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Common station surgical stations for final year medical students


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Common station surgical stations for final year medical students

  2. 2. Introduction: • Examination of a mass • Examination of an ulcer • Hernia examination • Diabetic foot examination • Examination of varicose veins
  3. 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. 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. 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. 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. 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. 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. 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. 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. 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. 12. Basic Anatomy
  13. 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. 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. 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. 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. 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. 18. Diabetic Foot exam • Common exam station • Mixed aetiology (peripheral neuropathy and peripheral vascular disease)
  19. 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. 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. 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. 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. 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. 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. 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. 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. 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. 28. • Any questions?