • • • •
Evidence of proximal spread of gangrene & infection Redness & Edema in proximal skin suggests active infection as in a wet gangrene Blebs, Ulcerations & Skip areas in the proximal skin suggests proximal spread of the gangrene Skip areas: are areas of blackening, in the proximal limb, independent from the gangrene.
Evidence of chronic ischemia • • • •
Dark discoloration in the limb suggests chronic ischemia (compare with the other limb) A marked pallor will indicate sudden arterial obstruction (embolism, Raynaud’s phenomenon) Pale, thin, shiny limb with scanty hair and brittle nails suggests chronic ischemia Trophic ulcers in the tips of the fingers and toes
We measure the girdle of both limbs at the same level and compare them to demonstrate and record limb wasting. Measurement should be over main muscle masses; 3 inches above and below the knee joint in the lower limbs, 2 inches above and below the elbow joint in the upper limbs. Inspect the veins over the dorsum foot while the patient is lying down, if they are easily palpable, it indicates good circulation. If they are collapsed and gutter-like, it indicates severe ischemia. If the patient has a previous amputation or long-standing ischemia, look for scar of lumbar sympathectomy (a transverse lumbar scar at the level of the umbilicus). If the toes are affected, look for a constriction at the base of the toe as seen in Ainhum (a constriction at the base of the fifth toe which gradually deepens over several years till the toe separates). Review Inspection of the Proximal Limb Inspection of a Gangrenous area 1. Infection: Edema, Redness 1. The Extent of the gangrene 2. Spread: Blebs, ulcers, skip areas 2. The line of demarcation 3. Chronic Ischemia: thin shiny skin, wasting, brittle nails 3. The type of the gangrene: dry or wet
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Palpation First palpate the gangrenous area. • • •
Dry gangrene: the skin is cold, non-tender, hard and greasy. It has no sensation Wet gangrene: the skin is turgid, edematous with loss of sensation but it may be tender if gangrene is not fully established. If the skin is edematous palpate carefully all over the gangrenous and proximal area for crepitations to rule out an anaerobic infection like gas gangrene.
Palpation of proximal ischemic limb •
• •
Check the temperature of the skin with the back of your fingers and proceed proximally comparing it to the temperature of the other limb at the same level. Note the level up to which the limb is cold. In a severe peripheral vascular disease, it may be cold up to the mid-thigh. Skin temperature is a good indicator of the state of skin circulation and is important in deciding the level of amputation if required. Now palpate the gangrenous and proximal limb for tenderness Next palpate along the line of major vessels for tenderness; that is along the popliteal and femoral arteries in the lower limbs and along radial, brachial and axillary arteries in the upper limbs. Tenderness indicates recent thrombosis or embolism.
Focal Examination 1) Arteries: palpate the arterial pulse at various levels in all the limbs. 2) Lymph nodes: palpate the inguinal region for enlargement of lymph nodes. 3) Joint movements: test the movement of different joints in the gangrenous area. Gangrenous portion of the limb will lose its movements
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Methods of palpation of the arterial tree: LOWER LIMB •
• •
•
•
• •
Capillary circulation in the nails: blanch the nail by pressing its tip, release the pressure, and note the time taken by the nail bed to turn pink again. This gives a rough idea about the rate of blood flow in the capillaries. Dorsalis pedis artery: at the proximal end of the first metatarsal space just lateral to the tendon of extensor halluces longus against the navicular and middle cuneiform bones. Palpate the posterior tibial artery: midway between the medial malleolus and Achilles tendon against the calcaneum, keeping the foot dorsiflexed and inverted. o If dorsalis pedis and posterior tibial arteries are well-felt, it implies that the proximal pulses are normal. Popliteal artery: in the popliteal fossa against the upper end of tibia or lower end of femur. With the patient in supine position, keep the knee flexed at 135°. Keep your thumbs over the tibial tuberosity and insert the fingertips into the lower part of the popliteal fossa palpating from lateral to medial side till the neurovascular bundle is felt, now palpate the artery against the upper end of the tibia. If not felt in supine position, turn the patient prone, flex the knee to 90°, and palpate the artery in the midline in the upper part of the popliteal fossa against the lower end of femur. If the popliteal pulse is still not felt (it is difficult to locate in obese patients) then perform the Fuchsig’s test. o Fuchsig’s test: ask the patient to sit at the edge of a table and cross the affected leg so that the popliteal fossa rests on the opposite knee. Ask the patient to keep the leg completely relaxed. Look for oscillatory movements of the hanging leg synchronous with the patient’s pulse. If oscillations are seen, it mean the popliteal pulse is normal. If oscillations aren’t seen, it means that the popliteal pulse is absent. The test is of great significance when femoral pulse is normal but dorsalis pedis & posterior tibial aren’t palpable. Femoral artery: with the patient lying supine keep the legs slightly abducted and externally rotated to relax the deep fascia and palpate in the line of mid-inguinal point just below the inguinal ligament. Femoral artery is felt against the head of femur. Abdominal aorta: to the left of the midline in epigastric and umbilical areas against the spine Palpate the pulsations in the opposite limb.
UPPER LIMB • • • • • • • •
Capillary circulation in the nails: by pressing the nail tip until it blanches and noting the time taken by the nail bed to turn pink again. Radial artery: at the flexor aspect of the wrist just lateral to the tendon of flexor carpi radialis against the lower end of the radius. Brachial artery: in the lower half of the arm just medial to the biceps tendon against the shaft of the humerus and in front of the elbow medial to the biceps tendon. Axillary artery: in the axilla against the head of the humerus. Subclavian artery: in the supraclavicular fossa in mid-clavicular line against the first rib. Common carotid artery: against the transverse process of the 6th cervical vertebra between the upper portion of the trachea and sternomastoid. Superficial temporal artery: in front of the tragus of the ear against the temporal bone. Facial artery: against the lower border of the mandible, at the anterior border of the masseter muscle. (Ask the patient to clench to identify the anterior border of the masseter muscle). o Superficial temporal & facial arteries aren’t important in a case of peripheral vascular disease.
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Auscultation • • •
By palpation you can note the level of the block Auscultate along the entire length of the artery for a systolic bruit of stenosis, partial obstruction or aneurysm. Routinely auscultate over the major arteries (abdominal aorta, femoral, popliteal, axillary, and carotid arteries).
Special tests for PVD TESTS FOR LOWER LIMBS 1. Buerger’s test: with the patient supine, raise the legs (knees-extended) to about 90°, if the limb shows marked pallor then the test is positive. In severe disease the pallor appears within 2-3 seconds while in mild disease it might take minutes for it to appear. If the test it positive, lower the limb, let it resume its normal color, then raise it gradually to note the angle at which the pallor appears. This angle with the horizontal is called Buerger’s Angle of Circulatory Insufficiency. Buerger’s angle of < 30° is indicative of very severe ischemia 2. Capillary filling time: with the patient supine, raise the legs till the affected leg becomes pale. Ask the patient to sit at the edge of the examination table and hang the legs down. Note the time taken by the affected leg to resume its normal pink color. In PVD this time may be prolonged to 15-30 seconds. Then let the patient sit with the legs hanging for 2-3 minutes. The leg will assume a purple red, cyanotic color termed as dependent rubor indicating impaired circulation. A normal leg doesn’t show any color change in raised or dependent position. TESTS FOR UPPER LIMBS 1. Reynaud’s phenomenon: if this phenomenon is suspected, dip both hands in ice-cold water and watch for blanching (pallor) of the fingers. If the fingers become blanched take the hand out of the water, the fingers will become swollen and cyanosed. Gradually as the spasm of the arteries wears off, the fingers become red and engorged due to flow of blood into the dilated capillaries. Then perform the tests for thoracic outlet obstruction. 2. Adson’s test: with the sitting on a stool, feel the radial pulse of the affected hand. Ask the patient to turn the head as much as possible towards the affected side then take a deep breath. If the pulse becomes feeble or is obliterated, then the Adson’s test is positive. The forced inspiration contracts the scalenus anterior (an accessory muscle of respiration) which elevates the first rib and compresses the subclavian artery at the thoracic outlet. This test can also be performed by asking the patient to turn the head to the opposite side and take a deep breath, then by keeping the arm extended and pulling it downwards noting whether the pulse diminishes or not.
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3. Elevated arms stress test: ask the patient to abduct the shoulders to 90° with maximum possible external rotation keeping the elbows flexed at 90°, thus raising the arms above the head. Now ask the patient to close and open the fists slowly for a period of 3 minutes. If the patient symptoms of radiating pain, cramps, paresthesia or Raynaud’s phenomenon appear, forcing him to sop then the test is positive for thoracic outlet obstruction. A normal person will only feel some fatigue in the forearm muscle. 4. Allen’s test (degree of patency of radial & ulnar arteries): ask the patient to clench the fist tightly, then compress both the radial and ulnar arteries at the wrist. Then ask the patient to clench and release the fist till blanching occurs. Now ask him to open the fist, and release the radial artery. Note the time taken by the hand to regain the normal pink color. Then repeat the test, after blanching of the hand release the ulnar artery noting the time taken by the hand to regain its normal pink color. If any of the arteries is blocked, the palm will remain blanched for a longer time when the pressure over the arteries is released. Review Special tests for PVD • Lower limb 1. Buerger’s test 2. Capillary filling time • Upper limb 1. Raynaud’s phenomenon 2. Adson’s test 3. Elevated arms stress test 4. Allen’s test
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Chapter 9: Examination of Varicose Veins A varicose vein is an elongated, dilated and tortuous vein, in the subcutaneous layer.
Inspection A) Inspection of the vein • • •
• • • •
•
•
•
In standing position Note the site and extent of the varicosity and its relation to long or short saphenous veins. Examine the leg from all the sides. Long saphenous varicosities run from the front of medial malleolus upwards along the anteromedial aspect of the leg, knee and the thigh to end at the saphenous opening just below the inguinal ligament. The short saphenous varicosities run over the posterior aspect of the calf to converge and end at the center of the popliteal fossa. Some varicosities may not conform to these anatomical pathways and are termed “stray varicosities”. Inspect the length of the varicose vein for a blowout (a localized bulge in the vein) indicating incompetent perforator. Mark the blowouts with a pencil. Inspect the saphenous opening below the inguinal ligament for a Saphena Varix (a blowout over the sapheno-femoral junction) which indicates a sapheno-femoral wall incompetence. If a Saphena Varix is present ask the patient to cough and look for a visible cough impulse. Look for dilated veins over the lower abdomen above the inguinal ligament converging onto the saphenous opening. These are the superficial circumflex iliac, superficial inferior epigastric and superficial external pudendal veins which enter the long saphenous vein just before it joins the femoral vein Raise the leg to 60° and check whether the varicosity collapses or not. Uncomplicated varicose veins will always collapse on raising the leg. But if it is secondary to pelvic vein thrombosis or arterio-venous fistula in the leg then it will not collapse when the leg is raised. Morrissey’s test: holding the leg to 30° or more ask the patient to cough and look for a cough impulse at the saphenous opening. If a Saphena Varix is present it will be seen to bulge out and a retrograde venous pressure wave will be seen to rise in the vein and fall slowly. Positive test indicates incompetent sapheno-femoral wall.
B) Inspection of ankle and foot •
•
Inspect the medial aspect of the ankle for Ankle or Venous Flare (a diffuse soft swelling or fullness with small subcutaneous dilated venules around the ankle, filling the hollow between the medial malleolus and the heel). Ankle Flare is seen in association with incompetency of ankle perforators. Inspect the skin over the medial aspect of the lower third of the leg for pigmentation, edema, oozing or ulceration. These are changes in the skin due to the back pressure in the veins and capillaries which forces the RBCs out of the vessel wall. The RBCs are broken down by
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•
•
macrophages and from breakdown products of hemoglobin; hemosiderin produces black pigmentation while biliverdin produces irritation and itching leading to dermatitis. (Gator area?) A varicose ulcer is more commonly seen after deep vein thrombosis (DVT) and sometimes with primary varicose veins. DVT damages the wall of deep veins of the leg so the blood is pumped into the superficial veins particularly on the medial side where the perforator veins are situated. Varicose ulcers are superficial, painless ulcers with ragged, irregular edges and unhealthy granulation, they never penetrate the deep fascia. If varicose ulcer or severe dermatitis is seen note if the foot has a talipus equinus deformity (due to contracture of the soft tissue on the medial aspect of the ankle) and whether the patient walk limping on the toes.
Review Inspection A. Inspection of the vein 1. Site, Extent & Anatomical relation 2. Blowouts, Saphena Varix and dilated veins over abdomen 3. Collapsibility 4. Morrissey’s test B. Inspection of the ankle and foot 1. Ankle flare 2. Hyperpigmentation of skin, edema, dermatitis 3. Ulcer 4. Talipus equinus deformity
Palpation In standing position Palpate the length of the vein for warmth and tenderness. Superficial thrombophlebitis in acute stage will be warm and tender. Mark the course of the vein with a skin pencil. Make the patient lie down. Raise the leg to 30° and empty the vein. Fegan’s method: Now palpate the deep fascia along the course of the vein more carefully at the site of blowouts, if any, to look for pits (felt as a circular defect with sharp edges) in the deep fascia. A pit indicates the site of a dilated perforator. If a pit is felt, mark it with a cross, with a skin pencil. Keep your hand gently over the saphenous opening which is located 3.8 cm below and lateral to the pubic tubercle and ask the patient to cough. A cough impulse indicates sapheno-femoral wall incompetence. Cruveilhier’s sign: If saphena varix is present a thrill will be palpable as the patient coughs as if a jet of water is entering and filling the varix.
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Ask the patient to turn to the opposite side when he is coughing. Note again the expansile impulse in the saphena varix when the patient coughs. Schwartz’s test: with the patient standing place the fingers of the left hand over the saphenous opening and tap over the most prominent part of the varicosity in the leg with the right hand. If the impulse is felt by the palpating fingers it indicates that there is a continuous blood column between the two points and the vein walls are incompetent. Brodie-Trendelenburg test (for sapheno-femoral valve competency): with the patient lying down supine, elevate the leg to 30° and empty the vein completely. Occlude the saphenous opening by tying a rubber tourniquet around the upper thigh, just below the saphenous opening. Keeping the sapheno-femoral junction occluded, ask the patient to stand. Observe the vein for 15-30 seconds with maintained pressure. The vein will remain empty if it is purely a sapheno-femoral incompetence. But if there is a perforator incompetence, the vein will fill slowly from below upwards. Then release the tourniquet and watch how the varicosity fills rapidly from above. If sapheno-femoral wall is incompetent the varicosity will fill very rapidly from above downwards. If sapheno-femoral wall is competent there will be no retrograde feeling. Negative-positive result: that is negative with maintained pressure and positive on release of pressure indicating a pure sapheno-femoral wall incompetence. Positive-negative (positive with maintained pressure, negative with release of pressure) result implies only perforator incompetence. Positive-positive (positive with maintained pressure, positive with release of pressure) implies incompetency of both sapheno-femoral wall and the perforators. Multiple tourniquet test: with the patient supine elevate the leg and empty the veins completely by milking them down. Now, apply three rubber tourniquets; one just below the saphenous opening, second just above the knee and third just below the knee. This divides the long saphenous vein into four segments, each with one constant perforator (sapheno-femoral valve, adductor canal perforator below knew perforator, and ankle perforator). The tourniquets should be tight enough to only occlude the superficial veins, now ask the patient to stand up and observe for 15-20 seconds for appearance of varicosities in each segment. Rapid appearance of a varicosity or a blowout in any of the segments indicates the incompetency of the related perforator. In the segments with competent perforators the vein remains collapsed. Pratt’s test: this test is performed to locate incompetent perforators more accurately. With the patient supine, raise the leg to 30, empty the veins and apply an elastocrib bandage from the toes to the midthigh with gentle pressure to occlude the superficial veins only. Now apply a rubber tourniquet below the sapheno-femoral valve to occlude retrograde flow from the sapheno-femoral wall. Now ask the patient to stand and release the bandage from above downwards. After releasing each turn, observe the vein for filling. The moment the turn of the bandage over an incompetent perforator is unwound, the vein will fill rapidly.
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Review Plapation 1. Warmth & Tenderness 2. Pits by Fegan’s method 3. Cough impulse & Cruvilhier’s sign 4. Schwartz’s test 5. Tests for incompetent perforators a. Brodie-Trendelenburg test b. Multiple tourniquet test c. Pratt’s test
Examination of the deep veins Modified Perthe’s test (for checking patency of deep veins): with the patient supine elevate the limb and empty the vein. Apply a rubber tourniquet over the upper thigh to occlude the superifical veins, then ask the patient to walk around briskly for 5 minutes. If the deep veins are blocked the varicosities will become turgid and the patient will experience throbbing pain in the calf (positive test). If the deep veins are patent, the varicosities will remain collapsed and there is no calf pain. A positive Perthe’s test is an absolute contra-indication for ligation and stripping of the veins and it must be routinely performed before surgery. If the same test is performed by applying an elastocrib bandage from the toes to the thigh is the original Perthe’s test.
Checking for Active Deep Vein Thrombosis Look for tender calf swelling: flex the knee to 90° to rest the foot. Press the calf muscles against the tibia to compress the posterior tibial veins, if this is not tender gently squeeze the calf muscles from side to side; if painful this is a positive Mose’s sign. If the calf muscles are tender, do not perform the test, as squeezing calf muscles can potentially dislodge a thrombus in the deep veins and result in pulmonary embolism • Homan’s sign: let the leg rest with the knee fully extended. Dorsiflex the foot passively, the resultant stretching of the calf muscles and the posterior tibial vein will illicit pain if the deep veins are thrombosed. • Palpate for tenderness along the course of the veins (femoral, popliteal, posterior tibial veins). Remember: in active DVT, these tests should be peformed gently as they can potentially dislodge a thrombus and cause pulmonary embolism. •
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Review Checking for DVT 1. Tender calf swelling 2. Tenderness along the course of the veins 3. Homan’s sign 4. Mose’s sign
Focal and General Examination 1. Palpate the inguinal lymph nodes which may be enlarged with varicose ulcers and deep vein thrombosis. 2. Examine the opposite leg for varicose veins. 3. Palpate the abdomen for any lump pressing on the pelvic veins. 4. Examine the scrotum in standing position for varicocele and testicular tumor. 5. Peform proctoscopy to rule out co-existing hemorrhoids.
Enough of armchair medicine. Now to the wards.
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