Note on sources: S. Das - A Manual on Clinical Surgery, 13th Edition is available in the library and forms the primary source for this guide. Makhan Lal Shah is not in the library's collection, so the content below draws from S. Das supplemented by standard MS-level surgical examination principles that align with what Shah's textbook covers (both books teach the same classical examination methods used in Indian MS General Surgery).

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MS General Surgery - Clinical Examination Guide

Source: S. Das, A Manual on Clinical Surgery, 13th Ed.

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1. PERIPHERAL VASCULAR DISEASE (PVD)

History Pointers

• Age/sex: Atherosclerosis - elderly males; Buerger's disease - males 20-40 yrs; Raynaud's - young females
• Intermittent claudication - claudication distance (Boyd's Grade I/II/III)
• Rest pain - continuous, worse at night, relieved by hanging leg down
• Bilateral (Buerger's, Raynaud's) vs unilateral (embolic, early atherosclerosis)

Inspection

• Colour: pallor, cyanosis, rubor, gangrene (dry vs wet)
• Trophic changes: loss of hair, nail changes, skin atrophy
• Ulcers: site, edge, floor, discharge
• Extent and type of gangrene - dry (mummified) vs wet (oedematous, crepitus in gas gangrene)
• Line of demarcation

Palpation

1. Temperature - cold limb compared to opposite side; use dorsum of hand; feel from distal to proximal to find level of temperature change
2. Pulses (always compare both sides):
   • Femoral - midpoint of inguinal ligament
   • Popliteal - knee flexed 40°, heel on bed, compress against posterior tibial condyles (also prone position)
   • Posterior tibial - behind medial malleolus (most reliable)
   • Dorsalis pedis - lateral to extensor hallucis longus tendon in 1st metatarsal space (absent in 10% normal)
   • Anterior tibial - just lateral to EHL tendon (extend great toe to make EHL taut)
   • "Disappearing pulse" - pulse absent after exercise = early arterial occlusion
   • Expansile pulsation = aneurysm
3. Capillary filling time (palpate): Raise leg, then lower - normal turns pink immediately; ischaemic limb takes >20-30 seconds to become pink, then turns purple-red (dilated skin capillaries with deoxygenated blood)
4. Venous refilling: After elevation - veins refill within 5 seconds in normal; delayed in ischaemia; veins collapse even at 10° elevation in severe ischaemia
5. Oedema - pitting suggests deep vein involvement
6. Tenderness along vessel - indicates recent thrombosis
7. Crepitus - gas gangrene

Special Tests

Auscultation

• Listen over femoral, popliteal arteries for bruits (indicates stenosis)
• AV fistula - machinery murmur over the fistula

Investigations

• Doppler USS, ABI (Ankle Brachial Index), Arteriography
• Capillary microscopy, MRA/CTA

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2. BREAST

Inspection (3 positions: sitting, arms at sides → raised → hands on hips pressing)

• Symmetry of breasts and nipples
• Nipple: retraction, inversion, deviation, discharge (blood = duct papilloma/carcinoma), eczema (Paget's disease)
• Skin changes: peau d'orange (lymphoedema of skin - press with fingertip), dimpling/puckering, erythema, ulceration, satellite nodules
• Axillae: swelling, skin puckering, ulceration; check shoulder movements

Palpation

• Positions: sitting → semi-recumbent (45°) → recumbent (pillow under scapula)
• Palpate normal side first
• Use palmar surfaces of fingers with hand flat (best for detecting cancer)
• Systematically palpate all four quadrants + axillary tail + behind the nipple (do not miss this)
• Express nipple to check for discharge

Percussion & Auscultation

• Rare in breast exam; may percuss sternum for retrosternal metastasis

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3. THYROID

Inspection

• Neck: note the swelling - position (front of neck), midline/off-midline
• Swallowing test: Ask patient to swallow water - thyroid swelling moves upward on deglutition (moves with thyroid which is enclosed in pretracheal fascia)
• Shape: diffuse/nodular; skin changes over swelling
• Visible pulsation, visible veins (retrosternal goitre)
• Signs of toxicity: exophthalmos (Graves'), lid retraction, lid lag, proptosis, periorbital oedema

Palpation

1. Size of the gland - both lobes and isthmus
2. Consistency: soft (parenchymatous), firm/rubbery (Hashimoto's), hard (carcinoma, Riedel's), cystic (colloid cyst)
3. Surface: smooth vs nodular (single nodule vs multinodular)
4. Tenderness: acute thyroiditis, haemorrhage into nodule
5. Mobility on swallowing: confirm by palpating while asking to swallow again
6. Fixity to trachea or surrounding structures: malignancy
7. Tracheal position: deviation by goitre
8. Carotid pulsation: feel bilaterally - obliterated = malignant engulfment of carotid sheath
9. Cervical lymph nodes: especially in malignancy - papillary carcinoma notorious for early lymphatic spread
10. Kocher's test: gentle lateral compression of thyroid - patient develops stridor if trachea is compressed (softened tracheal rings - tracheomalacia). Significant pre-operatively.
11. Pulsation/thrill: toxic goitre (increased vascularity in Graves')
12. Berry's sign: loss of carotid pulsation = malignant encasement

Percussion

• Over manubrium sterni - dullness = retrosternal goitre (more theoretical, but tested in viva)

Auscultation

• Systolic bruit over goitre = primary toxic goitre (Graves' disease) - increased vascularity
• Bruit absent in secondary toxic goitre (multinodular)

General/Systemic Examination

• Eyes: exophthalmos, lid lag (von Graefe's sign - lid lags when eye moves down), lid retraction (Dalrymple's sign), convergence weakness (Moebius' sign), periorbital oedema, chemosis
• Hands: fine tremor of outstretched fingers (primary toxicity only, not secondary), sweating, warm moist skin, palmar erythema, thyroid acropachy
• Pulse: tachycardia, AF (cardiovascular manifestations of toxicity)
• Pretibial myxoedema: bilateral non-pitting oedema over shin (Graves')
• Reflexes: brisk in hyperthyroid, sluggish in hypothyroid

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4. ABDOMINAL LUMP

Inspection

• Contour/shape of abdomen: distension, visible lump, asymmetry
• Respiratory movements: absent over peritonitis area
• Visible peristalsis: pyloric stenosis (gastric), intestinal obstruction
• Skin: striae, scars, sinuses, distended veins (direction of flow - caput medusae in portal hypertension; inferior to superior in IVC obstruction)
• Umbilicus: inverted/everted (ascites), position

Palpation

• Always palpate the normal quadrant first, moving towards the lump
• For a lump, determine:

• Liver: starts from RIF, moves obliquely to hepatic area; moves with respiration; notch (normal), irregular (cirrhosis/metastasis); pulsatile (tricuspid regurgitation); friction rub (perihepatitis)
• Spleen: starts from RIF, moves to left hypochondrium; cannot get between it and costal margin; notch; ballot movement
• Kidney (bimanual): loin to abdomen, ballottable, resonant over it (bowel in front), moves with respiration, can get above it (unlike spleen)
• Stomach: succussion splash (pyloric stenosis) - hand over epigastrium, short jerky movements or shake patient
• Bladder: midline lower abdomen, dull, arises from pelvis (cannot get below it)
• Aortic pulsation: midline expansile = aneurysm

Percussion

• Shifting dullness and fluid thrill for ascites
• Liver/spleen dullness for enlargement

Auscultation

• Bowel sounds: absent (peritonitis, ileus), increased/tinkling (obstruction)
• Bruit over liver (hepatocellular carcinoma), renal artery (renal artery stenosis), aorta (aneurysm)
• Friction rub over liver/spleen (peritonitis, infarction)

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5. VARICOSE VEINS

Inspection (patient standing, good light)

• Distribution: long saphenous territory (medial leg/thigh) vs short saphenous (posterior calf)
• Tortuous dilated subcutaneous veins
• Skin changes: pigmentation (haemosiderin), eczema, lipodermatosclerosis, atrophie blanche
• Ulceration (medial ankle = venous ulcer)
• Saphena varix (groin - bluish swelling, cough impulse, disappears on lying)

Palpation

• Temperature of varices (thrombophlebitis = warm, tender)
• Thrombosis in varix
• Thrill on coughing (tap over saphena varix)
• Percussion test / Schwartz test / Tap test: Place one hand over a varix, tap a varix higher up - if veins are incompetent, impulse is transmitted (fluid thrill transmitted down)
• Saphenofemoral junction - feel for saphena varix

Special Tests

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6. HERNIA

History

• Reducibility - does it go back spontaneously or require manipulation?
• Prolonged irreducibility = risk of obstruction/strangulation
• Predisposing causes: chronic cough, prostate, constipation, urethral stricture

Inspection (patient standing, then asked to cough)

• Site: groin (inguinal vs femoral), umbilical, epigastric, incisional
• Side and symmetry
• Cough impulse: visible expansion on coughing

Palpation

1. Ask patient to reduce hernia (if reducible)
2. Identify bony landmarks: pubic tubercle, anterior superior iliac spine (ASIS), inguinal ligament (midpoint)
3. Pubic tubercle test: Femoral hernia is below and lateral to pubic tubercle. Inguinal hernia is above and medial. Key differentiator.
4. Deep inguinal ring: ½ inch above midpoint of inguinal ligament (midpoint between ASIS and symphysis pubis)
5. Cough impulse: Place hand over hernia - expansile impulse on cough confirms hernia
6. Reducibility: Gently try to reduce in lying position; indirect hernia reduces obliquely upwards, outwards, backwards; direct hernia reduces directly backwards
7. Finger invagination test (Zieman's technique):
   • Right hand for right side: index finger → deep ring; middle finger → superficial ring; ring finger → femoral ring
   • Patient coughs - impulse on index = indirect; on middle = direct; on ring = femoral
8. Silk glove sign (children - encysted hydrocele of cord vs hernial sac): Feel for the sensation of two layers of silk rubbing together
9. Ring occlusion test: Reduce hernia. Press thumb over deep ring (½ inch above midpoint of inguinal ligament). Ask patient to cough.
   • Bulge is controlled = indirect (oblique) hernia (came through deep ring)
   • Bulge appears medial to thumb = direct hernia (comes through Hesselbach's triangle, medial to deep ring)
10. Child's test (Gornall's test): Hold child from behind, press abdomen, lift up - hernia becomes apparent

Percussion

• Resonant note = enterocele (bowel contents)
• Dull note = epiplocele (omentum) or extraperitoneal fat

Auscultation

• Bowel sounds in hernia sac = enterocele
• Absence of bowel sounds in irreducible hernia + signs of obstruction = strangulation

General Examination (mandatory)

• Chest: exclude chronic bronchitis, chronic cough
• Rectal examination: exclude enlarged prostate, chronic constipation
• Abdomen: intestinal obstruction

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7. HYDROCELE

Inspection (patient standing and lying)

• Scrotal swelling - size, shape (pear-shaped = primary hydrocele)
• Translucency (light test)
• Skin over swelling: normal in primary hydrocele

Palpation (4 essential steps)

1. Can you get above the swelling? - If yes = scrotal origin (not from abdomen); if no = hernia extending from abdomen
2. Testis and epididymis palpable separately from swelling? - In hydrocele, testis is posterior and cannot be palpated separately; in epididymal cyst testis is palpable separately
3. Fluctuation test: Press from two directions - fluctuation = fluid-containing swelling
4. Transillumination (torch test): Place torch behind swelling in dark room. Hydrocele = brilliantly transilluminant (clear amber fluid). Haematocele, tumour = opaque. (NB: Encysted hydrocele of cord also transilluminates)

Special Tests

Auscultation - NA

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8. COMMON SWELLINGS (General Approach)

Diagnosis of Any Swelling - S. Das Framework

Inspection

• Site, shape, size (approximately)
• Surface: smooth, lobulated, irregular
• Overlying skin: colour (erythema, pigmentation), punctum, scar, fistula, peau d'orange, dilated veins
• Translucency in daylight (before torch test)
• Visible pulsation

Palpation (the 10 steps - S. Das)

Percussion

• Resonant = gas-containing (Schwannoma of bowel, gas gangrene)
• Dull = solid, fluid

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9. ULCER

History

• Duration, mode of onset, painful/painless (painless = syphilitic, trophic, Marjolin's; painful = acute, Buerger's/arterial)
• Associated features: varicosities (venous), numbness (trophic), constitutional symptoms (TB, malignancy)

Inspection

Palpation

• Temperature of base and edges (warm = inflammatory; cold = ischaemic)
• Tenderness (tender = acute/venous; painless = trophic/syphilitic/Marjolin's)
• Edge consistency (indurated, everted, hard = malignant)
• Base - adherent to deep structures?
• Regional lymph nodes - ALWAYS (Marjolin's ulcer = lymph nodes NOT enlarged despite size, as lymphatics destroyed by fibrosis)
• Probe test: Direction, depth, foreign body (sequestrum moves), communication with viscus

General Examination

• Peripheral vascular system (arterial ulcer)
• Venous examination (varicose veins examination)
• Neurological - loss of sensation (trophic ulcer in diabetes, tabes, leprosy, syringomyelia)
• Blood glucose (diabetic ulcer)

Investigations

• Blood: CBC, ESR, blood sugar, WR/Kahn (syphilis)
• Urine: sugar (diabetes)
• Bacteriology: discharge culture/sensitivity; dark ground illumination for Treponema pallidum (syphilitic chancre)
• Mantoux test: TB ulcer (more important in children)
• Biopsy: from edge including adjacent healthy tissue (malignant ulcer)
• X-ray bone/joint if ulcer near bone
• Arteriography: ischaemic ulcer
• Ascending phlebography: deep vein involvement in venous ulcer
• Chest X-ray: TB (primary focus), malignant ulcer (lung metastasis)

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QUICK REFERENCE - KEY TESTS BY TOPIC

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