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by
Peshraw Karim

Shanyar Qadir

2014

Shvan Omar

Index

Chapter

Page

Chapter 1: Examination of a Swelling

Chapter 2: Examination of an Ulcer...

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

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

Please report any ideas, corrections and suggestions to:

clinicalexaminationinsurgery@gmail.com

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 dOrange)
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

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

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

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.

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 Marjolins ulcer

Review
Inspection
1. Size & Shape
2. Number
3. Location
4. Margin & Edge
5. Floor
6. Surrounding skin

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

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
(Rams 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 Fourniers 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

10

Palpation
Temperature and Tenderness

11

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

12

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.
Ziemans 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

13

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 isnt 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

14

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 (Cullens 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 McBurneys 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

15

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 (Tanyols 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 doesnt 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 dont 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.

16

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 (Troisiers sign)
The lymph nodes themselves are termed as Virchows 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)
Virchows 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, Virchows nodes)

17

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 dont 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 doesnt 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

18

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

19

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 cant 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 Virchows 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)

20

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

21

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 wont 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 its 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)
Auchinclosss 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

22

 Areola
Cracks
Fissures
Eczema
o Unilateral with destruction of the nipple: Padgets
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 dOrange 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 dOrange appearance
Ulcers and skin nodules
4. Inspect the arm for lymphedema
Lympatic obstruction in axilla

23

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 (Witchs 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.

24

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 arms 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 its 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

25

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 patients 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

26

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.

27

Palpation
Methods for palpation:
1) Standard method: test temperature of swelling with back of fingers, then look for any tenderness
2) Laheys method for palpation of the deep surface of thyroid
3) Criles 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, Kochers test for scabbard trachea

Kochers 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 Berrys 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

28

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 (Dalrymples sign), Lid lag (Von Graefes sign) & Infrequent blinking (Stellwags sign)
Actua l bulge (Naffzigers method), and sclera seen inferiorly
Absence of wrinkling and inability to converge:
o No forehead wrinkles Joffroys sign
o Difficulty everting the upper eyelids in thyrotoxicosis Giffords 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
cant converge the eyes in exophthalmos (Mobiuss 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

29

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: Pemberts 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

30

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, Raynauds 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

31

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

32

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
Fuchsigs test.
o Fuchsigs 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 patients
pulse. If oscillations are seen, it mean the popliteal pulse is normal. If oscillations arent
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 arent 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 arent important in a case of peripheral vascular disease.

33

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. Buergers 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 Buergers Angle of Circulatory Insufficiency.
Buergers 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 doesnt show any color change in raised or dependent position.
TESTS FOR UPPER LIMBS
1. Reynauds 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. Adsons 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 Adsons 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.

34

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 Raynauds 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. Allens 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. Buergers test
2. Capillary filling time
Upper limb
1. Raynauds phenomenon
2. Adsons test
3. Elevated arms stress test
4. Allens test

35

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.
Morrisseys 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

36

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. Morrisseys 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.
Fegans 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.
Cruveilhiers 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.

37

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.
Schwartzs 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.
Pratts 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 Fegans method
3. Cough impulse & Cruvilhiers sign
4. Schwartzs test
5. Tests for incompetent perforators
a. Brodie-Trendelenburg test
b. Multiple tourniquet test
c. Pratts test

Examination of the deep veins

Modified Perthes 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 Perthes 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
Perthes 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 Moses 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
Homans 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. Homans sign
4. Moses 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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