How to Take a Good Obstetrical History & Performing a Thorough Clinical Examination

HISTORY:

Demographical Details/Personal Profile:

1. Name

2. Age

3. Education

4. Occupation

5. Marital Status (if married, for how long? )

6. Residence

7. Date, time & mode of Admission

8. Which pregnancy?

Presenting Complaints:

1. Gestational amenorrhoea and its duration (in weeks)

2. Any other complaint

a. Labor pains

b. PROM

i. PROM at term

ii. PPROM

c. Vaginal bleeding (APH, PPH etc.)

d. Abdominal pain (other than labor pains)

e. Decreased/absent fetal movements

f. Seizures

g. HTN or Pre-eclampsia or Eclampsia (Symptoms)

h. DM or GDM (Symptoms)

i. Anemia (Symptoms)

j. Hyper/hypothyroidism (Symptoms)

k. Ischemic Heart Disease (Symptoms)

l. Valvular Heart Disease (Symptoms)

History of Present Pregnancy:

1. Planned/ Unplanned

2. Wanted/ Unwanted

3. Reaction to pregnancy

4. LMP (first day of last menstrual period)

5. Use of Contraception

6. Any spotting or bleeding

7. Specific things to ask in First Trimester

a. Confirmation of pregnancy, how and when?

b. Any symptoms of pregnancy (Nausea, vomiting etc.)

c. Urine/Serum Pregnancy test

d. Ultrasonography

e. Any antenal visit?

8. Specific things to ask in Second Trimester

a. When did patient start to feel fetal movements?

b. Any anomaly scan?

c. Any prenatal diagnosis? If yes, then what?

9. Specific things to ask in Third Trimester

a. Any CTG, USG or BPP done

b. Results of the above

c. Any findings on antenatal visits

d. Any hospital admission? If yes, then for what problems?

e. Fetal movements

f. Vaginal discharge (PROM)

g. Vaginal bleeding

Depending upon the other presenting complaint, following questions may be relevant to ask

1. Onset

2. Duration

3. Intensity/Severity

4. Aggravation and relieving factors 5. Associated features

Past Obstetrical History:

1. Number of children

2. Ages of all children

3. Mode of deliveries of all children

4. Gestational age of all children at the time of delivery (Term/Preterm etc.), present state of health (Alive/Died Later/Handicapped/Retarded)

5. Number of miscarriages and duration of gestation at those

6. Termination of pregnancy/pregnancies, At what gestation? For what reason?

Menstrual History:

1. Age of menarche

2. Cycle Regular or Irregular

3. Duration of Cycle

4. Quantity of Blood loss

5. Dysmenorrhoea

6. Intermenstrual Bleeding

7. Post coital Bleeding

8. Dyspareunia

9. LMP

10. Cervical Smear

Past Gynecological History:

1. Any previous gynecological problems

2. Any treatment for the same

3. Cervical Swab

Sexual History:

1. Age at first intercouse

2. Coital freuency

3. Any coital difficulty

4. Number of sexual partners

5. Number of sexual partners of the patient’s partner/husband

Past Medical History:

(Please refer to clinical methods of Internal Medicine for details.)

Past Surgical History:

(Please refer to clinical methods of Internal Medicine for details.)

Systemic Inquiry:

From CVS, CNS, RS, GIT, GUT & MSK

(Please refer to clinical methods of Internal Medicine for details.)

Family History:

About Infectious diseases, IHD, HTN, DM, Multiple Pregnancy, Gynecological and other malignancies

(Please refer to clinical methods of Internal Medicine for details.)

Social/ Socioeconomic/ Biosocial History:

1. Place of living

2. Type of family

3. Monthly Income

Personal History:

(Please refer to clinical methods of Internal Medicine for details.)

Drug History:

(Please refer to clinical methods of Internal Medicine for details.)

Treatment History:

(Please refer to clinical methods of Internal Medicine for details.)

Examination:

General Physical Examination:

(Please refer to clinical methods of Internal Medicine for details.)

Systemic Examination:

CNS (Please refer to clinical methods of Internal Medicine for details.)

CVS (Please refer to clinical methods of Internal Medicine for details.)

RS (Please refer to clinical methods of Internal Medicine for details.)

Abdominal Examination:

1. Inspection

2. Palpation

a. Assessment of fundal height

i. Palpatory method

ii. Measurement method

b. Assessment of fetus

i. First manoeeuvre (Fundal palpation)

ii. Second manoeuvre (Lateral palpation)

iii. Third manoeuvre (Pawlik’s grip; palpation of presenting part)

iv. Fourth manoeuvre (For attitude of fetal head & engagement of head in fifths; 5/5, 4/5, 3/5, 2/5, 1/5)

3. Ausculation (with pinard stethoscope for fetal heart sounds)

Pelvic Examination: (Generally not required, specially contraindicated in vaginal bleeding (APH) or vaginal discharge)

(Ensure Adequate Privacy)

1. Inspection

a. Hair Distribution

b. Labial Appearance

c. Episiotomy Scar etc.

d. Stress incontinence

e. Vaginal Discharge

2. Palpation

3. Speculum Examination (for vaginal discharge, to confirm/exclude PROM)

4. Vaginal Examination (Not indicated if woman not in labor)

Only done in two conditions;

i. Before labor (Bishop scoring)

ii. During labor (to assess progress of labor; Dilatation of cervix & length of cervix)

Provisional/Working Diagnosis + Risk Scoring (High/Low Risk):

Differential Diagnosis (es):

Investigations:

a. Routine

b. Specific

Definite Diagnosis:

Plan of Management:

SUMMARY:

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How to Take a Good Gynecological History & Performing a Thorough Clinical Examination

HISTORY:

Demographical Details/Personal Profile:

1. Name

2. Age

3. Education

4. Occupation

5. Marital Status (if married, for how long? )

6. Residence

7. Date (and time) of Admission

8. Mode of Admission

Presenting Complaints:

Common complaints encountered in a gynecological patient are

1. Abnormal Menstruation

a. Pattern (Regular/Irregular)

b. Amount of blood loss

c. Passage of blood clots

d. Duration of menstruation

e. Intermenstrual Bleeding

f. Post coital Bleeding

2. Bleeding in early pregnancy i.e. before 24 weeks of gestation (Abortion/Miscarriage)

3. Something coming out of vagina

4. Pelvic Mass

5. Vaginal Discharge – amount, colour, odour, presence of blood, relation to periods

6. Pelvic pain – site, nature and relation to periods. Anything that aggravates or relieves the pain

History of Present Illness:

Depending upon the presenting complaint, following questions may be relevant to ask

1. Onset

2. Duration

3. Intensity/Severity

4. Aggravation and relieving factors

5. 5. Associated features

Menstrual History:

1. Age of menarche

2. Cycle Regular or Irregular

3. Duration of Cycle

4. Quantity of Blood loss

5. Dysmenorrhoea

6. Intermenstrual Bleeding

7. Post coital Bleeding

8. LMP

Past Gynecological History:

1. Any previous gynecological problems

2. Any treatment for the same

3. Cervical Swab/ Cervical Smear

Past Obstetrical History:

1. Number of children

2. Ages of all children

3. Mode of deliveries of all children

4. Gestational age of all children at the time of delivery (Term/Preterm etc.) + Presence state of health

5. Number of miscarriages and duration of gestation at those

6. Termination of pregnancy/pregnancies, At what gestation? For what reason?

Sexual and Contraceptive History:

1. Age at first intercouse

2. Coital freuency

3. Dyspareunia

4. Any coital difficulty

5. Number of sexual partners

6. Number of sexual partners of the patient’s partner/husband

7. Use of contraception? Type of contraception used?

Past Medical History:

(Please refer to clinical methods of Internal Medicine for details.)

Past Surgical History:

(Please refer to clinical methods of Internal Medicine for details.)

Systemic Inquiry:

From CVS, CNS, RS, GIT, GUT & MSK

(Please refer to clinical methods of Internal Medicine for details.)

Family History:

About Infectious diseases, IHD, HTN, DM, Multiple Pregnancy, Gynecological and other malignancies

(Please refer to clinical methods of Internal Medicine for details.)

Social/ Socioeconomic/ Biosocial History:

1. Place of living

2. Type of family

3. Monthly Income

Personal History:

(Please refer to clinical methods of Internal Medicine for details.)

Drug History:

(Please refer to clinical methods of Internal Medicine for details.)

Treatment History:

(Please refer to clinical methods of Internal Medicine for details.)

Examination:

General Physical Examination:

(Please refer to clinical methods of Internal Medicine for details.)

Systemic Examination:

Abdominal (Please refer to clinical methods of Internal Medicine for details.)

CNS (Please refer to clinical methods of Internal Medicine for details.)

CVS (Please refer to clinical methods of Internal Medicine for details.)

RS (Please refer to clinical methods of Internal Medicine for details.)

Pelvic Examination: (Not expected from Final Year students.)

(Ensure Adequate Privacy)

1. Inspection

a. Hair Distribution

b. Labial Appearance

c. Episiotomy Scar etc.

d. Stress incontinence

e. Vaginal Discharge

2. Speculum Examination

a. Inspection of vaginal walls (Atrophic/Healthy/Hyperemic/Growth/Ulcers/Polypi etc.)

b. Appearance of cervix (Ectopy/Suspicious Polypi)

c. Vaginal discharge

3. Bimanual Examination/Palpation

a. Consistency of cervix

b. Cervical os

c. Uterine consistency, size, shape and mobility

d. Uterus retroverted or anteverted

e. Adnexal Mass

f. Adnexal Tenderness

g. Pouch of Douglas

Provisional/Working Diagnosis:

Differential Diagnosis (es):

Investigations:

a. Routine

b. Specific

Definite Diagnosis:

Plan of Management:

SUMMARY:

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Introduction to Hernia, its types, mechanism of development, signs, symptoms and treatment

OBJECTIVES:

• What is meant by hernia
• The mechanism of developing a hernia
• Signs and symptoms produced by a hernia
• The types of hernia
• Complications produced as a result of hernia
• Treatment of hernia
• Preventive measures against development of hernia
  

DEFINITION:
A hernia is a protrusion of any viscus from its proper cavity. The protruded parts are generally contained in a sac-like structure, formed by the membrane with which the cavity is naturally lined.

MECHANISM:
The wall of the abdomen, the gastro-oesophageal valves, and other areas of the body, comprising muscle and tendon, performs several functions, one of which is to provide strong support to the internal organs which are exerting significant outward pressure. The opening of a gap in the tissue can occur of its own accord at a point of natural weakness, or by over-stretching a part of the tissue. Overexertion can cause a hernia eg, lifting heavy loads or chronic cough

TYPES OF HERNIA:

• Groin hernia (inguinal, femoral, scrotal)
• Umbilical
• Incisional
• Hiatal
• Congenital diaphragmatic
• Ventral / Epigastric Hernia
• Spigelian Hernia
• Recurrent Hernia
• Stoma Hernia
  

1. INGUINAL HERNIA:

A portion of intestine or internal fat protrudes through a weakness in the inguinal canal.
Appears at the groin crease.
May be DIRECT or INDIRECT.
More common in males.

2. FEMORAL HERNIA:
Hernia through the femoral canal in the femoral triangle.
Appears between the thigh and groin region.
More common in females.

3. UMBILICAL HERNIA:
Hernia in the abdominal wall from or around the umbilicus (paraumbilical)

4. INCISIONAL HERNIA:
From defects created due to previous surgeries

5. HIATAL HERNIA:
Stomach passes from the gastro oesophageal sphincter into the oesophagus

6. EPIGASTRIC:
From a defect between the umbilicus and xiphisternum in the midline

7. SPIGELIAN:
This rare hernia occurs along the edge of the rectus abdominus muscle, which is several inches to the side of the middle of the abdomen.

8. OBTURATOR HERNIA:
This hernia protrudes from the pelvic cavity through an opening in the pelvic bone (obturator foramen).
Causes no bulge
Difficult to diagnose

9. RECURRENT HERNIA:
Occurs at the site of previous hernia repair

10. CONGENITAL DIAPHRAGMATIC HERNIA:
A diaphragmatic hernia is a birth defect in which there is an abnormal opening in the diaphragm

11. STOMA HERNIA:
Occur at the site of surgical stoma

RISK FACTORS:

• Family history
• Overweight or Obesity
• Undescended testes (groin hernias)
• Gastro-oesophageal reflux disease (GERD)
• Any condition that increases the abdominal pressure:e.g.,
  

– chronic coughing,
– chronic constipation
– enlarged prostate causing straining with urination,
– carrying or pushing heavy loads

SYMPTOMS:

• Lump
• Painful swelling
• Nausea/ vomiting
• Sepsis
  

SIGNS:

• Lump

– Reducible/ irreducible: can or cannot be pushed back to its original position
– Direct/ indirect (inguinal hernia): comes through the abdominal wall (direct) or through the inguinal canal (indirect)
– Tender

• Fever
• Signs of Intestinal obstruction
• Sepsis
  

COMPLICATIONS:

• Incarceration:

– Hernia contents get “stuck” in the hernia sac causing irreducibility

• Obstruction:

– Intestinal obstruction as a result of incarceration

• Strangulation:

– Blood circulation to the hernial contents is compromised
– Necrosis/ gangrene formation
– Sepsis


DIAGNOSIS:

• Clinical, based on physical examination
• U/S
• C.T. scan
• Fetal U/S for congenital defect
  

TREATMENT:

1. CONSERVATIVE:
2. DEFINITIVE:

Surgical repair

PREVENTION:

• Few preventive measures

Avoid heavy weight lifting and straining
Avoid food that precipitate reflux from stomach into oesophagus (hiatal hernia)

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Clinical Thyroid Examination scheme

Thyroid Examination

• Hand hygiene

• Introduce self, gain consent and cooperation.

• Ensures patient seated in good light, with access to examine from behind and

• appropriate exposure of the neck.

From end of bed

• Is patient dressed appropriately for room temp?

• Composure – hyperactivity, fidgety & restless (hyperthyroid);

• immobile & uninterested (hypothyroid)

• Observes patient from any obvious lumps/swellings.

• Asks patient to swallow to check upward movement of thyroid gland and to ascertain whether any visible lumps/swellings ascend with the thyroid.

Hands

• Increased sweating (due to hyperthyroidism)

• Palmar erythema (due to hyperthyroidism)

• Thyroid acropachy (Grave’s disease)

• Onycholysis (Plummer’s nails) – hyperthyroid

• Coarse, dry skin, anaemia, yellow discolouration of

• hypercarotenaemia (in hypothyroidism)

• Areas of vitiligo (seen in association with autoimmune disorders such as Grave’s disease)

• Fine tremor – place sheet of paper on outstretched hands

Pulse

• Rate, rhythm

• Tachycardia or atrial fibrillation in hyperthyroidism

• Bradycardia in hypothyroidism

Blood pressure:

Pemberton’s sign:

• Lift both arms as high as possible.

Findings:
Patients with large retrosternal goitres develop signs of congestion (plethora) & cyanosis on raising their arms above their heads, leading to suffusion of face, giddiness or syncope.

Eyes:

• Loss/thinning of hair on outer 1/3 of eyebrows (hypothyroidism)

• Periorbital oedema (hypothyroidism)

• Test visual acuity & visual fields.

• Anaemia

• Eye movements – ophthalmoplegia, diplopia

• Exopthalmos – whiteness of sclera visible below the iris

• Lid retraction – sclera visible above the iris

• Proptosis – eye protrusion beyond level of supraorbtial ridge

• Chemosis – conjunctival oedema

• Lid lag

THYROID EXAMINATION PROPER:

1. INSPECTION:

• Examine front of neck – goitre, symmetry, skin changes, scar

• Ask patient to open his mouth & stick his tongue out at far as possible. If the lump moves on protrusion, it is likely to be a thyroglossal cyst.

• (Ask patient to swallow – thyroid & thyroglossal cyst will rise during swallowing)

2. PALPATION:

Best performed from behind

• Ask patient to take a sip of water, hold it in his mouth & swallow when asked. Feel the thyroid gland rise.

• Consider the size, symmetry, consistency, tenderness & mobility.

• Try to work out whether the thyroid is diffusely enlarged or nodular.

• Palpate the cervical lymph nodes – may be involved in thyroid cancer.

3. PERCUSSION:

• Over the sternum, from notch downwards. A change in resonant to dull indicates a possible retrosternal goitre.

4. AUSCULTATION:

• Listen for bruits over each lobe

Upper/lower limbs

• Proximal myopathy

• Reflexes (slow, relaxing - hypothyroid)

Tibia

• Pretibial myxoedema

• Consider the main differential diagnosis of a thyroid goitre:

_ Simple goitre (iodine deficiency)

_ Thyroid adenoma (follicular commonest)

_ Multinodular goitre

_ Thyroid carcinoma (papillary > follicular > anaplastic > medullary)

_ Thyroiditis (Hashimotos, De-Quervains)

_ Graves disease

The most informative diagnostic test if asked, is TSH level – don’t say ‘thyroid function tests’

Investigate with ultrasound and fine needle aspirate, or core biopsy.

Consider the differential diagnosis of neck lump and additional steps to conduct in the examination:

_ Lymphadenopathy – remember the jugulodigastric node which is the sentinel node for many head and neck carcinomas, so LOOK IN THE MOUTH – you would look silly to miss out on an obvious tongue tumour!

_ Branchial cyst – anterior to upper 1/3 sternocleidomastoid

_ Thyroglossal cyst – cyst in the embryological passage of thyroid from posterior tongue. Moves up on protrusion of tongue

_ Cystic hygroma – cystic degeneration of lymphatics commonly found in babies

_ Submandibular gland – arises from under the posterior mandible. The commonest cause of unilateral enlargement is stone in duct, so MUST palpate with gloved finger, under tongue, where duct opens onto the floor of the mouth, and bimanual palpation can be conducted, including potentially palpating the calculus. Other causes include neoplasia both benign and malignant.

_ Parotid gland – overlies the angle of the jaw. Stensons duct opens opposite to the upper 2nd molar teeth, and should be inspected and palpated intra-orally.

Common causes of enlargement include: sjogrens, sarcoidosis, mumps, duct calculi. Neoplasia is commonest – benign pleomorphic adenoma being commonest, followed by Warthins tumour, commonly affecting the older patient. Cystic adenoid carcinoma is commonest malignant neoplasm. You must assess the facial nerve which passes through the gland – expecting a lower motor neurone lesion – although recognise that individual nerves can be affected preserving others (temporal, zygomatic, buccal, mandibular, cervical).

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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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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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