This document provides guidance on common surgical examination stations for finals, including examination of a mass, ulcer, hernia, diabetic foot, and varicose veins. For each station, it describes the relevant anatomy and outlines the key steps of the physical examination, including important aspects to inspect, palpate, percuss, and auscultate. Special tests are also described where applicable, such as tests to evaluate for hernia reducibility or venous valve incompetence. The document emphasizes performing a full systematic examination and considering the related clinical context for each case.

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?