Abdominal Examination with Lump

By: Wade Jodeh

Preparation:

-Introduce yourself

– permission of the patient, explain why you want to examine (I'm here for a medical
purpose , I'm in a test, … )

- privacy

- environment: good light source and room temperature.

- position : Make sure patient is lying down with a pillow, he/she’s comfortable, arms on
the side and bed is inclined 15-20 degrees.

- Expose patient from nipples to waist ( say that I must expose the pt from nipples to
mid thigh but for his/her dignity »till suprapubic area)

General:

-male or female

- middle aged

- Identify how the patient lying is.

- looks well or ill

-Is he/she in pain, conscious, sweating

- ortiented?? (time ~ night or day , place ~ where are you, person~ men e7na)

-in respiratory distress ? On ventilator ? tachypnic, dyspnea (from respiratory accessory

muscles~ internal intercostals, latissimus dorsi, SCM)

- has any canulas or leads? IV line ? Drains ? Chest tube ?

- color (jaundice, palor, cyanosis)

 How know if jaundiced or not ? Ask pt to look down, see the sclera ( 3shan nshof
el fo2 l2no dayman m3`a6a o ma bebayen )

If yellow skin but not sclera : hyperkeratosis

You can know degree of jaundice : see from up downwards : till neck , bilirubin 5
, the 10 then 15 ,if all then bilirubin is 20 or more

Addison's :black gum, skin, stria

- hands (color and shape and number of creases, temperature, texture of skin, radial
pulse)

- fingers ( splinter hemorrhage (subacute endocarditid), spoon shaped (iron def anemia),
clubbing)

- eyes (eyes up and lateral >> color of sclera, hemorrhage, pupils,…. )

- mouth (teeth for hygiene, cyanosis, gum bleeding, mucocutaneous pigmentation,

leukoplakia, candidiasis )

- shape of face (moon-face if hypothyroidism)

- vital signs (Temperature, BP,RR,HR)

Inspection:

At foot of the bed identify:

1) shape (distended, flat or scaphoid) + flanks

How do you know ?? USE A RULER !! form xiphoid process till pubic symphysis
and see how the direction of the ruler goes

2) symmetry + umbilicus ( NEVER say that it is centrally located in an obese pt ,, it is not )

-umbilicus (location, inversion and discharge)

Nazleh la ta7et : bladder extrophy, ascites

6al3a la fo2 : ovarian tumors, pregnant

Everted: umbilical hernia , fat in umbilical ring, ascetic fluid in massive ascites,
feculent material in enteric fistula, clear fluid in patent urachus (crying umbilicus)
3) -inguinal hernia & masses (cough impulse)

4) diverticuli of recti

At the right side of the patient identify:

– type of breathing _better if you kneel to level of pt

(thoracic, abdominal or thoracoabdominal) (a silent abdomen or a surgical

abdomen may indicate peritonitis as pain is restrained)

-male/female hair distribution (cirrhosis or abnormal estrogen level

-visible peristalsis

-superficial dilated veins (portal HTN, SVC obstruction)

-caput medusa

-epigastric pulsation (normally present in skinny people . if prominent, differentiate if

due to mass or AAA by pulsation) (“i7bis nafsak”)

SCARS (site, length, width, color, type, healing 1 st degree, 2nd degree, surgical incision(
with sututres placed ?? ) , keloid (upward AND exceed the margin of wound, permanent,
more in blacks) , hypertrophied (only upward, disappears after 6 months, best example
are burns) , discharge?, etc.)

Y ?? >> 1- high risk of incisional hernia

2- think about adhesions of previous surgery ,,, may be SBO

3- y had a surgery ?? may be relevant in this condition

p.s. : you could also see hyperpigmented skin crease because of obesity

-bulge (site, shape, size, symmetry, skin changes, scar, color, visible pulsation)

-intact inguinal orifices

-striae (albicans» white , gravidarum»brown, cellulari »purple in cushing`s)

-bruises (Cullen, Gray-Turner, Fox{inguinal})

-cherry spots (aka hemangiomas/senile angiomas/Campbell De Morgan spots)

- pigmentation

-scratches (commonly infraumbilical due to pruritis of cirrhosis/portal HTN)

-scaling

-healing laceration

-cautery marks

-crust

-rash

-tattoos

- cough impulse

-stomas ( ileo-, colo-, cysto-)

P.s.: ileo : R-side, more fluid

Colo: L-side, feces

-drains (type, content, amount, is it functioning?)

-abdominal wall edema (peau d’orange)

- accessory nipple

Palpation:

-Make sure during palpation you’re 50 cm from the patient, have direct eye-contact,
forearm at the level of the patient, use the ventral aspects of your fingers, ask about
tenderness and start on the opposite side (if no tenderness start palpating on the LIF,
move counterclockwise ( as S or G) , if pain is generalized , ask about the maximum
point of pain and start away from it). ALWAYS look at the patients eyes in palpation to
check for tenderness.

Superficial:
-Performed to gain the patient’s trust and confidence, adjust your hand’s temperature,
and palpate guarding, superficial tenderness and superficial epigastric pulsation.

- NEVER talk to doctor about masses or bulges in superficial

- ALWAYS say that this is to gain confidence

- SLOW DOWN on epigastric area to feel pulsation

Deep:

- Performed to palpate tenderness, rebound tenderness, rigidity and deep masses.

Liver:

- The liver is normally 8-15cm wide from the 7th-12th ribs.

- It’s palpated with the radial aspect, it’s only felt if it’s enlarged or forced
downward with respiration. Start from the RIF; push downwards with expiration
and upwards with inspiration.
- -Upon palpation identify the: edge (round/sharp), surface (smooth, irregular,
nodular if cyst or cirrhosis or metastatic cancer), consistency (soft, hard, firm),
tenderness, pulsation ( hemangioma,R sided heart failure) and movement with
respiration.
- If can’t be palpated (as in ascites), resort to percussion. If can’t be percussed
resort to “Liver Scratch” (auscultate as you scratch starting from the RIF, once
the liver has been reached the volume will increase suddenly). If can’t be
percussed due to ascites resort to “Liver Dipping” (liver will bounce superficially
after being dipped).
- End with an approximation of the liver width.

Spleen:

- The spleen is normally 12 cm long, residing under rib 9, 10 and 11. It extends
inferomedially as it enlarges and may have to be 3x the normal size to be
palpable.
- Palpate with the radial aspect (or with the tip of your fingers), downward with
expiration and upward with inspiration. Start at the RIF and start supporting the
back with your left hand after crossing the umbilicus.
- If palpable identify the: edge (round/sharp), surface (smooth, irregular),
consistency (soft, hard, firm), tenderness, pulsation and movement with
respiration.
 - If not palpable, rotate patient to his/her right. If still not, say it’s not palpable
(don’t say it isn’t enlarged).

Right + Left Kidney:

- The kidney is normally 12 cm long, extending from T12-L3.

- Ballot the kidney with your left hand under the flank and right hand above.
Perform 2-4 cm lateral to the umbilicus, midway between the costal margin and
iliac crest. If the patient is thin you may feel the inferior pole of the kidney. Right
kidney is more easily balloted.

Differences between Spleen and Kidney:

Spleen Kidney
-Can’t get above it -Can get above it
-Regular borders if enlarged -Irregular borders of enlarged
-Can feel superomedial notch -Can’t feel a notch
-Moves earlier with respiration -Moves later with respiration
-Moves inferomedially and superficially -Moves inferiorly and deep
-Can’t be balloted - Can be balloted
-Dull Resonant

Gallbladdar :

Check Murphy's sign

Berry's sign : pain radiates to right shoulder

Urinary Bladder:

-Palpate using the ulnar aspect of your left hand. Start compression from the above the
umbilicus and move inferiorly, the bladder doesn’t move with respiration. The bladder is
palpable with acute/chronic urinary retention, prostatic hyperpalsia, prostate
carcinoma. If palpable the border will be rounded.

Lymph Nodes:

-Paraortic (above umbilicus)

-Ileal (between ASIS and umbilicus)

-Inguinal (right below inguinal ligament)

Lumps/Bulges:
Palpate for the:

- surface (smooth/irregular),
- edge (well/poorly defined),
- consistency (soft like nares /hard like nasal point/firm like nasal septum)
- fixation (skin/underlying tissue)
- mobility (in what planes)
- temperature (use dorsum of hand)
- transilluminability (transparent/translucent/opaque)
- pulsatility (expansile/transmitted),
- compressibility/reducibility/indentability
- fluctuation (2 fingers on each side, press with the other hand’s index, Paget’s
Sign)
- fluid thrill if very large

Don’t forget to acknowledge the flank, scrotum, rectum (with digital rectal
examination), femoral pulse (at midinguinal point, 2cm down), vital signs and virchow’s
lymph nodes (ask patient to shrug and rotate head in direction of palpation).

Percussion:

-Percuss using your middle finger of right hand on the middle phalanx of the isolated
middle finger of the left hand. Percuss with the same precautions as palpation. It is
betterbe done while seated. The abdomen is normally tympanic. If there’s dullness,
define if it’s general or localized.

-If there’s general dullness suspect ascites and perform a “fluid thrill” and “shifting
dullness”. For partial dullness, execute “succussion splashing” (the splash comes from
the stomach).

-If there’s tenderness with percussion, suspect peritonitis.

-If there’s hyperresonance, suspect dilation from obstruction.

-Locally percuss masses (dull/resonant)

Liver:

-Only percuss liver if it remained undefined by palpation. Start from the RIF and then
from the 2nd intercostal space ( at level of sternal angle midclavicular line OR first rib you
feel under clavicle is the second, the space under it is the second intercostal)
afterwards. If the liver is enlarged it may reach the 4 th rib.

P.s : Sternal angle contains : 1) arch of aorta 2) bifurcation of trachea (cardia)

3) level of lower border of T4 vertebra 4) level of 2nd intercostal space

5) meeting of jugular and SVC

-if resonant o Chilaiditi syndrome »transposition of a loop of large intestines between

the liver and diaphragm )

Spleen:

-The spleen should be percussed for dullness at Traube’s area. Between the midline and
AAL should be resonant, and between AAL and MAL should be dull.

If dull at Traube's area » suspect splenomegaly

Traube's area : inferiorly.

-Execute Castell’s test. Percuss the last IC space in left AAL . A positive Castell’s test is
resonant on deep expiration and dull on deep inspiration. Castell’s sign indicates
splenomegaly.

Kidney:

-Percuss kidney at costovertebral angle. Any tenderness indicates inflammation (ex:

pyelonephritis).

Urinary Bladder:

-Percuss suprapubic area. Dullness indicates urinary retention; if so execute a fluid thrill.

Auscultation: ( a stethoscope and a watch !!! )

-First generally auscultate the abdomen. Bowel sounds should be heard every few
seconds (3-12 / minute) . They are normally low-pitched. 30 seconds without bowel
sounds indicates paralytic ileus. High frequency of bowel sounds indicates
gastroenteritis. High pitch of bowel sounds indicates dilation. High pitch and frequency
indicates rapid peristalsis in the early phases of obstruction, later, absent sounds either
because cessation ( t3bo) or strangulation (ischemia) or release (rarely)
-RIF (where the bowels change from small to large at the ileocecal junction).

- A bruit is turbulent blood flow that can be auscultated. A thrill is a bruit that can be
felt. Auscultate for bruits from the aorta (above umbilicus), common Iliac, femoral and
the 2 renal arteries (2.5 cm superlateral from umbilicus).

-A bruit in bulges/lumps indicates hypervascularization.

-A bruit in the liver indicates a hemangioma / alcoholic hepatitis

-Auscultate the spleen for a bruit and friction rub (indicates tumor or inflammation).

-Auscultate for Kenaway sign (indication of esophageal varices or portal HTN). Listen for
venous humps at the lower esophagus with inspiration (venous hump would occur due
to negative intrathoracic pressure).
At the end DON'T FORGET :

1) palpate supraclavicular lymph nodes (most findings are on the right because the left

side contains thoracis duct

Ex : Virchow's node (btw the two heads of SCM muscle ) is enlarged in gastric

carcinoma, also pancreatic, skin, breast,etc.

2) check aortic, renal and femoral arteries pulsation

Aorta » epigastric area

Ranal » 2cm up, 2cm lateral at 45°angle to the umbilicus

Femoral » 2cm below the midinguinal point

Common iliac (sometimes) » midway btw umbilicus and ASIS

Internal iliac (sometimes) » midway btw site of common iliac artery and pubic tubercle

3) Hernial orifices again

4) PR and external genitalia

5) hands , nails and facies

Differential Diagnoses of Abdominal Pain:

RUQ= cholecystitis, choledocholithiasis, hepatitis(only if pressing in capsule), hepatic

abscess or cyst, peptic ulcer, pancreatitis, pyelonephritis, nephrolithiasis, retrocecal
appendicitis, MI, pneumonia, empyema, gastritis, intestinal obstruction, IBD, duodenitis,
cardiac cirrhosis (HF >> congestion of portal vein)

LUQ= gastritis, pancreatitis, splenic infarction, splenic aneurysm, splenic enlargement,

pyelonephritis, nephrolithiasis, pneumonia MI, empyema, diverticulitis, intestinal
obstruction, IBD.

RIQ= appendicitis, intestinal obstruction, IBD, mesenteric adenitis, perforated ulcer,

abdominal wall hematoma, ectopic pregnancy, ovarian cyst/torsion, salpingitis,
mittelchmerz, endometriosis, psoas abscess, hernia, nephrolithiasis, ureteral calculi.

LLQ= diverticulitis, intestinal obstruction, IBD, abdominal wall hematoma, ectopic

pregnancy, ovarian cyst/torsion, salpingitis, mittelchmerz, endometriosis, psoas abscess,
hernia, nephrolithiasis, ureteral calculi.
 Scars/Incisions Examination
An ideal scar is easy to open, easy to close, minimizes tissue damage, allows
sufficient access and if necessary is extendable.

Observe the scar acknowledging:

- site (to nearest landmark)

- length
- width
- color
- type (if it’s incision refer to picture below)
- healing 1st degree, 2nd degree, surgical, keloid, hypertrophied, etc…
(hypertrophied scars remain in boundaries of wound, keloids exceed the
boundaries).
1=Kocher (usually for cholecystectomy) 2= Thoracoabdominal 3=Midline
4=Muscle splitting loin 5= Pfannenstiel (usually for gynecological
operations) 6=rooftop/Gable
7=Transverse 8=Lanz/Rocky Davis 9=Paramedian 10= McEvedy

Other incisions include: McBurney’s (for appendectomy), Kidney transplant (curved

lower queadrant), Mercedes Benz/Chevron, and Laparascopic cholecystectomy (4 trochar
incisions).
 Groin and Inguinal Hernia
Examination
Review:

- Know that the midinguinal point is the midpoint between the ASIS and
symphysis pubis. The femoral pulse is felt at the midinguinal point. The
midpoint of the inguinal ligament is between the ASIS and pubic tubercle,
which is where the deep inguinal ring is located. The inguinal crease separates
the trunk from the thigh.
- Complications of hernia include: obstruction, strangulation and irreduciblty.
- Direct inguinal hernia is caused by episodes of increased abdominal pressure
breaking down the anterior abdominal wall. It occurs through the Hesselbach
triangle. The most common cause of indirect inguinal hernia is patent ductus
vaginalis (mainly in pediatrics). It occurs through the internal ring of the
inguinal canal, and is the most common hernia overall.
- The Hesselbach triangle is bound by the inguinal ligament, inferior epigastric
vessels and lateral border of rectus abdominis.
- The types of hydrocele are vaginal (most common type, occurs due to infection
and testicular tumors, fluid accumulates but doesn’t extend up to cord), congenital
(sac communicates directly with peritoneum), infantile (due to incomplete
absorption of fluids from Trichomonas vaginalis, fluid is part of cord and
scrotum), and hydrocele of the cord (around the cord).
- Retractile Testes occur due to excessive cremasteric muscle activity, drawing up
the testis. It can descend with milking, unlike undescended testis.
- Hernias with bowel content are soft, resonant, fluctuant, transilluminable and
auscultation may emit bowel sounds. Hernias with omental content are firm,
non-fluctuant, dull, non-transilluminable and don’t have peristalsis.
- In cases of hydrocele, you can’t get above it, the testes aren’t separated from it, its
transilluminable and has a negative cough impulse.
- The femoral canal is bound by the inguinal ligament anteriorly,
Pectineal/Cooper’s ligament posteriorly, femoral vein laterally and lacunar
ligament medially.
- The main contents of the spermatic cord (passing through the inguinal canal) are 3
arteries (1- Artery to vas from inferior vesicular, 2- Testicular artery from aorta,
3- Cremasteric artery from inferior epigastric), 3 nerves (1- Ilioinguinal nerve
from L1 anterior to cord, 2- nerve to cremaster from genitofemoral and 3-
 sympathetic autonomic fibers from T10) and 3 other structures (vas deferens,
pampiniform plexus and lymphatics draining to para-aortic nodes).

A few general questions:

- Do you have a chronic cough or asthma?

- Do you do any heavy lifting?
- Do you have to strain in order to defecate?
- Does the lump become painful?
- Do you have any abdominal pain?
- Have you vomited recently?
- Do you experience constipation?

Preparation:

- Introduce yourself and ask permission of the patient, attain privacy, and make
sure there’s a good light source and room temperature.
- Unless you have time to spare, examine the patient in standing position (even
though supine is the ideal position), and let the examiner know why you chose for
the patient to stand. Standing also exposes varicoceles.
- Expose the patient from umbilicus to the knee.
- Ask the patient what positions increase or decrease the swelling.

Inspection:

- From the front, observe for: skin changes/discoloration/visible scars/visible

veins/symmetry/bulge. Be thorough, because scars are usually hidden by hair.
- If you find a bulge inspect it as a lump
- Ask patient to cough for an expansile cough impulse
- Then observe posterior aspect of scrotum by pulling down skin (not testes).

Palpation:

- Ask if there’s any pain

 - Palpate both testes by rolling each one between your thumb (feel) and index
finger (support)
- Define axis of the testes
- Locate epididymis
- Feel spermatic cord
- If you’d like execute the “glove silk sign” (most drs. don’t use it)
- If you found a swelling examine as a lump. If you can get above it suspect
hydrocele, if you can’t get above it, suspect a hernia. If it’s a hernia and
fluctuation is positive, it’s bowel in origin. If fluctuation is negative, it’s omental
in origin.
- Finally percuss and auscultate the swelling.
-
If hernia detected:
- Start from the normal side, make sure it’s free.
- Switch to side of hernia, let one hand support the patient from the lumbar spine
and the other be used for palpation. Treat like a lump.
- Do the cough test, check if it reaches the scrotum and don’t forget
transillumination/reducibility. First ask patient to reduce it, and cough again to
release it. If he/she can’t reduce the lump yourself by compressing posterior-
superior-laterally (direction of the inguinal canal). If the cough impulse is
negative, it may be because the neck of the hernia is blocked by adhesions or
strangulated.
- If the bulge is superior to the inguinal crease, or medical to the pubic tubercle it’s
inguinal; if inferior to the crease or lateral to the pubic tubercle it’s femoral.
- To differentiate Direct from Indirect, reduce the hernia and put a finger 1 cm over
the midinguinal point and perform the Occlusion test (close the deep ring with
finger and ask patient to cough, if you feel the bulge then its indirect, if you don’t
feel anything its direct), and Invagination test (this test is irritating to the patient,
so its better to mention it to the examiner but don’t do it).

Differential Diagnoses:

 Inguinal hernia, femoral hernia, lipoma of the cord, hydrocele of cord/cana of

Nuck, ectopic testis, undescended testis, lymphadenopathy, saphena varix,
femoral aneurysm, psoas abscess, vaginal hydrocele.
 Neck and Thyroid Examination
Wade Jodeh
Review:

-Before initiating a neck examination, make sure you understand the cervical regions.

1) SCM Regions:

The SCM is a key muscular landmark as it divides each side of the neck into anterior and lateral
segments. The SCM has 2 heads: sternal head (attached to manubrium by anterior surface) and
clavicular head (attached to superior surface of medial 1/3 of clavicle). The SCM is superiorly
attached to the mastoid process. Contents include: SCM muscle, Greater Auricular Nerve,
Transverse Nerve of neck and superior part of Ext. Jugular Vein.

2) Anterior Triangle (Anterior cervical region):

The anterior triangle is bound anteriorly by the median line, posteriorly by the ant. border of the
SCM, superiorly by the inf. border of the mandible. The floor is formed by the pharynx, larynx
and thyroid. The digastric and omohyoid muscles divide the triangle further into 4 regions.

a) Submental Triangle: bound inf. by body of the hyoid and laterally by the ant. bellies of
the digastrics muscles. The submental triangle contains the submental lymph nodes and
anterior jugular veins.
b) Submandibular Triangle (digastrics triangle):bound by mandible and ant. + post.
Bellies of digastrics muscle. It contains the submandibular gland and lymph nodes. The
hypoglossal nerve and part of the facial artery and vein.
c) Carotid Triangle: bounded by sup. belly of omohyoid, post. digastrics belly and SCM.
The carotid triangle contains the common carotid artery, external carotid artery, internal
jugular vein, vagus nerve, carotid body and sinus.
d) Muscular Triangle (omotracheal triangle): bound by sup. belly of omohyoid, SCM
and median plane. Contains thyroid and parathyroids.

3) Posterior Triangle (lateral cervical region):

Bound by SCM, Trapezius and middle 1/3 clavicle inferiorly (between trapezius and SCM). The
posterior triangle contains part of the trapezius muscle. The inferior belly of the occipitaldivides
it into occipital and omoclaviculartriangles. The occipital triangle contains the external jugular
vein and cervical lymph nodes. The omoclavicular triangle contains the subclavian artery (3 rd
part), subclavian vein, supraclavicular artery and lymph nodes.

4) Posterior Cervical Region (contains Trapezius)

- Remember how to deal with any mass.

1) Inspect by verifying site, size, shape, skin changes, symmetry, scars and color.

2) Palpate to characterize the surface (smooth.irregular), edge (well/ill defined),

consistency (soft/firm/hard), temperature (use doral surface of hand), tenderness,
transilluminability, pulsatility (expansile/transmitted), compressibility,
fluctuation(use 2 fingers of same hand), fixation(to skin/underlying tissue), mobility(in
what planes), and fluid thrill.

3) Percussion (dull/resonance)

4) Auscultation

Preparation:

- Introduce yourself, attain permission, verify light source, room temp. and privacy.
- Make sure patient is sitting upright in a chair with ideal exposure up to the nipples (in
order to expose superficial dilated veins that may be due to tumor compression).
- Have a glass of water ready.

Inspection:

-Generally inspect the patient (sitting, pain, anxiety, tachypnea, stridor, awareness of
whereabouts, sweating, cannulas or leads).

- From the front of the patient, inspect the bulk of the neck at eye level (you’ll likely have to
bend down). Check for symmetry (ask patient to lift head), any bulges (if observed examine as a
lump), scars, goiter, distended neck veins, hyperemia of the skin, and hyper/hypopigmentations.

-Inspect both sides of the neck.

- Ask the patient to protrude his/her tongue as far as possible, and observe if a lump moves. If
this happens, the lump is likely a thyroglossal cyst because persistence of the thyglossal duct is
attached to the base of the tongue by a fibrous track through the hyoid.

- Ask the patient to have some sips of water, hold it in his/her mouth, and then swallow.
Observeof lump moves, if so it’s likely originated form the thyroid. This is because the thyroid,
cricoids and the larynx are enclosed by the pretracheal fascia which moves upon swallowing.
(berry ligament attaches trachea to thyroid)
 Note: By now if you’ve discovered a goiter, proceed directly to thyroid examination, otherwise
continue to palpation.

Palpation:

- Begin palpation behind the patient, but be gentle as you can’t see the patient’s facial
expressions. Rub your fingertips from both hands, some Drs. Recommend using all
fingers simultaneously. Make sure anterior neck muscles are relaxed.
- First define the triangles, if you’ve previously noticed a lump identify which triangle it’s
in and keep in mind differential diagnoses.
- Continue with the “up and down technique”. Start from chin and proceed backwards to
below ears, palpating the submental, submandibular, parotid and preauricular nodes.
Palpate post-auricular (mastoid) nodes behind the ears and then continue down the ant.
border of the SCM and feel ant. triangular nodes, such as the jugulodigastric node
(tonsillar). Move laterally along the clavicles feeling for both supra and infraclavicular
nodes. Return up the post. border of the SCM feeling for post. triangular nodes. Complete
by palpating occipital nodes on the back of the neck.
- If you find anything, confirm it from the front of the patient observing his/her reaction.
Multiple palpable lumps are definitely lymph nodes. Visible pulsation is likely due to
neck vein obstruction due to mass effect.

Differential Diagnoses:
Midline Mass Anterior Triangle and SCM Posterior Triangle

-thyroid swelling -lymphadenopathy(see below) -lymphadenopathy(see below)

-thyroglossal cyst -chemodectoma(solid -pharyngeal pouch (aka zenker’s

paraganglioma of chemoreceptor diverticulum, it’s the #1
-submental lymphadenopathy tissue) diverticulum of the esophagus,
cystic in nature)
-dermoid cyst (teratoma) -branchial cyst (epithelial cyst due
to failure of fusion of 2rybranchial -cystic hygroma(#1 lymphangioma
-laryngocele(common in glassblowers and cleft) in pediatrics, itstransilluminable)
saxophone players)
-cold abscess (aka collar-stud -clavicle tumor
-paramedian lobe of thyroid tract (80% on left) abscess 2ry to TB)
-subclavian aneurysm
-delphiannode (enlarges in thyroid disease, it drains -carotid aneurysm
the thyroid and larynx)
-prehyoidal bursitis -parathyroid tumor
-lipoma
-cartilage tumor -SCM tumor(seen in the 1st 2
-thymus weeks of life after a complicated
-CA of larynx, trachea or esophagus delivery, disappearing in 4-6
-sebaceous cyst months)
-isthmus
- Remember LIST as the most common causes of Cervical Lymphadenopathy

L= lymphoma and leukemia

I=infection either bacterial (b-hemolytic strep., TB), viral (CMV, EBV, HIV), protozoal
and Toxoplasmosis
S=sarcoidosis
T=tumors

- An alternative method of localizing cervical lymph nodes:

level 1=submental
level 2= superior cervical
level 3= middle cervical (1st area of cervical tumor metastesis)
level 4= lower cervical
level 5= lateral to SCM
level 6= medial to SCM
level 7= retromanubrial

- Don’t forget the Percussion and Auscultations segments of the lumps/mass.

Bonus Examinations for the Thyroid:

- For the most part, the thyroid is examined following the steps of the neck and lump
examination but with some variations.
- For instance, when taking a history it pays to concern yourself with some of the signs of
hyperthyroidism such as: palpitations, sweating, light clothing, increased appetite,
decreased weight, diarrhea, decreased IQ, bad temper, oligomennorhea, insomnia,
tremors, shiny skin etc…
- Some of the signs of hypothyroidism include: overdressing, constipations, mennorhagia,
infertility (more common than in hyperthyroidism), dry scaly skin etc…
- Ask about previous exposure to radiation, and a family history of thyroid conditions.
- As the patient talks listen for a hoarse voice (recurrent laryngeal palsy)

In General Examination, pay attention for:

- horizontal scars (previous thyroid surgeries)

- raised jugular venous pulse (vein obstruction from mass effect)
 - Check face for “peaches & cream” appearance (rounded face and pinkish flushing,
indicates hypothyroidism)
- Check for Berry’s Sign (absence of carotid pulse) which indicates a malignant
thyromegaly covering the carotid artery
- Let patient raise arms and observe for Pemburton’s Sign (facial flushing, neck
distension, engorged neck veins, and stridor in large substernalgoiters obstructing the
SVC).
- Check hands for sweating (hyperthyroidism), palmar erythema (hyperthyroidism),
acropachy/pseudoclubbing (Graves’ disease), onycholysis(separation of nail plate and
bed), vitiligo/depigmentation (Graves’ disease), pulse for tachycardia/atrial fibrillation or
bradycardia (hyper/hypothyroidism) and fine tremor.
- Check eyes and face for Queen Anne’s sign (hair loss in outer 1/3 of eyebrow in
hypothyroidism), Dalrymple’s sign (lid retraction), lid-lag, ophthalmoplegia (ask about
diplopia when finger is up and out because superior recti and inferior oblique are most
likely affected, due to deposition of Glycosaminoglycans), Morbius’ sign (difficulty in
convergence), exophthalmos (sclera is visible all round iris), chemosis (swelling of
conjunctiva), proptosis (eye is visible beyond supraorbital ridge, observe looking
overhead) and Joffroy’s sign (absence of wrinkling of forehead when patient bends head
and looks up).
- Check knee jerk for hyperreflexia (hyperthyroidism) or hyprefelxia (hypothyroidism).

In Palpation:

- makes sure you ask if swelling is tender before you begin behind the patient
- use your index finger
- generally palpate the thyroid anteriorly, before switching behind the patient
- palpate one lobe of the thyroid at a time
- then palpate the isthmus
- perform swallowing test and protrusion test again, but this time while palpating the
thyroid (in general examination you didn’t know if the thyroid was tender)
- describe the thyroid swelling by: surface, edges, consistency, temperature, tenderness,
transilluminability, pulsatility, fixation (to skin/SCM/trapezius/platysma), mobility,
homogenous, can you get above it, nodules, and is the isthmus enlarged.
- Palpate trachea for deviation, it should be equidistant between heads of clavicles.
- check for pretibial myxedema (hypothyroidism)

In percussion:

- percuss over sternum from suprasternal notch downward (listening for retrosternal
extension). One finger is enough.
- percuss medial parts of clavicles
In auscultation:

- listen for systolic bruit cause by hypervascular thyroid (almost always due to Graves’
disease)
-

Thank the patient

 Breast Examination
Review:

- The chief complaint of Breast diseases are either pain, lump (most common),
discharge, heaviness (likely a malignancy), axillary node enlargement or change
in nipple/areolar size/shape.
- Hyperprolactinemia can cause nipple discharge, headaches and vision problems.
- Mastitis is usually due to Staph. aureus in breast feeding women.
- Most common site of lump is UOQ, most commonly missed lumps are subareolar.
- Most common Breast CA is invasive ducatal carcinoma, and most common cause
of bloody discharge is ductal papilloma.

A few general questions:

If it’s about a lump ask:

- When did you notice it, what made you notice it, what symptoms were associated
with it, has it changed/disappeared since you noticed it, have you any lumps in the
past and has anyone in your family had any breast disorders or prostate cancer?

If it’s about discharge ask:

- Which nipple(s) discharge, what color, scent, have you been breast feeding, does
it occur in multiple orifices, is it spontaneous, is it recurrent?

If it’s about pain ask:

- Is it cyclic (usually day 14), unilateral/bilateral, site (quadrant), characteristic

(prickling/throbbing), does it resolve spontaneously, and any recent trauma.

Whatever the complaint is ask:

- Have symptoms altered with menstrual cycle (cyclic)?

- Ask about her menstrual cycle (regular, duration, menorrhagia)
- Menarche and menopause
- Gravida, Para, Abortions, length of breast feeding, age of 1 st pregnancy
- Ask about OCPs and other hormone altering pills.
Preparation:

-Introduce yourself and ask permission of the patient (have a chaperone), attain privacy,
and make sure there’s a good light source and room temperature.

-Make sure patient is lying down with a pillow, she’s comfortable, arms on the side and
bed is inclined 45 degrees. Expose patient from waist up.

Inspection:

- Inspect both breasts anteriorly.

- Concerning the breasts look for size, symmetry, scars, dilated veins, stretching,
puckering (pulled inward), dimpling, tethering (mass pulls inward if you move it),
peau d’orange erythema, edema, ulcerations, and pigmentations.
- Concerning the nipples/areola look for the 7 Ds: discoloration, discharge,
depression (inversion, suspect duct ectasia), displacement (elevated), destruction,
deviation (normally points downward-outward), duplication (accessory, look
along milkline), Montgomery tubercles and eczema (suspect Paget’s).
- Lift breast and search for skin rashes (ex: intertrigo, scabies) and accessory breast.
- Acknowledge differences in 3 stages: arms at side, arms raised (best for
puckering) and arms clenching waist (emphasizes lump attachment to pectoralis)
- Inspect axilla and arms for edema.

Palpation:

- Let the patient point out the lump and if it’s tender. Begin with the normal breast
at LIQ (least likely to have a defect) and continue to each quadrant. Retract breast
with left hand and plapate with right. Use 3 fingers, start from nipple and move
outward. If any mass is felt localize it by like a clock (ex: 3 oclock), state distance
from nipple and examine as a mass.
- Execute bimanual examination (sandwich the breast)
- Test for nipple discharge
- Palpate Axillary tail of Spence
- Palpate for the 5 groups of Axillary nodes (directions: anterior, posterior, medial,
lateral and apical) while supporting the patients arm with your free arm.
- Palpate for supraclavicular nodes.
- If you have time, proceed to complete chest, abdominal and back examination.
Differential Diagnoses:

Singular lumps are most likely to be fibroadenoma (mobile, well defined, firm, age 15-
30), cysts (distended involuted lobules, age 40-55, fluctuant, well defined, smooth, may
be tender), fat necrosis or breast cancer (surface irregularity/nodularity, poorly defined
edges, firm, non fluctuant, non tender, fixed to either skin or pectoralis, nipple change,
bloody discharge).
 Ulcers Examination
- Ask the patient what he/she thinks caused the ulcer.
- Examine remembering BEDDS:

Base: look for granulation tissue, necrotic tissue, or possible malignancies. The
base may be the same or deeper than the floor.

Edges: there are 5 types,

1- Sloping (indicates healing, so usually traumatic/venous)

2- Punched Out (ischemic or neuropathic)
3- Undermined (pressure necrosis or TB)
4- Rolled (BCC)
5- Everted (SCC)

Describe what structure is visualized at the base (ex: fascia, muscle, bone)

Discharge and what type:

1- serous (clear)
2- sanguinous (bloody)
3- serosanguinous (mixed, orange)
4- purulent (infected)

Surrounding Skin

- Remember the types of ulcers:

 Vascular Examination (Arteries)
Review:

- Most vascular pathologies are detected around the feet.

- Dorsalis Pedis pulse is absent in 10% of people. And 2% of people have neither
Dorsalis Pedis or Posterior Tibial pulses.
- Ankle-Brachial Pressure index= ankle pressure (DPA or PTA) / brachial artery
systolic pressure. 1-1.1 is the normal index. The ratio falls as leg perfusion
decreases. 0.5-0.8 indicates intermittend claudication and mild ischemia. Less
than 0.5 indicates rest pain and severe ischemia. Less than 50 mmHG ankle
pressure can be considered part of critical ischemia.
- Patients with the 6 Ps need interventions (pulseless, pale, painful, paralysis,
parasthesia).

Preparation:

- Introduce, permission, light, privacy, room temp. Expose patient from groin and
downwards (keep underwear on). Patient should be in supine position.

Inspection:

- Color Changes: white (advanced ischemia), red (vasodilation due to early

ischemia), and purple/blue (doxygenation).
- Trophic Changes: loss of hair, gangrene (especially between toes), loss of digits,
ischemic ulcers (usually found at pressure areas such as melleoli, fibula, heels
and lateral aspect of foot).
- Other skin changes including guttering (collapse) of veins, dryness, blistering,
discharge, pressure sores and shininess.
- Measure Bueger’s (vascular) angle by lifting foot until it becomes white
(perfusion drops. Less than 20 degrees indicates severe ischemia Healthy
individuals don’t lose perfusion. Comtinue with Buerger’s Test by helping
patient drop legs of side of bed. Reactive hyperemia causes the affected leg to
become red/purple.
- Assess muscles and nerves (I just skip this part)
Palpation:

- Make sure the patient has been exposed for atleast 5 min. by now, and start
feeling for temperature changes with the dorsum of your hand, starting from the
toes and going superiorly.
- Test for capillary refill in big toes, shouldn’t be more than 2 seconds.
- Feel the peripheral pulses, bilaterally and compare each as present, reduced or
absent. Femorals (2cm below midinguinal point), Pobliteals (the pobliteals aren’t
easy to palpate, if it’s too prominent suspect an aneurysm. Palpate by compressing
it against the posterior aspect of the tibia, between the heads of the gastrocnemius.
Either bend knee at 135 degrees, limb flat or have patient switch to prone
position), Dorsalis Pedis (lateral to extensor hallucis longus), and Posterial
Tibial (one finger breadth inferolateral to medial malleolus). Upper pulses
include carotid, brachial (cubital fossa, medial to biceps tendon, its an end artery),
ulnar and radial.
- Perform Allen’s Test to test radial and ulnar patency (obliterate both arteries and
test perfusion of each, shake hand in between).

Auscultation:

- Using the bell, auscultate the carotid, aorta, renal arteries, pobliteal and femoral
for bruits/murmurs. May indicate AV malformations or fistulae.

Varicose Veins
Review:

- The Saphenofemoral junction is located 2 finger breadths inferolateral to the

pubic tubercle. The tributaries (besides GSV and femoral) are the superficial
epigastric, superficial iliac circumflex, and superficial external pudendal veins.
- Syndromes associated with varicose veins include: Kippel-Trenauny Syndrome
(varicose veins, port wine stain, and bony/soft tissue hypertrophy of limbs) and
Parkes-Weber syndrome (multiple AV fistulae, limb hypertrophy and cardiac
output failure if severe).
- Varicose veins can be itchy due to destruction of RBCs (inhibited blood return),
leading to accumulation of bilirubin.
 - The tourniquet test is advantageous over trandelenburg because it permits
examination of the perforators in midthigh and below knee.
- In using a Doppler U/S, a “swooshing” sound indicates incompetent veins
allowing blood reflux.
- The dorsalis pedis is a continuation of the anterior tibial artery.
- The saphena varix can be mixed up with hernias because it has a positive cough
impulse and is reducible.
- Venous Ulcers are most commonly found in the gaiter area (immediately above
the medial malleolus). They’re caused by valvular disease, (varicocele, deep vein
reflux), outflow tract obstruction (post DVT) or muscle pump failure (stroke,
injury).

Preparation:

-Introduce yourself and ask permission of the patient, attain privacy, and make sure
there’s a good light source and room temperature.

-Make sure patient is standing (because veins are collapsed in the supine position), and
expose both lower limbs up to the groin but cover the genitalia.

Inspection:

- Check for 7 Ss: shape of legs, site and size of varicosity, skin changes and scars
(especially lower 1/3 of medial calf), saphena varix at SFJ and swelling of the
ankle.
- Check especially around medial malleolus (gaiter area) for LEGS:
lipodermatosclerosis (or inflamed areas), eczema, gaps (ulcers) and swelling
(edema). These are the signs of venous insufficiency.
- Check for Ankle flare (triangular lesion), reticular veins (blue veins appear larger
than ankle flare), spider veins, atrophy blanche (whitish scar with underlying
venous change) and blow-outs (circular dilated perforators). With these previous
signs suspect chronic venous insufficiency.
- If varicose vein observed differentiate if it’s great or lesser saphenous.
Palpation:

- May feel like a bag of worms. Feel for tenderness, induration,

lipodermatosclerosis (fibrin deposition) and check for pitting edema.
- Palpate the course of the GSV and LSV and feel for any fascial defects and
induration, also feel if the path is cordlike or nodular.
- Palpate the SFJ, and perform Cruveilhier’s Test, (positive cough impulse
exposing a saphena varix indicating saphenofemoral incompetence).
- Perform Chevrier’s Tap Test (place finger on lower limit of varicose vein, tap
the vein superiorly and feel for a transmitted impulse).
- Perform a Touniquet Test (let patient lie down, raise his/her leg until superficial
veins empty, tie rubber tourniquet at SFJ, let patient stand for 15 seconds and
observe). Filling of veins above tourniquet indicates incompetence of SFJ. If
filling occurs below the tourniquet indicates incompetence of perforators below
tourniquet. If the perforators are incompetent keep repeating the test (or use
multiple tourniquets) to localize the incompetent valve.
- If tourniquet test is positive in upper thigh, verify with a Trandelenburg test. Let
patient lie down, raise legs until veins collapse, and apply pressure to the SFJ (2
fingers), ask patient to stand, the veins should not refill; verifying SFJ
incompetence.
- Perform Schwartz Test. As patient is standing, put a finger at the lower part of
the dilated saphenous vein and another finger at the upper part. Percuss with the
upper finger, if you feel the thrill at the lower finger, the saphenous valves are
incompetent (as blood normally flows upwards).
- Check the patency of the deep femoral vein with the Perthes Test: let patient
elevate limbs, tie crepe bandage from toes to upper 1/3 of thigh obliterated
superficial veins, or tie a tourniquet below the knee. Let patient take a walk for 5
minutes, if he/she experiences claudication the deep system is incompetent.

Auscultation:

- Auscultate venous clusters, a murmur may indicate an AV-malformation.

Say you would like to examine the abdomen, pelivis (abdominal/pelvic mass may
obstruct IVC), DRE and groin.
 Surgical Sutures:

Sutures are used to hold body tissue together after an injury/surgery or to ligate blood
vessels. Most sutures in Rafidya belong to the company Ethicon®.

Classification is based:

-absorbability

-material

-size

-natural/synthetic

Absorbable sutures are hydrolyzed and absorbed by the body.

Ex: Prolene, Ethilon, Nylon and Silk are nonabsorbable (PENS)

The rest (including Vicryl) are absorbable.

Material is either monofilament or multifilament. The thicker the stronger but worse for
tissue reactions. Ex of multifilament PGA (polyglycolide) and ex monofilament is PDS
(polydioxanone).

Natural sutures are made of silk (protein filaments) and catgut (plain or chromic).

Sizes are based on the USP (United States Pharmacoepia) collagen diameters:

11-0 (thinnest), 10-0 (0.02 mm), 9-0…..3-0, 2-0, 0, 1 (0.5 mm), 2, 3…7 (thickest).

So ex:

Prolene®= synthetic monofilament nonabsorbable polyprolene duture.

 Drains Notes Wade Jodeh
A surgical drain is used to remove pus, blood, and other fluids from a wound. It’s also
used to remove potential space in apposition of tissue. When draining pus or bile, the
drain should remain intact until nil (pus and bile are irritative to internal cavities). As for
blood and serous fluid, they are drained in amounts less than 50 cc/day. There are 2 main
drainage systems:

Open Drains:

Open drains are “open” on one end and exposed to the atmosphere/dressing on the
other end. There are two types: Corrugated (has a radioopaque line) and Penrose
(rubber-tube). Their usage depends on the doctor’s preference. Open drains are used for
superficial cavities to remove pus, hematomas, drain dirty wounds and post-thyroid
surgery (but closed system is preferred).

Open drains have complications including: high risk of infection, need for daily
dressing and the discharge can’t be measured.

Closed Drains:

Closed Drains are “closed” on one end and attached to a system on the other.
They have 4 main types: Under-Gravity (ex: NGT, Foley’s), Under-Water Seal (chest
tube), Under-Vacuum (Jackson pratt) and Under-Suction.

1) Chest Tube (aka Thoracostomy):

Chest tubes are inserted by 2 methods: the open-method without a trochar (complete
incision must be made before insertion, including the skin, subcutaneous tissue, external
ICM, internal ICM, innermost ICM and parietal pleura) and the closed-method with a
trochar (only the skin is cut before insertion). The open-method is safer and under-vision.
Chest tubes are ideally inserted (safest from visceral injury) at the 4 th/5th ICS on the
MAL (the triangle of safety is bound by the latissimus dorsi, AAL and 4 th rib). The
incision is made above the rib to avoid injury to the neurovascular bundle. In case of
pneumothorax the drain is directed superoposteriorly (towards the apex), and in case of
fluid drainage it’s directed inferoposteriorly (towards the costophrenic angle).
 Chest tubes are indicated after any surgery involving the pleural cavity, and with any
fluid/air collection in the pleura. Complications include infection, vascular/nerve injury,
injury to lung parenchyma, injury to thoracic aorta, diaphragm, liver, spleen, heart,
stomach, and surgical emphysema.
At all times the chest tube is either functioning + producing, functioning +
nonproducing or nonfunctioning. A functioning tube is properly inserted and not
occluded. A producing tube is either oscillating (column moves with ventilation, aka
tidling), producing gas bubbles or fluid. In order to remove a chest tube, it must be
nonproducing. Then clamp it (like a safety valve), do a P/E, CXR (to confirm findings
from physical) and clamp for 6-24 hrs. If its nonproducing afterwards, do another P/E and
CXR, then remove drain.

2) Foley’s Catheter:

Foley’s Catheter is inserted into the urethra (averaging 4cm in females and 20 cm in
males). There are two types: Latex (rubber) which can be used for up to a week, and
Silicon (less irritative) can be used for 1-2 months. There are also 2 forms: 2-way
(urinary output + balloon) and 3-way (output + balloon + irrigation). 3-ways are used
following most urinary operations. The catheter must be lubricated until it reaches the
bladder.
Foley’s catheters are indicated to monitor urine output, post-op (ex: prostatectomy,
TURT, C-sections), bladder decompression, MCUG, and ureteric impantation (ex: in
VUR). It’s contraindicated in cases of urethral injury (can become a complete cut).
Urethral injuries are usually noticed by blood on the external meatus. Complications
include injury, bladder perforation, stricture and UTI (in MCUG).

3) Nasogastric Tube (aka feeding tube):

NGTs have a closed end with side holes. They can be with or without radioopaque
lines. They’re indicated for diagnostic procedures: assess stomach content, differentiate
upper/lower GI bleeding, and esophageal atresia. Therapeutic procedures include: feeding
(pts with dysphagia or unconsciousness), gastric decompression and gastric lavage. NGTs
are contraindicated in pts with coagulopathies, esophageal ulcers/obstruction/perforation,
maxillary facial trauma and nasal fractures. Complications include: esophageal
perforation, bleeding, and insertion towards the skull. NGT insertions is checked by the
appearance of stomach contents, CXR or blowing on the tube and listening with a
stethoscope.
 4) Suction

Suction drains have an open end and a side with a hole (to control pressure, which is
greater when youcover the hole with your finger). Suctions are used to clear airways (ex:
after RTA), assist in labor and at the site of surgery (recommended not to use
intraperitoneally to avoid omental adhesions).

5) Rectal Tube

Rectal tubes are used for high-washout rectal enema and to decompress volvulus.
They’re used for only a few hours.

6) Endotracheal Tube

It’s inserted orally via laryngoscope. It can be cuffed (with a balloon valve) or non-
cuffed. Cuffed tubes have a higher risk of pressure necrosis, and non-cuff have a higher
risk of air leaks. Size is determined by age: (Age+16)/4. If by tracheostomy, endotracheal
tubes are inserted ideally 1 cm above the carina (bifurcation of the trachea at the sterna
angle). Endotracheal tubes are indicated to secure airways (ex: coma pts and respiratory
insufficiency) and for anesthesia. Complications include ulceration on the tracheal
mucosa, perforation, epistaxis, and Mendelson’s Syndrome (acid aspiration).

7) Jackson-Pratt (aka Readivac)

It’s inserted under vision, and side holes must be within the closed space. The
collector functions by “thumping”. It’s used to drain dead spaces and cavities post-op (ex:
thyroidectomy, orthopedic operations, intra-abdominal operations, herniorrhaphy).

8) Central Line

Central Lines can be inserted into the subclavian (under midclavicle), internal jugular
(between heads of SCM), external jugular, axillary or femoral (1cm medial to femoral
pulse) veins. They are either single/double/ or triple lumen/needle. To insert the central
line, spread lidocaine on area of insertion. Put wire through the distal line (usually brown)
and attach syringe to large needle. Advance and aspirate as you enter slowly. When
needle reached vein remove syringe. Advance until 30 cm of the wire has been inserted.
Central lines are indicated in TPN, chemotherapy, dialysis, when fluid has osmolarity
>12.5 osmol/L, calculating central venous pressure, monitor fluid loss in pancreatitis and
when peripheral line can’t be inserted (ex: in neonates). Complications include
thrombosis, infection (if line kept over 3 weeks), hematoma, penumo/hemothorax,
cardiac fibrillations, air embolus and nerve injury (ex: vagus, phrenic). Central lines are
contraindicated in skin infections, coagulopathies and patients with arrhythmias. Patient
should remain under ECG.