CLINICAL EXAMINATION OF VARICOSE VEINS:

CLINICAL EXAMINATION OF VARICOSE VEINS:


INSTRUCTION: EXAMINE THIS GENTLEMANS LEFT LEG.


TO PATIENT:

HELLO MR.JONES. MY NAME IS DR. SO N SO. HOW ARE YOU FEELING TODAY? REPLY ACCORDINGLY.

MAY I PLEASE EXAMINE YOU? THANK YOU.

LET ME JUST DRAW THE CURTAINS TO ENSURE PRIVACY. I HAVE ALREADY WASHED MY HANDS.

COULD YOU PLEASE TAKE OFF YOUR TROUSERS AND KEEPING YOUR BRIEFS ON PLEASE STAND UP IN FRONT OF ME?

ARE YOU COMFORTABLE SIR?

DO YOU MIND IF I TALK ABOUT YOU TO THE EXAMINERS AS I GO ALONG?

I AM JUST GOING TO HAVE A LOOK FIRST OF ALL.


ACT:
KNEEL DOWN AND LOOK AT BOTH THE LEGS SYSTEMATICALLY BUT BRISKLY.


TO EXAMINER:
THERE IS ON INSPECTON IN THIS MIDDLE AGED GENTLEMAN, VISIBLE DILATED VARICOSE VEINS ON RIGHT/ LEFT/ BOTH LEGS , IN THE DISTRIBUTION OF LSV (LONG SAPHENOUS VEIN)/ SSV (SHORT SAPHENOUS VEIN). THERE IS EVIDENCE OF VENOUS INSUFFICIENCY IN THE GAITER AREA (THAT IS SKIN OF LOWER THIRD OF MEDIAL SIDE OF CALF) WITH EDEMA, BROWN HEMOSIDERIN PIGMENT DEPOSITION, LIPODERMATOSCLEROSIS (SWOLLEN EDEMATOUS CALF WITH THIN ATROPHIED ANKLE) AND ECZEMA. ON THE RIGHT LOWER LEG THERE IS A LARGE VENOUS ULCER. VENOUS STARS (MINUTE INTRADERMAL VEINS) ARE NOT PRESENT AND THERE IS NO EVIDENCE OF ANY SCARS NOR ATROPHIE BLANCHE (WHITE SKIN SCARRING WITHOUT ULCERATION) OR REDNESS IN THE OVERLYING SKIN.

AND NOW THE OTHER LEG.

TO PATIENT:
SIR, CAN YOU PLEASE TURN AROUND. THANK YOU.

ACT:
LOOK AT THE BACK OF LEGS (OVER SSV).

MENTION THE INSPECTION FINDINGS IF PRESENT.

TO EXAMINER:
THERE IS NO EVIDENCE OF ANY VARICOSE VEINS, SIGNS OF VENOUS INSUFFICIENCY IN THE DISTRIBUTION OF SSV.


TO PATIENT:
I AM JUST GOING TO FEEL THE VEINS. PLEASE LET ME KNOW IF IT IS TENDER.

ACT:
FEEL TEMPERATURE OVER VARICOSITIES AND PALPATE ANY OBVIOUS VARICOSE VEINS.

TO EXAMINER:
ON PALPATION, SKIN OVER VARICOSITIES IS NOT WARM. VARICOSITIES ARE PALPABLE AND NON TENDER.


TO PATIENT:
I AM NOW GOING TO PRESS FOR A SECOND ON YOUR ANKLE.

ACT:
PRESS 5 CMS ABOVE MEDIAL MALLEOLUS FOR 3 SECONDS FOR PITTING EDEMA.

TO EXAMINER:
PITTING EDEMA IS PRESENT.

TO PATIENT:
COULD YOU PLEASE TURN BACK AROUND TO FACE ME?

ACT:
AGAIN CHECK TEMPERATURE, TENDERNESS OVER VEINS.

TO PATIENT:
I AM GOING TO FEEL ALONG THE LEG JUST BEHIND THE MEDIAL BORDER OF TIBIA FOR TENDER DEFECTS IN THE DEEP FASCIA (THAT IS ABOUT 5, 10 AND 15 CMS ABOVE THE MEDIAL MALLEOLUS)

TO PATIENT:
PLEASE LET ME KNOW IF IT IS TENDER ANYWHERE. I AM LOOKING FOR EVIDENCE OF PERFORATOR INCOMPETENCE.

TO EXAMINER:
PALPATION ALONG THE COURSE OF THE VEIN JUST BEHIND/ ALONG THE MEDIAL BORDER OF TIBIA DOES NOT REVEAL ANY TENDER DEFECTS IN THE DEEP FASCIA (WHERE THE COMMUNICATING VEINS PASS FROM THE SUPERFICIAL TO THE DEEP SYSTEM ….PHALENS TEST)


TO PATIENT:
DO YOU MIND IF I FEEL IN THE GROINS.

ACT:
FEEL ANATOMICAL LANDMARKS:
1. PUBIC TUBERCLE….FEEL IT AND ABOUT 3-4 CMS BELOW AND LATERAL TO IT LIES SFJ (SAPHENO FEMORAL JUNCTION).
2. OR FEEL ASIS AND PUBIC SYMPHYSIS, MID INGUINAL POINT…..THAT IS FEMORAL PULSE…PALPATE JUST MEDIAL TO FEMORAL PULSE FOR SFJ.


TO EXAMINER:
I AM PALPATING THE SFJ ABOUT 3.5 CMS BELOW AND LATERAL TO THE PUBIC TUBERCLE.

NOTE:
THE PUBIC TUBERCLE CAN BE DIFFICULT TO PALPATE BUT FORMS THE POINT OF INSERTION OF THE PROMINENT ADDUCTOR LONGUS TENDON WHICH RUNS MEDIALLY UP THE THIGH (TENDON CAN BE MADE MORE PROMINENT BY FLEXING, ABDUCTING AND EXTERNALLY ROTATING THE PATIENTS THIGH).

ACT:
FEEL FOR SAPHENA VARIX (PRESENTS AS A LUMP A LUMP IN GROIN AND IS A DILATATION OF LSV JUST BEFORE IT ENTERS FEMORAL VEIN. IT EMPTIES ON MINIMAL PRESSURE AND REFILLS ON RELEASE.

TO EXAMINER:
THERE IS A VARIX HERE ON THE RIGHT/ LEFT GROIN.


TO PATIENT:
COULD YOU PLEASE TURN YOUR HEAD TO THE OTHER SIDE AND COUGH PLEASE. (FOR EITHER VARIX OR SIMPLY SFJ)

TO EXAMINER:
I CAN FEEL A STRONG COUGH IMPUSLE SUGGESTING AN INCOMPETENT SFJ.

TO PATIENT:
I AM JUST GOING TO TAP IT (AT SFJ) AND FEEL LOWER DOWN.

ACT:
REST A HAND ON THE MEDIAL CALF JUST BELOW THE KNEE ALONG THE COURSE OF THE VARICOSE VEIN AND TAP THE SAPHENA VARIX/ SFJ/LSV FROM ABOVE DOWNWARDS.

TO EXAMINER:
PERCUSSION AT SFJ DEMONSTRATES TRANSMISSION OF WAVES DOWN THE VEIN (CRUVHEILLIERS SIGN) INDICATING A POSITIVE TAP TEST (INDICATES INCOMPETENT VALVES BELOW SFJ).

I WOULD NOW LIKE TO PERFORM THE TOURNIQUET TEST.

TO PATIENT:
COULD YOU LIE DOWN PLEASE? I AM GOING TO LIFT YOUR ANKLE GENTLY AND REST IT ON MY SHOULDER. KEEP YOR LEG STRAIGHT IF YOU CAN PLEASE.

ACT:
LIFT THE LEG, PUT THE ANKLE ON ONE SHOULDER AND STROKE THE LEG FIRMLY (WITH PALMAR SURFACE OF FINGERS).

TO PATIENT:
I AM JUST EMPTYING THE VEINS.

ACT:
PUT THE RUBBER TOURNIQUET TIGHTLY AROUND THE UPPER THIGH BELOW SFJ.

TO PATIENT:
STAND UP PLEASE.

ACT:
WATCH BELOW THE TOURNIQUET. DO THE VEINS FILL IMMEDIATELY?
1. IF YES……THE VARICOSITIES ARE NOT CONTROLLED AT THE LEVEL OF THE SFJ SUGGESTING INCOMPETENT PERFORATORS LOWER DOWN.
2. IF NOT….THE VARICOSITIES ARE CONTROLLED AT THE LEVEL OF SFJ.

NOTE:
IF ASKED THEN ONLY MENTION….

KEEP REPEATING THE PROCEDURE, MOVING THE TOURNIQUET PROGRESSIVELY DOWN THE LEG (JUST ABOVE KNEE, JUST BELOW KNEE) THAT IS BETWEEN THE SITES OF THE PERFORATOR VEINS. REPEAT UNTIL THE VEINS BELOW THE TOURNIQUET STAY COLLAPSED. IT DEFINES THE SEGMENT OF LEG CONTAINING INCOMPETENT PERFORATORS.

TO EXAMINER:
THE TOURNIQUET TEST REVEALS THAT THE VEINS ARE CONTROLLED AT THE SFJ.

NOTE:
ONLY DO THIS IF ASKED BY EXAMINER SPECIFICALLY OTHERWISE OMIT…
TRENDELENBURG TEST:
ASK PATIENT TO LIE FLAT. ELEVATE THE LEG UNTIL THE SUPERFICIAL VEINS ARE EMPTIED. ONLY PERFORM THE TEST IF THE TOURNIQUET TEST IS POSITIVE AT THE UPPER THIRD OF THIGH. PLACE TWO FINGERS AT THE SFJ. ASK PATIENT TO STAND UP, KEEPING YOUR FINGERS FIRMLY IN PLAE. WATCH LEG. NO FILLING OF SUPERFICIAL VEINS BELOW FINGERS, FILLING ON RELEASE OF FINGER PRESSURE INDICATES SFJ INCOMPETENCE.

TO EXAMINER:
I WOULD LIKE TO PERFORM PERTHES TEST.

TO PATIENT:
LEAVING THE TOURNIQUET ON COULD YOU PLEASE WALK AROUND/ STAND UP AND DOWN ON TIPTOES PLEASE.

ACT:
WATCH LEG.
IF VEIN GET BETTER.THE DEEP VENOUS SYSYTEM APPEARS TO BE FUNCTIONING.
IF VEINS GET WORSE AND PATIENT DEVELOPS SEVERE DISCOMFORT THERE MAY BE PROBLEMS WITH THE DEEP VENOUS SYSTEM THAT IS THERE IS OCCLUSION OF THE DEEP VEINS.

TO EXAMINER:
PERTHES TEST REVEALS THAT THE DEEP VENOUS SYSTEM IS FUNCTIONING.

TO PATIENT:
I AM JUST GOING TO FEEL IN YOUR GROINS SIR.

ACT:
PALPATE ALL PULSES INCLUDING FOOT PULSES.

TO EXAMINER:
ALL THE PULSES INCLUDING FOOT PULSES ARE PALPABLE AND PERFUSION IS GOOD.

TO PATIENT:
I AM JUST GOING TO LISTEN OVER VEINS.

ACT:
PLACE BELL OVER SITES OF MARKED VENOUS CLUSTERS.

TO EXAMINER:
AUSCULTATION OVER THE CLUSTER OF VEINS DOES NOT DETECT ANY CONTINUOUS MACHINERY MURMUR OF AV FISTULA.

TO PATIENT:
THANK YOU SIR. YOU MAY WEAR YOUR TROUSERS. LET ME HELP YOU WITH IT. THANK YOU AGAIN.


TO EXAMINER:
THE TOURNIQUET TEST CAN BE PERFORMED AT DIFFERENT LEVELS. A COMPLETE EXAMINATION WOULD INCLUDE:
1. LOOKING FOR SIGNS OF ARTERIAL INSUFFICIENCY AND PALPATION OF ALL PULSES INCLUDING FOOT PULSES.
2. ABDOMINAL EXAMINATION.
3. RECTAL EXAMINATION.
4. PELVIC EXAMINATION.
5. EXTERNAL GENITALIA EXAMINATION (TESTES IN MALES).MASSIVE ENLARGEMENT OF ABDOMINAL LYMPH NODES BY METASTASES FROM SMALL TESTICULAR TUMORS CAN CAUSE IVC OBSTRUCTION.
6. DOPPLER ULTRASOUND ASSESSMENT OVER SFJ OR SPJ (SAPHENO POPLITEAL JUNCTION).


TO EXAMINER:
THIS PATIENT HAS VARICOSE VEINS WITH SIGNS OF VENOUS INSUFFICIENCY.


I WOULD LIKE TO WASH MY HANDS.

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Common Medical Procedures

• Anoscopy
  
• Fine Needle Aspiration of Thyroid
• Paracentesis
• Reducing Rectal Prolapse
• Rigid Sigmoidoscopy
• OroGastric Intubation
• Lumbar Puncture
  
• Nasogastric Intubation
• Percutaneous Suprapubic Cystotomy
  
• Shunt Tap
• Male Urethral Catherization
• Breast, Lymphnode, and Soft Tissue Fine Needle Aspiration Biopsy
• Excising Thrombosed External Hemorrhoid
  

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LIPPINCOTT PHARMACOLOGY EBOOK FREE DOWNLOAD

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INGUINAL HERNIA EXAMINATION SCEHEME

Hernia Examination

Always start with the patient STANDING

Inspect standing

- Exposure is very important – ensure you can see from umbilicus to knees at
least!
- Look in the groin for evidence of a swelling – if you cant see one, then ask the
patient which side they have noticed a lump
- Look for evidence of previous hernia surgery – oblique scar often well hidden
in pubic hair line
- Any other obvious skin changes, swellings, lumps that may be relevant
- Ask the patient to look over their shoulder and cough (so they don’t cough into
your face!)
- As they cough, look at the lump to see if there is a cough impulse

Palpate standing

- Palpate the swelling
- Can you get above it (suggesting originates in scrotum/spermatic cord e.g.
hydrocoele)
- Does it feel soft, fluctuant, Pulsatile etc.
- Ask the patient again to cough, palpating for a cough impulse
- Ensure that you feel the opposite side, as bilateral hernias are very common,
often one being much more prominent

Auscultate

- Take this opportunity to auscultate the lump, as if it is readily reducible, there
will be nothing to listen too when the patient lies down.

Lie the patient down

Inspection

- Again, inspect the groin to ensure there is nothing missed from standing
inspection.
- Offer to palpate the abdomen for any cause of raised intra-abdominal pressure
such as ascites or mass, which can predispose to herniation

Palpation

- Having identified a hernia, the next task is to assess if it is indirect or direct.
- Ask the patient if they can reduce the hernia, if it has not done so by being
supine – NEVER do this standing as it is painful.
- Palpate the groin to assess if the hernia has completely reduced
- Warn the patient that you will palpate some bony points
- Feel for the anterior superior iliac spine and the pubic tubercle (delineating the
inguinal ligament – as opposed to the ASIS to pubic symphysis, to identify the
mid-inguinal point, the landmark for the femoral artery)
- Palpate the midpoint of the inguinal ligament (the surface landmark for the
deep inguinal ring) and ask the patient to cough
- If the hernia is CONTROLLED by pressure over the deep inguinal ring, it
suggests that the hernia is indirect.
- In order to confirm that you were in fact controlling the hernia, ask the patient
to cough without pressure to ensure that the hernia now appears.
- Offer to examine the scrotum, where you should palpate the testis and
epididymis (my finals hernia case had epididymal cysts which were expected
to be found)
That completes the examination of the hernia, but offer to examine the abdomen for
masses etc.
People often find hernias difficult as there is not much opportunity to practice –
however, as finals loom ensure you seek out hernia lists in day surgery as these cases
often come up.


Some theory

Hernia = protrusion of viscus through the confines of the cavity within which the
viscus normally lies

There are many types of hernia – ensure you are aware of the following types
- Inguinal – see below
- Femoral
o 1/3 hernias in women – i.e. more common in women but inguinal still
commoner
o Rare in males
o Arise inferiorly and laterally to the pubic tubercle
o More rigid boundary - inguinal ligament, pectineal ligament, lacunar
ligament and femoral vein being the boundaries
o More likely to strangulate
o Can be ‘richter hernia’ where a knuckle of bowel wall is trapped rather
than the entire circumference
o Can present as obstruction with no localising signs
- Sphigelian
- Umbilical
- Para-umbilical
- Epigastric
- Lumbar
- Obturator
- Hiatus

Inguinal hernias

These are the commonest type of hernia in both males and females.
Indirect – hernial sac passes through the deep inguinal ring, through the inguinal canal
and can pass into the scrotum. These tend to be found in younger men
Direct – hernial sac passes directly through the transversalis fascia and rarely pass
into the scrotum. These tend to be more prevalent in the older man. More precisely,
direct hernias pass through Hasselbachs triangle, delineated by the inferior epigastric
artery laterally, the rectus abdominus muscle medially and inguinal ligament
inferiorly.
In the exam, it would be prudent to comment that although your clinical findings
suggest that this is an indirect/direct hernia, this can only be confirmed at operation.
The precise definition of direct vs indirect is in relation to the inferior epigastric
vessels. Direct hernias arise medially to these vessels and indirect laterally.
It would be worth revising the anatomy of the inguinal canal and the contents of the
spermatic cord:
- 3 arteries – testicular artery, artery to vas, artery to cremaster
- 3 nerves – genital branch of genitofemoral, sympathetics and ilioinguinal (this
nerve actually travels WITH the spermatic cord rather than within
- 3 others – vas deferens, lymphatics, pampiniform venous plexus
- Some also include the 3 layers of fascia.

Common exam questions

1. What is the difference between indirect and direct? – see above
2. Discuss anatomy of inguinal canal
3. What investigation could be performed if unsure if hernia? – ultrasound is
often used if it is unclear if there is a hernia or not
4. What is the management?
- The answer should be repair of the hernia, as there is a risk of the hernia
becoming strangulated – unless there are contraindications to surgery –
however the repair can even be done under local anaesthesia
5. What are the operative options?
- There is the option of performing the repair open (Lichenstein procedure)
or using a pre-peritoneal laparoscopic approach which has the advantage in
bilateral hernias to do both with the same incision, and in redo operations.
The ‘pre-peritoneal’ means that the peritoneum is not breached.
Laparoscopic surgery is becoming more popular and is associated with
sooner return to work. Both types can be done as day surgery. The
principal of both types is the use of ‘tension free mesh repair’, whereby a
mesh is used to incite a fibrous reaction to create a strong barrier to
herniation that doesn’t rely upon the tension of sutures closing the defect
6. What is the differential diagnosis of a lump in the groin?
- Approach this systematically:
o Skin – sebaceous cyst
o Subcutaneous – lipoma, fibroma
o Arterial – femoral pseudo/aneurysm
o Venous – saphena varix
o Lymphatic – lymphadenopathy
o Psoas abscess
o Hernia – inguinal, femoral
o Ectopic testis

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How to Perform Male Urethral Catherization

URETHRAL CATHETERIZATION

• Indications:
  • Therapeutic
    • Urinary retention
    • Urinary output monitoring
    • Evacuation of blood clots
    • Intravesical chemotherapy
    • Postoperative urethral stenting
  • Diagnostic
    • Collection of urine for culture
    • Measurement of the postvoid residual urine
    • Retrograde instillation of contrast agents (cystourethrography)
    • Urodynamic studies
    
    
• Contraindications:
  • Acute prostatitis
  • Suspected urethral disruption associated with blunt or penetrating trauma
    • Blood at urethral meatus
    • Hemiscrotum
    • Perineal ecchymoses
    • Nonpalpable prostate
    • Inability to void
  • Severe urethral stricture

• Anesthesia:
  Recommend 2% lidocaine jelly

• Equipment:
  • Urethral catheterization kit (includes Foley catheter, povidone-iodine solution, lubricating jelly, 10-ml syringe with sterile normal saline, gloves, sterile towels, and urinary drainage bag)
  • Recommend 18F Foley catheter for male and 16F for female patients
  • Recommend 22F–24F Foley catheter for blood clot irrigation
  
  
• Positioning:
  Supine (men)

• Technique:
• Place sterile towels around the penis.
  

• Test the balloon of the catheter, lubricate the catheter with lubricating jelly, and set it aside on the sterile field.
• Retract the foreskin (if present). Grasp the penis laterally with the nondominant hand and place it on maximum stretch perpendicular to the body to straighten the anterior urethra.
• Swab the glans with povidone-iodine with the dominant hand. Observe sterile technique at all times.
• Inject 10 ml of 2% lidocaine jelly into urethra. Place a sterile urethral clamp for 5 minutes to provide anesthesia as well as additional lubrication. If lidocaine jelly is not available, it is helpful to inject 10 ml of lubricating jelly into the urethra.
• Grasp the catheter with the dominant hand.
  
• Using steady, gentle pressure, advance the catheter into the urethra until both the hub of the catheter is reached and urine is returned. Inflate the balloon with 10 ml normal saline.
  

• If urine is not returned, irrigate the catheter to confirm correct placement prior to inflating the balloon.
• Replace the foreskin to prevent a paraphimosis. Connect the catheter to a urinary drainage bag.
• If the catheter cannot easily be passed, a strategy for successful catheterization must be planned.

• Strategies for Difficult Catheterization of Men
  If resistance is met during catheter advancement, manually palpate the catheter tip to define the point of obstruction along the urethra . Once the location and nature of the lesion is defined, the next step is to develop a strategy for bypassing the obstruction.

• Anterior urethral obstruction”urethral stricture, a concentric
  narrowing of the lumen by scar tissue. Can occur at the fossa navicularis, bulbous urethra, or along the penile urethra.
  • Etiology: sexually transmitted disease, prior urethral instrumentation including transurethral resection of prostate (TURP), trauma.
  • Signs/symptoms: splayed and/or slow stream, straining.
  • Strategy for penile urethral stricture:
    • Use 16F or smaller straight-tip Foley catheter.
    • If unsuccessful, consult urology department to attempt catheter placement.
  • Strategy for bulbous urethral stricture:
    • Same as above.
    • If unsuccessful, 16F coudé-tip catheter will better negotiate the natural angle of the bulbomembranous junction. A coudé catheter has a curved tip that enables one to better engage the normal S-shaped curve of the bulbomembranous junction or to bypass an enlarged, obstructing prostate in the male urethra. To insert a coudé catheter, always keep the angled tip pointing superiorly and follow steps 6a–6j.
• Posterior urethral obstructions
  • Spasm of the external urinary sphincter
    • Etiology: contraction of the voluntary sphincter secondary to anxiety or pain. Often the cause of unsuccessful catheterization of men < 50 years old.
    • Signs: As the catheter tip approaches the sphincter, the patient becomes tense and complains of pain.
    • Strategy: (a) Inject 10 ml of lubricant (water-soluble jelly works as well as 2% lidocaine jelly). (b) After reaching the sphincter, pull the catheter back a few centimeters. (c) Distract the patient with conversation and by having him breathe deeply. (d) Advance the Foley catheter steadily with a slow, gentle pressure when the patient is relaxed.
  • Benign prostatic hypertrophy (BPH)
    • Suspect with age >60 years, prior transurethral resection of the prostate (TURP), treatment with finasteride (Proscar), terazosin (Hytrin), doxazosin (Cardura), or tamsulosin (Flomax).
    • Symptoms: hesitancy, intermittent and/or slow stream, straining, sensation of incomplete emptying.
    • Strategy: (a) A large catheter (18F or 20F) provides the additional stiffness needed to overcome the obstruction. A coudé-tip catheter is often helpful for negotiating the angle between the bulbous and membranous urethra . (b) Use the two-person technique: While catheter placement is attempted in the usual fashion, the assistant places a lubricated index finger in the rectum and palpates the apex of the prostate. The tip of the catheter usually can be felt just distal to the apex . The index finger presses anteriorly, thus elevating the apex and straightening out the area of obstruction.
      

• Prostate cancer: typically is not the sole cause of difficult catheterization unless the cancer is locally advanced. Strategy is similar to that for BPH.
• Bladder neck contracture.
  • Etiology: prior open or radical retropubic prostatectomy, bladder neck incision, or TURP.
  • Symptoms: hesitancy, intermittent and/or slow stream, straining, sensation of incomplete emptying.
  • Strategy: (a) Attempt a 12F catheter placement, following steps 6a6. (b) Consult urology department.

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Breast, Lymphnode, and Soft Tissue Fine Needle Aspiration Biopsy

• Indications:
o Evaluation of palpable masses
o Aspiration of breast cysts
o Differentiation of benign from malignant lesions. In breast disease, stereotactic large-gauge needle biopsy by radiologists has become the technique of choice for evaluation of breast lesions. However, FNA continues to be a valid technique and is essential for centers lacking stereotactic facilities.

• Contraindications:
None

• Anesthesia:
Anesthesia is not routinely used for FNA. However, if needed, a small amount of 1% lidocaine may be infiltrated locally, taking care not to distort the palpable lesion.

• Equipment:
o Alcohol prep
o 10-ml syringe
o 1 1/2-inch 25-gauge needle
o Syringe holder (optional)
o Glass microscope slides (two)
o Spray fixative
o Gauze

• Positioning:
o Breast: For upper quadrant lesions, the patient is placed in an upright seated position. Lower quadrant lesions are better managed in a supine position.
o Lymph node and soft tissue: depends on location of lesion.

• Technique:
o Prep the area for aspiration with an alcohol prep pad as if for phlebotomy.
o Palpate the lesion and immobilize the mass between the fingertips of the nondominant hand.
o Using the dominant hand, advance a 25-gauge needle with an attached 10-ml syringe into the lesion.
o Note the consistency of the mass upon entering it with the needle (firm, soft, rubbery, doughy, gritty).
o Once the lesion is entered, a full 10 ml of suction is applied to the syringe.
o While maintaining suction, move the needle back and forth through the lesion several times in different directions.
o Release the syringe plunger and allow it to return to a neutral position prior to removing the needle from the lesion. At this point the specimen is within the needle and hub and should not be in the syringe.
o Remove the needle from the patient, and have the patient apply pressure to the puncture site with a gauze pad.
o Detach the needle from the syringe.
o Fill the syringe with air.
o Reattach the needle onto the syringe.
o Touch the needle tip to a glass microscope slide with the bevel at a 45 angle to the slide surface.
o Expel material within the needle onto the slide.
o Make a smear by using a second glass slide to gently press down and draw out the material to a feathered edge. If the material is more liquid, it is pulled in the same fashion as a blood smear, except that before the feathering process is completed, the spreading slide is raised, leaving a line of particles across the slide. The spreading slide is then turned and again pressed down against the line of particles and drawn out into a feathered edge.
o Air dry or apply cytological fixative to the slide per the protocol of the cytopathology laboratory that will be processing the specimen. (If a fixative is applied, it must be applied very quickly, usually within seconds of preparing the smear.)
o Most cytopathologists require 3 “6 needle passes (samples) for an adequate pathological diagnosis.
o If a cyst is aspirated, the cyst fluid should be sent for cytology. The region of the cyst should then be re-examined; if a residual mass is felt, it should then undergo FNA.

• Complications and Management:
o Bleeding and hematomas
Breast FNA can be associated with significant hematomas and ecchymoses.
Apply firm direct pressure to puncture sites immediately following aspiration.
o Pneumothorax
More likely in thin patients and deep lesions
If tension pneumothorax suspected, decompression with 16-gauge intravenous line (IV) into second intercostal space and then tube thoracostomy
If 10% to 20% pneumothorax, observation and serial chest radiographs.
If .20% pneumothorax, tube thoracostomy.
o Infection
Extremely rare in FNA but has been reported.
Antibiotics as appropriate.

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Health Frequently Asked Questions (FAQs)

Central Nervous System

---

• Bilateral Spastic Paraparesis
• Hemiplegia
• Cerebellar Syndrome
• Nystagmus
• Speech related Disorders
• Horner's syndrome and Ptosis
• Argyll Robertson pupil
• Parkinson's disease

Cardiovascular System

---

• Angina Pectoris
• Hypertension
• Acute Myocardial Infarction
  
• Infective Endocarditis
• Mitral Stenosis
• Dextrocardia
• Coarctation of Aorta
  

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THYROID EXAMINATION VIDEO

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Special Histology Practical Copy Drawings set -1

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FCPS PAST PAPERS: MEDICINE JUNE 2010

1. H+ ion secretion in the kidney causes
bicarbonate reabsobtion
bicarbonate excretion

2. which is pivot joint
temporomandicular
atlanto occpital
Atlanto axial

3. Drug used for mountain sickness
acetazolamide
scopolamine

4.Corneal opacities r caused by
ethambutol
phenothiazides


5. Captopril causes
hypokalemia
hyper kalemia

6. Ph =7.5 HCO3= 48 PCO2= 45 diagnosis is
metabolic alkalosis
respiratory alkalosis
partially compensated metabolic alkalosis
partially compensated respiratory alkalosis

7. Which is P450 inducer
isoniazid
phenobarbitone
cometidine
ketoconazole

8. Which causes decreased gastric motility
Magnesium Sulphate
Aluminium Hydroxide


9. Serum gastrin levels are incresed by prolonged use of
antacids
PPI
H2 blockers
anticholinergics
beta blockers

10.Esophago gastric junction competence is maintained by
lying supine
incresed intra abdominal pressure
diaphragm paralysis
use of metoclopramadie
use of morphine

11. Patient has acute blood loss the mechanism triggered imediately is
baro receptor mechanism
renin angiotensin system

12. Carotid body receptors respond to
arterial PO2
arterail Pco2
13. propylthyouracil acts by
decreasing iodine uptake
decreasing TSH levels
decreasing thyro globulin levels

14. which is increased in first responce
Ig G
Ig M
Ig A

15. which crosses placenta
Ig G
Ig M
Ig A
Ig E

16. which is secreted in breast milk
Ig G
Ig A
Ig M

17. which has memory function
Ig G
Ig M
Ig A
Ig E

18. which drug causes abnormal differentiation between red and green colours
ethambutol
amiodarone
pyrazinamide

19. for best verbal communication skill one should hav
good vacabulary
competence in presentation
fluent speech
20. which is not caused by parasympathelic stimulation
increased GIT motility
micturation
miosis
sweating

21. ejaculation is caused by
sympathetic
parasypathetic
both

22. Alpha receptors stimulation causes
pupilaary dilation
increased heart rate
increased contractility

23. fracture of surgical neck of humerus, patinet cant raise arm and sensory loss on lateral surface of arm. damage to
axillary nerve
musculo cutaneous nerve

24. action of gluteus medius n minimus is
abduction n medial rotation
abduction n lateral rotation
adduction n medial rotation
adduction n lateral rotation

25. thymus is formed by
3rd pharangeal pouch
4th pharangeal pouch

26. bromocriptine causes decresed prolaction levels by acting on
dopamine receptors
cholinergic receptors

27. patients ecg shows increasing PR intervals and then a missed beat
first degree block
sinus arrythmia
Mobitz type 1 block
Mobitz type 2 block
3rd degree block

28. Digoxin is drug of choice in
Atrial flutter
Atrial Fibrillation
Ventricular Tachycardia
Bradycardia

29. patient after ischemic attack has ventricular tachycardia. drug that must b used is
lidocaine
amiodarone
verapamil

30. apex beat is
4th left intercostal space mid clavicular line
8cm to the left of midline in 5th intercostal space

31. young patient has bruises on the body and no other significant history n examination unremarkable. he has

idiopathic thrombocytopenic purpura
aplastic anemia
Hemophilia

32. Hemophilia is
X linked recessive
Autosomal dominant
Autosomal recessive

33. which investigation to be done in patient with hemophilia
PT
APTT
bleeding time
complete blood count

34. patient has hemoptysis and glomerulonephritis. diagnosis is
good pasture syndrome
wegeners granulomatosis
35. P falciparum causes
black water fever

36. C perferingens acts by
producine lecithinase
depleting ATP
causing hypoxia

37. Gonococcus in easily identified in exudate specimen by
gram staining
Z N staining
culture

38. which is not oncogenic
Hep B virus
Hep D virus
Herpes Simplex virus
EBV

39. Middle meingeal artery passes through
foraman spinosum
foraman lacerum
foraman rotundum
foraman ovale

40. damage to middle meningeal artery causes hematoma formation between
duramater n calvaria
duramater n arachnoid mater
arachnoid mater n piamater

50. which is present in cavernus sinus
abducent nerve

51. which cranial nerves r parasympathetic
III, VII, IX, X

52. patients right eye has moved upward n has his neck tilted to left to avoid diplopia. damage to
superior oblique
inferiour oblique

53. patient has homonymous hemianopia. lesion is at
optic nerve
optic tract
retina
optic chiasma

54. germ cells r derived from
ectoderm
endoderm
mesoderm

55. foreign body in trachea goes in which bronchus
right upper
right middle
right inferior
left inferior

56. which lobe has only 2 brocho pulmonary segments
right middle
right upper
left upper
left middle

57. during iso volumetric contraction
atrial pressure decreases
semilunar valves r open
coronary blood flow decreses
first heart sound is produced
second heart sound is produced

58. which is thick filament
actin
myosin

59. a sacromere is present between 2
Z lines
H band
A band

60. in muscle cells calcium is released from
endoplasmic reticulum
sarco plasmic reticulum
61. in kidney select the best order of arteries
renal > arcuate>interlobar>interlobular>efferent arteriole
renal>interlobular>interlobar>arcuate>efferent arteriole
renal>interlobar>interlobular>arcuate>afferent arteriole
renal>arcuate>interlobular>interlobar>afferent arteriole

62.after normal saline infusion
blood volume increases
Na excretion decreases
osmolality increases
renin secretion increases

63. after renal transplant which malignancy is common ???


64 babinski sign is positive in
pyramidal lesion
cerebellar lesion

65. ventral spino thalamic tract ends at
lumbar region
mid thoracic
end thoracic

66. commonest site of lumbar puncture is
L4-L5
L2-L3
S1-S2

67. which is not punctured during lumbar puncture
duramater
ligamentum flavum
longitudinal spinal ligament

68. after Rh incompatabilty what is given to the mother to prevent it next time
anti D antibodies

69. patient has blood group A+ which cannot b given to him
O+
O-
A-
AB-

70. hamartoma is
benign tumor
malignat tumor

71. medullary rays r present is
cortex
medulla

72. in Addisons disease what does not occur
hyper kalemia
hypokalemia

73. which is essential amino acid
phenyal alanine


74. which is teratogenic
alcohol

75. which is associated with cancer
methyl alcohol
propyl alcohol
76. HLA- DR4 is associated with
rheumatoid arthritis
SLE
scleroderma

77. which is present in SLE
anti DNA antibodies
anti jones antibodies
anti smith antibodies


78. which causes dysphagia
ankylosing spondylitis
scleroderma
dermatomyositis

79. iron deficincy anemia is
hypochromic microcytic

80. patients had gastrectomy , after 3 months she presents with
iron deficiciency anemia
pernicious anemia
hemolytic anemia

81. pregnant lady has MCV of 70 fl. and Hb 8.1 g/dl, she is suffering from
iron deficiency anemia
megaloblastic anemia

82. which is tributary of portal vein
superior rectal
inferior rectal



83. what arches in front of the root of left lung
Arch of aorta
Azygus vein

84. selective beta blockers do not cause
broncho spasm

85. how will the effect of warfarin immediatelty reversed
vitamin K
FFP
protamine sulphate

86. RCA supplies
right atrium only
right atrium n right ventricle

87. tunica vaginalis is derived from
transversalis muscle
transversalis fascia
peritoneum
inter oblique muscle

88. turner syndrome has karyotype
45 XO
45 XX
45 XXy
45 XXX


89. which muscles divied submandicular gland in to super ficial n deep part
omohyoid
mylohyoid
anterior belly of digastric

90. patient has difficulty closin right eye and distorted facial appearance. he has damage to
right fascial nerve
left fascial nerve
right trigeminal nerve
left trigeminal nerve

91. which does not cause thenar muscle wasting
carpel tunnel syndrome
C8 neuritis
cervical rib
scalene muscle spasm
cervical spondylosis

92. a pregnat lady from hilly area presents to. fetal scan at term shows no anomaly. which of the following can still b present in the newborn
ASD
VSD
PDA
pulmonary stenosis
93. what is end product of glucose metabolism in the presence of oxygen
lactic acid
1 molecule of pyruvate
2 molecule of pyruvate


94. beetle chewing causes
submucuous fibrosis
leukoplakia
keratosis

95. which is last mediator in septic shock
IL-1
IL- 6

96. antigen antibody reactions r most reduced in
Liver failure
Low neutrophils
97. Clavulanic acid
destroys B lactamases
causes decreased penicillin excretion

98. Dose of Gentamicin is reduced in elderly due to
reduced renal function


99. GFR can b best estimated by
creatinine clearance
serum urea levels
serum creatinine levels

100. best test for diabetic nephropathy is
serum urea levels
serum creatinine levels
urinary albumin

101. which protein maintains red cell shape
integrin
secretin
spectrin

102. Cyanosis is due to
increased deoxy hemoglobin in blood
decresed PO2 in blood.
103 which of the following causes natriuresis
stretch receptors in atria
carotid bodies

104. patient has gall stones , which enzyme could b most likely raised
Alkaline Phosphatase
LDH
ALT

105. diffusion through alveoli is directly proportion to
thickness of membrane
total cross sectional area

106. transpot of materials by carrier proteins is example of
simple diffusion
facilitated diffusion
active transport

107. which does not has lymphoid follicles
speen
thymus
lymphnodes
payer patches

108. in congestive cardiac failure there is
incresed pressure in venous system

109. ventricular contraction causes which wave in JVP
a
c
v

110. site for venesection
great sephanous
short sephanous
111. which is not part of limbic system
vermis of cerebellum
amygdala
anterior thalamus
hippo campus

112. right gastric artery is branch of
gastro duadenal
right gastro epiploic

113. thiazide diuretics
donot require potassium supplemets

114. behaviour sciences is branch of science which deals with
behaviour of persons in different social , psychological conditions

115. pateint has loss of proprioception on right n loss of pain n temperature on left, lesion is
right hemisection of spinal cord
left hemisection of spinal cord

116. cerebral cortex is concerned with
voluntary movements of body

117. DVT is causes by
stasis of blood

118. lacrimal duct opens in
inferior meatus
middle meatus

119. in asthma
FEV1/FEV less than 65%
FVC is reduced

120 6 years old girl has meningitis. most common organis is
streptocossus pneomonie
Neiserria meningitidis
Hemophilus Influenzae
E Coli

121. exudate has
protein more than 3g/dl
specific gravity is less than 1.010

122. a young boy has distorted nose and cervical lymphadenopathy. lymph node biopsy shows non caseating granuloma and sputum AFB is positive, diagnosis is
TB
leprosy
sarcoidosis
syphilus

123. Lambda chain is present in
amyloidosis

124. which does not follow oro fecal route
tenia solium
trichuris trichuria
entrobius vermicularis
Ankylostroma duodenale

125. cholangio carcinoma is caused by
C Sinensis
paragonimus watermani
taenia solium


126. young boy has bilaterla parotid enlargement. diagnosis
bacterial parotitis
mumps
infectious mononuclosus

127.about Mycobacterium TB , which is false
causes disease only in humans
favors aerobic conditions
128. which is false about spores
produced under nutrient rich conditions
B Anthracis producs spores
C tetani produes spores
they r killed under 121 degree for 15 min in autoclave

129. fetal brain development is caused by
Growth hormone
thyroid hormone

130. gastric Acid increases most after taking
carbohydrate
protein
fats

131. which hormone effects carbohydrate, protein and fat metabolism
insulin
Growth Hormone

132. which is not an epithelial tumor
sq cell CA
adeno carcinoma
sarcoma

133. Bence jones protein are produced in
multipla myeloma

134. which hormone effects both nor epinephrine n serotonin metabolism
Mono amine oxidase

135. patient presents with epistaxis and bruising on body. best invertigation is
complete blood count
PT
Aptt

136. ADH acts on
Proximal tubule
Distal Tubule
Collecting Tubule

137. which is most slow growing malignancy of thyroid
Follicular CA
Medullary
Papillary
Anaplastic

138. Cerebellar lesion causes
Ataxia

139. patient with cerebellar lesion
cannot touch objects with his finger tip

140. PTH remains normal in
renal insufficiency
osteoporosis

141. Neonatal Rubella infection is screened by measuring which antibody?
IgM
IgG
IgM and IgG

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