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Introduction
These notes are just a guide for a quick review of the most important clinical
examinations and history taking in surgery block. For more details, you can go
back to your reference book.
Before OSCE:
o Sleep well: Sleeping well is more beneficial than studying all night long.
o Introduce yourself.
References:
o Nicholas J Talley Clinical Examination, 6th Edition.
o Browses's Introduction to the Symptoms & Sign of Surgical Disease,
th
4 Edition.
o Lecture Notes Ophthalmology, 11 Edition.
th
o Anesthesia
o Ophthalmology
o ENT
o Plastic Surgery
Coordinator:
o Sulaiman AlHefzi
o Abdulaziz AlTurki
o
Hamad AlThiab
Mohammed AlMahmood
o Faisal Abuabah
o Ahmad Batarfi
o Eiad Gutub
o Faisal AlAnbar
o Waleed AlHumaid
o Hussain AlMulla
o Abdulmalik AlAjroush
o Mohammed Mater
Don't forget us from your Dua'a and
Dua'a and best of luck in your exam and your future
career.
General Surgery
Abdominal Examination
Position and Exposure:
Lying flat with both hands on the side & expose from nipples to mid-thigh.
o Organomegaly:
a) Liver: Palpate the liver edge & percuss for span "8-12 cm" from above.
b) Spleen: You can't go above it, has a notch, and enlarges inferomedially.
Palpate "pt. flat" & "pt. lying over his right side".
Percuss over left costal margin-anterior Axillary line with
full expiration.
Auscultation:
o Bowel sounds: Exaggerated: Proximal to the obstruction.
Others:
o Special test for appendicitis: Obturator, Psoas, Rovsing signs.
o Lymph nodes: including supraclavicular (Virchow's node).
o Rectal and genitalia examination + Back & leg examination (edema).
History of a Lump
Age and gender.
When did he/she notice the lump? Is it the first time?
What made the patient notices the lump?
Site.
Predisposing events.
Symptoms of the lump: pain, discharge, disfiguring, or restrain certain
movements, respiratory or swallowing, change in voice.
If discharge: Quantity, quality, color, smell.
Associated Symptoms: fever, weight loss, night sweats, fatigue.
Has the lump changed? Size, shape, color, tenderness since first notice
Does the lump ever disappear? On lying down or exercise.
Previous exposure to radiation to the neck.
Any other lump.
Treatment done for this lump before.
What does the patient think caused the lump?
Examination of a Lump
Wear gloves and proper exposure (If in the limb, expose both for comparison).
Inspection:
o Site, size, shape, color, surface, and edge (well or ill defined), symmetry.
Palpation:
o Temperature, tenderness.
irregular)
o Mobility, fixation to skin, attached to underlying tissue, going above it.
o
Pulsatility
Percussion:
, reducibility, fluctuation, translumination (fluid-filled lesion).
Resonant or dull, fluid thrill.
Auscultation: Bruit if A-V malformation.
Surrounding tissues:
o Regional lymph nodes.
Abdominal Hernia
Common physical signs to all hernias but are not always present:
o Congenital or acquired weak spots in the abdominal
a bdominal wall.
o Most hernias can be reduced.
The last two signs may be absent, especially if the hernia is tightly constricted at its neck.
Ask the patient to stand up
o During a routine supine abdominal examination, you discover a lump that
looks like hernia, complete the examination then ask the patient to
stand up in order to determine the size correctly.
Inspection: From the front.
o Site and shape.
In men, examine its upper edge. If you can get above it Scrotal
o
swelling NOT hernia.
Palpation: From the side.
o On the same side as the hernia. Place one hand in the patients back to
support him, and your examining hand on the lump with your fingers
and arms roughly parallel to the inguinal ligament.
o You must ascertain the following facts about the lump:
Expansile cough impulse:
o Compress the lump firmly with your fingers then ask the pt. to cough.
lump. Then gently compress the lower part of the swelling. As the lump
gets softer, lift it up towards the external ring. Once it has all passed
pa ssed in
through this point, slide your fingers upwards and laterally towards the
internal ring to see if the hernia.
o If there is any difficulty in reducing the hernia, ask the patients to lie
bowel sounds.
Examine the other side:
o Inguinal hernia is commonly bilateral, particularly when it is direct.
Rectal Examination
Position and Exposure:
Inspection:
o
Thrombosed external hemorrhoid.
o Skin tags, rectal prolapse, anal fissure.
Palpation:
Rectal Bleeding
Bleeding:
o Onset, frequency, progression, color (bright red or mixed), amount.
Endoscope
Explain procedure
o Indications: Dysphagia, diagnosis of ulcer, UGI bleeding etc.
o Pre-endosco
Pre-endoscopypy "PT-aPTT", NPO 24 hours – abdominal examination.
o Inside the unit IV cannula, sedation, throat spray.
Colonoscopy: Bowel prep
o Chemical bowel prep for 3 days.
History of an Ulcer/Wound
When did he notice the ulcer? Is it the first time?
What made the patient notice the ulcer?
Site.
Predisposing events: Trauma, surgery, immunocompromis
immunocompromised.
ed.
Symptoms of the ulcer: pain, discharge (mucous, purulent, blood).
If discharge: Quantity, quality, color, smell.
Associated Symptoms: fever.
Has the ulcer changed? Size, shape, color, tenderness since first notice
Any other lump.
Treatment done for this ulcer before.
Systemic diseases: DM, HTN, CAD, atherosclerosis.
Examination of an Ulcer/Wound
Wear sterile gloves, proper exposure, and take vital signs.
Inspection:
o Site, size, shape, depth.
o Edge:
smell).
Palpation:
o Tenderness.
Relations:
o To its surrounding tissues.
Surrounding tissues:
o Induration, pigmentation and scars.
o Local lymph nodes.
Thyroid Examination
Position and Exposure:
o Sitting & expose the neck and the chest. Mention about dressing.
Hand:
Acropachy "thyrotoxicosis".
o
o Palmer Erythema.
Eye:
o 6 Cardinal eye movement, ask if there is diplopia to any of the direction.
o Exophthalmos, proptosis "Grave's".
o Lid lag (the lid lag behind the orbit… should be performed slowly ).
o Anemia, Jaundice.
o
Mouth: Macroglossia "Hypothyroidism
"Hypothyroidism".
".
Neck:
Inspection:
o Little bit flexed , From Behind R and L lobes (Push with one hand and
o Tracheal deviation.
Auscultation: Ask the pt. to hold the breath to listen for bruit "thyrotoxicosis".
Lower Limb
Pretibial myxedema (Non pitting, Itching, Anterior Chin) "Grave's disease".
Reflexes:
Breast examination
Before examining the patient, maintain privacy and ask for a nurse.
Hands against the hip: to contract pectoralis muscles.
Example how to comment: Both breasts look symmetrical and the apparent
size looks the same. There is erythema on lower outer quadrant at the right
r ight
breast, there is peudo orange on the upper inner quadrant of the left breast
between 2 and 4 o’clock, there is dimpling on the outer upper quadrant of the
right breast at 10 o’clock.
Palpation:
The patient lay down in 45 degree with the hands behind her head.
Palpate the normal size first.
Using one hand (the other one to support) with the palm of your fingers,
palpate the whole 4 quadrants including the axillary tail.
Palpate the nipple-areola complex by squeezing it looking for discharge.
If you find a lump, describe it: SSSSS: Site - Size – Shape - Skin attachment (or
muscle attachment) – Surface - (consistency and mobility)
Consistency: Soft – firm – hard. Mobility: Mobile – fixed.
Hard as a skull, firm like a nose, soft like the cheek.
Axillary: Hold patient's left hand with your right hand and examine using your
Other:
Breast history
ID: name, age, marital status, pregnancy.
Present complaint: lump, bleeding, discharge, skin changes, pain (if advanced or
inflammatory).
o Breast lump: onset, site, how did you notice it, trauma, progression,
painful, skin changes, relation to menstruation (fibrocystic change),
previous history.
o Breast pain: Complete history of pain, relation to menstruation.
o Bone pain.
o Cord compression: Back pain, sensory, motor, urinary/bowel symptoms.
Differential Diagnosis:
Fibroadenoma.
Fibrocystic change including breast cyst.
Mastitis.
Breast cancer.
While stabilizing patient's head, assess airway patency by asking the patient to
talk e.g. asking his/her name.
If not, assess for obstruction. (Chin lift if no C-spine injury and jaw thrust).
Consider: Nasophargeal, orophargeal, ETT intubation, cricothyroidotomy.
C-collar & spine immobilization (sand bags).
C
LFT, amylase.
o Start 2L of warm LR or 20 ml/kg in children.
Expose patient: front, lateral and back (log rolling).
Cover with blanket to prevent hypothermia.
F: Foley's catheter.
Secondary survey:
History (AMPLE): Allergy, medication (tetanus), past history, last meal, event.
Radiological assessm
assessment:
ent: CXR, pelvic X-ray and cervical X-ray lateral and PA +
Full body CT scan.
Orthopedics
Spine Examination
Look: The patient is standing and from the back and side.
Feel:
Move:
Special test:
Straight leg raising (L5): Flex the hip and extend the knee then
t hen raise the leg.
Femoral stretch test (L3-L4): Extend the hip and flex the knee
Cervical:
o Dermatomes : C4: Supraclavicular. C5: Lateral Forearm. C6: Thumb. C7:
Middle finger. C8: Little finger. T1: Medial forearm. T4: Nipple. T10:
Umbilicus.
o Myotomes: C4: Shoulder elevation. C5, 6: Elbow flexion . C6, 7: Wrist
Lower:
o Dermatomes: L2: Anterior thigh. L3: Knee. L4: Medial Leg. L5: Lateral Leg.
Shoulder Examination
Look:
o Temperature.
o Bones: Manubriosternal J., manubrioclavicular J., clavicle, coracoid,
Trabezius.
Move:
Serratus anterior: push on the wall then see the back ( winged scapula).
Shoulder stability (if you suspect dislocation):
o Apprehension test: abduction and external rotation.
o
Jobe's test (Empty can test): Supraspinatus
o Lift-off test: Subscabularis.
Note: In all orthopedic examination you have to mention that you would examine the
function of the joint and you would examine joint above and joint
joint below the joint you are
examining).
Elbow Examination
Look:
Feel:
Move:
Special tests:
Medial epicondylitis (Golfer's elbow): Resisted flexion.
Lateral epicondylitis (Tennis elbow): Resisted extension.
Varus and valgus stress test: Supinated and flexed 5 degree.
P a g e | 15 Quick Review for OSCE | AlBrahim-Al-Enezi
AlBrahim-Al-Enezi
Hip Examination
Look: (Patient Standing &Supine)
Deformity (flexion deformity) & Leg length discrepancy.
Ant. Sup. Iliac spine symmetry.
Scars, skin changes, swelling.
Feel:
Greater trochanter and Ant. sup. Iliac spine.
Move:
Flexion, extension.
Lateral and medial rotation (in knee extension and flexion).
Abduction & adduction (The pelvis by on hand and the leg by the other one).
Special test:
Thomas test: For flexion deformity (flex the other leg and put your hand under
his back and check the lordosis then check the leg raising and push on it).
Trendelunburg: Put your hands behind on the pelvis then ask the pt. to raise
his leg then see if your hand dropped on the other pelvis, if it is +, check the
superior gluteal nerve.
Faber test: For sacroiliac j. (Flexion, abduction and external rotation then push
on the leg to see if he has any pain). Not IMP.
Rectus femoris: Like stretch femoral test but if the pain on the back(nerve) or
on the thigh( rectus femoris).
Neurological:
o Femoral nerve (M: Knee extension, S: Ant. Of the thigh, medial of the
thigh and leg-saphanous n.).
o Obterator n. (M: Thigh adduction).
Knee examination
Look: setting position.
Feel:
o Popliteal fossa.
Move:
Fluid displacement test:
o Patellar tap test and milking test.
Patellar Apprehension test: Push the patella of the extended knee laterally
then flex the knee. If there is pain patellar dislocation.
Varus/valgus stress test: extended knee and flexed 30 knee.
o Varus stress test: Lateral ligament torn.
McMurray’s test: flexed hip and knee 90, then look for pain.
o Rotate the foot externally and abduct then extension: Medial meniscus.
o Rotate the foot internally and adduct then extension: Lateral meniscus.
Neurological:
Gait
Ankle examination
Look: Setting position.
position.
Scars, swelling, skin changes, deformity, wounds, and dryness.
Pulse: Dorsalis pedis and tibialis posterior .
Tenderness: systematical ly palpate then compress the whole foot.
systematically
Special test:
Anterior drawer test: Lying down then check the stability of the ankle by
holding the leg and moving the foot.
Talar tilt: Foot is stressed in inversion.
Reflex:
Calcaneal tendon S1
Neurological:
Deep peroneal, superficial peroneal and tibial nerve.
Gait:
On the toes and on the ankle then complete the regular gate.
Look:
Deformity (proximal and distal), swelling, bleeding, and exposed bone.
Describe the wound:
o Size, site, shape, edge.
Neurovascular Examination:
Upper limb:
o Vascular: Radial pulse, ulnar pulse, allen's test, and capillary refill.
Lower limb:
o Vascular: Dorsalis pedic pulse and posterior tibial pulse.
o
Neurological: Superficial peroneal, deep peroneal and tibial nerves.
Management:
Remove obvious foreign material.
Cover wound with sterile dressing soaked in warm normal saline.
Realign the limb and splint.
Reexamine the neurovascular.
X-ray.
IV antibiotics:
o Gustilo class 1 (<1cm) cefazolin 72 hrs. (gram +ve)
o Gustilo class 2 (1-10 cm) cefazolin + gentamicin. (gram +ve and -ve)
o
Displacement: Dorsal, frontal, medial, lateral.
o Distraction: Fragments are separated by a gap.
Example
o Patient X and date.
o Lateral x-ray for Right femur showing hip, pelvis and knee there is oblique
Feel:
o Gently for tenderness and crepitus.
Neurovascular:
o Pulses and capillary refill.
Management:
o Splint the limb.
o Give analgesia.
o Call orthopedic.
Anesthesia
Pre-Operative Assessment
History:
o Liver.
o Ob/Gyn.
Previous surgeries, anesthesia, and complication.
Allergies & medications.
Smoking, alcohol, drug abuse.
Family History: malignant hyperthermia.
Examination:
Vital signs.
CVS & Respiratory.
Airway assessment:
o (I) Tempormandibular joint (TMJ) click.
o
(III) Thyromental distance: 3 fingers.
o (IV) Range of movement of the neck: should 30 degree.
o Mallampati score.
o Teeth and deformity.
Intubation:
o Bag-mask ventilation: Hold it in C-E technique. If it's not OK, put airway
Ophthalmology
Eye Examination
Inspection (both eyes):
o Swelling, conjectival injection, redness, and discharge.
Palpation:
o
o
Tenderness.
Swap for the discharge.
Visual acuity:
o Snellen chart at 6m with the patient's glasses.
Eye movements:
o All 6 cardinal gazes, accommodation , and saccadic eye movements.
o
Ask for diplopia and look for nystagmus.
Pupillary reaction:
o Inspect pupil size, shape, asymmetry (anisocoria).
o Accommodat
Accommodation ion reflex.
o Swinging flash light test for relative afferent pupil defect (RAPD ).
(glaucoma).
o Macula and vessels: hemorrhage, exudates, cotton wall spots, A/V
o
Iris and pupil: shape, vessels (pterygium), adhesion (synechia).
o Lens: cataract.
o Anterior vitreous .
Loss of Vision
History:
Acute/chronic, painful/ painless.
Onset, duration, progression, frequency (constant, intermittent, diurnal
variation), uni/bilateral, distant/near, central/peripheral.
Associated symptoms: Pain (ocular or with movement), headache, diplopia,
redness, discharge, photophobia, flashes, glaring, floater.
Past history: Trauma, ocular diseases, systemic diseases (DM, HTN,
rheumatology, hematology).
Medications: steroid (cataract, glaucoma), ethambutol (optic neuritis),
chloroquine (maculopathy and pigmentation), OCP (vascular occlusion), and
anticholinergic.
Family history: Glaucoma, cataract, decreased vision.
Social history: Alcohol, smoking, sexuality.
Acute painful:
Acute angle closure glaucoma "corneal edema and clouding":
o Symptoms: blurred vision, pain, red eye, photophobia, and watering.
o
History of recurrent attacks precipitated in the dark (pupillary dilation).
o Signs: decreased visual acuity, corneal clouding, high IOP, reduced
accommodation, fixed/dilated
fixed/dilated pupil, and red eye.
o Treatment:
Acetazolam
Acetazolamideide IV then oral (decrease secretion).
Topical pilocarpine (constrict pupil).
Beta-Blocker (decrease secretion).
Surgery (iridotomy/iridectomy).
Keratitis:
o Symptoms: Severe pain, red eye (peri-limbus),
(peri-limbus), discharge, trauma history.
o
Treatment: Viral (HSV): Oral acyclovir, topical steroid unless dendritic
ulcer present.
Bacterial: Topical antibiotics.
Corneal ulcer/abrasio
ulcer/abrasion:
n:
o Symptoms: Red eye, pain, watery, photophobia.
Uveitis:
o Symptoms: Red eye, pain, photophobia, autoimmune diseases.
Acute transient:
Acute painless:
Vitreous hemorrhage
hemorrhage..
Central vein/artery occlusion (whole visual field). Branch (peripheral field).
Retinal detachment: Floater, flashing, curtain like visual loss.
Ischemic optic neuropathy: Giant cell arteritis (jaw claudication, shoulder pain)
Acute bilateral:
Refractive error.
Cataract: decreased vision with glaring.
Chronic glaucoma.
DM macular edema.
Age related macular degeneration.
Chronic painful:
Chronic uveitis.
Corneal disease.
- Endophthalmitis:
after surgery.
- Orbital cellulitis
ENT
History of Hearing Loss
If the patient is a child, confirm hearing loss –response, speech … etc.
Uni\Bilateral.
Onset, duration, and progression.
Any events happened before (trauma, infection-URTI-, drugs)
Associated Symptoms: Tinnitus, vertigo, otalgia, otorrhea , and fever.
Snoring and sleep apnea (wake up at night, daytime sleepiness…etc.).
Impact on patient life: (severity).
Past History: the same episodes, ENT problem, medical (asthma).
Family History.
Social life and occupation.
Ear Examination
Inspection:
o
Pinnae (Auricle): helix, antihelix, tragus, antitragus & behind the ear.
o Look for atresia, microtia , scars, redness, swelling, and discharge.
Palpation:
o
Tympanic membrane: Redness, retraction, bulging, light reflex.
Hearing:
o Tuning fork test (512 Hz): Rinne's test & Weber test.
o Audiometry: if air-bone gap CHL. if both under 20 SNHL.
Nose Examination
Inspection:
Nose speculum:
o
Polyps, turbinate hypertrophy.
Mouth Examination:
Plastic Surgery
Hand Examination
Look:
o Skin: Scars, redness, swelling & moisture.
o Abnormal posture.
o
Muscle wasting & fingertip.
Feel: Ask about area of pain.
o Temperature, tenderness & swelling.
o
FDP & FDS of the index are separate from the other fingers.
o Nerve supply: Median except FCU and ulnar side of FDP which are Ulnar.
Intrinsic muscles:
o
Thenar muscles: APB, FPB & OP: Abduction of the thumb & opposition.
o AdP: Froment's sign "when holding a paper between the thumb & index".
o Lumbrical muscles: Flex the MCP & extend IP.
o Hypothenar muscles: ADM, FDM & ODM: bring the small finger away.
Nerve:
o Sensation: 2PD "dynamic < 3mm, static < 6mm"
o Motor: R: index extension, M: OK sign, U: Froment's sign.