1. COMMON SURGICAL
STATIONS FOR FINALS
Dr Anisha Sukha
2011

2. Introduction:
• Examination of a mass
• Examination of an ulcer
• Hernia examination
• Diabetic foot examination
• Examination of varicose veins

3. Examination of a Mass
• Site
• Size
• Shape (reasonable to use descriptive terms e.g.
pear shaped)
• Surface (smooth, irregular etc)
• Temperature (assess with dorsal aspect of hand)
• Tenderness (watch patients face as you palpate)
• Colour and texture of overlying skin (erythema)
• Edge (clearly defined or indistinct)

4. • Composition
• Consistency
• Stony hard
• Firm
• Rubbery
• Soft
• Fluctuation (feel two areas of lump whilst pressing on
third)
• Fluid thrill
• Transillumination (if positive lump may contain water,
serum, lymph or plasma, NOT blood)
• Resonance
• Pulsatility (transmitted pulsation/expansile pulsation)
• Bruit (AV fistula-systolic murmur, Hernias-audible bowel
sounds)

5. • Reducibility
• (important in hernias and some vascular lumps)
• Relationship to surrounding structures
• State of regional lymph glands
• State of local tissue ( and any neuro-vascular
abnormality)
• General Examination (always examine the whole patient)

6. Examination of an Ulcer
• An ulcer is a break of the continuity of an epithelium
• Generally examination of an ulcer will follow the same
pattern as examination of an lump (e.g. site, size, shape
etc)

7. • Base- or floor of the ulcer may contain
• Slough
• Granulation tissue (capillaries, collagen, fibroblasts,
inflammatory cells)
• Deeper structures such as tendon or bone may also be
visible
• Edge- 5 types
• Sloping (healing ulcer)
• Punched out (commonly caused by diabetic neuropathy,
peripheral arterial ischaemia)
• Undermined (tuberculosis, pressure necrosis)
• Rolled (basal cell carcinoma)
• Everted (squamous cell carcinoma)

8. • Depth-recorded by anatomically describing the structures
it has penetrated
• Discharge- may be serous, purulent. Always take a swab
• Relations- may be adherent or invading deeper structure
such as tendons, periosteum, bone. Local lymph glands
may be enlarged (infection,malignancy)
• State of local tissue (neurovascular examination
especially important in lower limb ulcers)

9. Examination of a Herniae
• “Any protusion of the whole or part of a viscus
through an opening in the wall of its containing
cavity that causes it to lie in an abnormal
position.”
• Certain physical signs are common to all herniae;
• They occur at congenital or acquired weak spots
in the abdominal wall
• Most herniae can be reduced
• Most herniae have an expansile cough impulse

10. Basic Anatomy you must know!
• The inguinal ligament runs between the ASIS and
pubic tubercle
• The deep inguinal ring is an opening midway
between the ASIS and pubic tubercle (midpoint of
inguinal ligament). It lies lateral to the inferior
epigastric artery
• Inferior epigastric artery (continuation of femoral
artery) lies at mid-inguinal point (halfway between
ASIS and pubic symphysis)
• The superficial inguinal ring lies above and
medial to the pubic tubercle.

11. • The inguinal canal lies above the medial half of the
inguinal ligament between the superficial and deep
inguinal rings
• Direct Inguinal Hernia -occur at site of superficial
inguinal ring
• Indirect Inguinal Hernias -occur at deep inguinal ring,
travel down inguinal canal and may protrude through
superficial inguinal ring into scrotum.

12. Basic Anatomy

13. Borders of the Inguinal Canal
• Anterior border is the external oblique aponeurosis
• Posterior border is the transversalis fascia
• Inferior border is the inguinal ligament
• Superior border is the fibres of internal oblique and
transversus abdominis (known as the conjoint tendon)
• Please note this is a common exam question!!
• M
• A
• L
• T

14. Examination
• Introduce yourself, wash hands, chaperone
• Patient should be examined standing up and undressed
from waist down
• Start with Inspection.
• Look for an visible lumps, any scars, overlying skin
changes.
• Inspection should also reveal whether the lump extends
into the scrotum

15. Palpation
• Stand at the side of the patient, with one hand in the small
of the patients back to support him.
• Your examining hand and arm should be roughly parallel
to the inguinal ligament when palpating the lump.
• Ascertain the following facts
• Position
• Size
• Shape
• Temperature
• Tenderness
• Can you get above it?
• Presence of an expansile cough impulse-diagnostic of a
hernia. May not be present if the neck of the sac is
blocked by adhesions.

16. Is the swelling reducible?
• Attempt to reduce the hernia by lifting upwards towards
superficial inguinal ring.
• Once passed through this point, slide finger upwards and
laterally towards the deep inguinal ring.
• Aim to see if the Hernia can be kept inside by pressure at
this point.
• If lump reduces into abdominal wall above and medial to
the pubic tubercle- INGUINAL HERNIA
• If reduces into abdominal wall below and lateral to pubic
tubercle- FEMORAL HERNIA
• Once reduced, press over the deep inguinal ring and ask
the patient to cough.
• If remains reduced- INDIRECT INGUINAL HERNIA
• If protrudes- DIRECT INGUINAL HERNIA

17. To complete examination
• Worth percussing and auscultating the lump (may be
audible bowel sounds)
• Always examine the other side
• Examine the abdomen (for any cause of raised intra
abdominal pressure e.g. enlarged bladder, ascites etc)

18. Diabetic Foot exam
• Common exam station
• Mixed aetiology (peripheral neuropathy and peripheral
vascular disease)

19. Inspection
• Colour (rough marker of state of perfusion)
• Ulcers- especially at pressure points. Take care to
look in between digits!
• Amputation of digits
• Dryness of skin
• Shiny hairless leg
• Charcots joints (painless disorganised joints due
to loss of pain sensation)
• Pes Cavus (due to peripheral neuropathy)
• Infections (e.g. paronychia)

20. Palpation
• Start with Circulation in particular;
• Temperature
• Capillary filling time
• Peripheral pulses (dorsalis pedis and posterior tibial)
• Neurology
• Light touch sensation, vibration, propioception, pain.

21. Special tests
• Request Ankle-brachial Pressure Index
• 10g nylon monofilament to formally test peripheral
sensation in diabetic foot.
• To complete examination, dipstick urine and look at the
back of eyes for any evidence of diabetic nephropathy or
retinopathy.

22. Examination of Varicose Veins
• Veins of lower limb divided into superficial and deep
systems.
• Valves in communicating veins only allow blood to
pass from superficial into deep system.
• The superficial veins all join either the great or lesser
saphenous system
• The great saphenous vein joins the femoral vein at
the sapheno-femoral junction, approximately 2.5cm
below and lateral to the pubic tubercle.
• The lesser saphenous vein joins the popliteal vein at
the sapheno-popliteal junction, in the popliteal fossa.

23. Inspection
• Visible, dilated and tortuous subcutaneous veins
• Hyperpigmentation due to haemosiderin
deposition
• Oedema
• Lipodermatosclerosis
• Eczema
• Venous ulcers (notably in the gaiter region-lower
medial third of leg)
• Varicosities at sapheno-femoral, sapheno-
popliteal junction

24. Palpation
• Palpate along the course of the main veins.
• Feel for any areas of tenderness, especially along the
medial aspect of the calf.
• Temperature
• Peripheral pulses

25. • Cough test
• Used to detect saphena varix (dilated great saphenous
vein at sapheno-femoral junction due to incompetent
valve)
• Palpate the sapheno-femoral junction and ask the
patient to cough. Positive if cough impulse felt.
• Tap test
• Again used to detect incompetent great saphenous
valves.
• Tap over dilated veins in upper thigh and place other
hand over great saphenous vein below knee.
• If percussion wave transmitted downwards, valves must
be incompetent.

26. Tourniquet test/Trendelenberg
• Patient should lie on couch
• Limb to be examined is elevated (onto examiners
shoulders) to empty veins
• Further expedited by stroking blood in veins towards the
heart.
• Tourniquet then pulled tight around upper thigh.
• Patient asked to stand and legs observed for 10-15
seconds
• If veins below tourniquet do not rapidly fill, reflux
controlled at this level. Thus sapheno-femoral junction site
of incompetence.
• BUT if veins below fill, must be other sites of superficial to
deep incompetence below level of tourniquet.

27. • Keep repeating with tourniquet moving progressively
down the whole length of leg until you identify all site
of incompetence.
• Trendelenberg test is a modification and works by
applying direct digital pressure to prevent retrograde
filling
• Hand-held dopplers can also be used to detect valve
incompetence.
• A uniphasic signal indicates competent valves
• A biphasic signal indicates reflux and valvular
incompetence.

28. • Any questions?