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History-Taking Points for Full Marks

General Framework (ask for ALL topics)

• Name, age, sex, occupation, address
• Chief complaint in patient's own words
• Duration
• Mode of onset (sudden vs. gradual)
• Progression (static, worsening, improving)
• Previous similar episodes
• Past medical/surgical history
• Drug history and allergies
• Family history
• Social history (smoking, alcohol, diet)
• Menstrual/obstetric history (for female patients)

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1. Laparoscopic Cholecystectomy (Symptomatic Gallstones / Cholecystitis)

• Site, onset, character (colicky vs. constant dull ache), radiation (to right shoulder tip / back - classic biliary colic)
• Severity (1-10)
• Duration and frequency of attacks
• Aggravating factors: fatty meal (key trigger), lying on left side
• Relieving factors: analgesics, vomiting
• Associated features:
  • Nausea and vomiting
  • Fever and chills (suggests cholecystitis or cholangitis)
  • Jaundice (suggests CBD stone / cholangitis)
  • Dark urine / pale stools (obstructive jaundice features)
  • Pruritus
  • Dyspepsia, bloating, flatulence
• Previous episodes - how managed?
• Any previous ERCP or imaging done?

• Diet: high fat, low fibre
• Oral contraceptive pill use (female)
• Parity (more pregnancies = more risk)
• Rapid weight loss (bariatric surgery, prolonged fasting)
• Haemolytic anaemia (pigment stones)
• Family history of gallstones
• BMI / obesity

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2. Acute Appendicitis

• Classic migration: started as central/periumbilical pain, shifted to right iliac fossa (McBurney's point) - ask specifically
• Onset: sudden vs. gradual
• Character: constant dull ache (peritoneal irritation)
• Severity and progression
• Aggravating factors: movement, coughing, walking
• Relieving factors: lying still, flexing right hip
• Associated features:
  • Anorexia (often the first symptom - ask if they want to eat)
  • Nausea and vomiting (usually after pain onset - important sequence)
  • Low-grade fever
  • Constipation or diarrhoea (pelvic appendix can cause loose stools)
  • Dysuria / frequency (pelvic appendix near bladder)
  • Last menstrual period (to rule out ectopic in females)
• Any previous similar episodes (recurrent appendicitis)
• Any prior treatment for this episode (antibiotics may mask)

• Similar pain before?
• Family history of IBD (Crohn's can mimic)
• Recent travel / gastroenteritis (mesenteric lymphadenitis as differential)

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3. Multinodular Goitre (MNG)

• Duration of swelling (years vs. months)
• Rate of growth (slow = benign MNG; rapid = malignant change)
• Pain or tenderness in the swelling
• Change in size with swallowing
• Pressure symptoms (very important):
  • Dysphagia (difficulty swallowing)
  • Dyspnoea / stridor (tracheal compression)
  • Hoarseness of voice (recurrent laryngeal nerve involvement - suggests malignancy)
  • Congestion in face/neck on bending (SVC obstruction - Pemberton's sign)
  • Disfigurement
• Thyroid status symptoms:
  • Hyperthyroid: weight loss despite good appetite, palpitations, heat intolerance, excessive sweating, tremor, irritability, diarrhoea, irregular menstruation, eye changes (exophthalmos - more Graves')
  • Hypothyroid: weight gain, cold intolerance, constipation, lethargy, dry skin, hair loss, bradycardia, menorrhagia, hoarse voice
  • Euthyroid: no such symptoms
• Any previous thyroid problems or treatment
• Radioiodine therapy or neck irradiation in the past
• Medications: amiodarone, lithium (cause thyroid dysfunction)
• Iodine intake / dietary history (endemic goitre in iodine-deficient areas)

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4. Cellulitis

• Site of involvement
• Duration and rate of spread (mark the edge and ask if spreading)
• Onset: was there a preceding wound, insect bite, skin crack, tinea pedis (athlete's foot - classic portal for leg cellulitis)?
• Character: diffuse redness vs. focal fluctuant swelling (suggests abscess)
• Fever, chills, rigors
• Systemic upset: malaise, nausea
• Any discharge / pus from wound
• Skin changes: blistering, necrosis, black discolouration (necrotising fasciitis - surgical emergency)
• Lymphangitis (red streaking) or lymphadenopathy (lymph node tenderness)
• History of trauma, cuts, IV drug use, animal bite

• Diabetes (major predisposing factor - always ask)
• Peripheral vascular disease, venous insufficiency
• Immunosuppression (steroids, chemotherapy, HIV)
• Recurrent cellulitis in the same area
• Obesity
• Chronic oedema / lymphoedema

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5. Inguinal Hernia

• Duration of swelling
• Onset: sudden (after straining) vs. gradual
• Location: right, left, bilateral
• Character:
  • Reducibility - does it go back on lying down or with manual pressure? (key question)
  • Does it come out on coughing / straining / standing?
  • Size - constant or variable?
• Pain: mild discomfort vs. severe pain (irreducible / strangulated hernia - emergency)
• Any episode of sudden pain with irreducibility (incarceration / strangulation - ask specifically)
• Vomiting and inability to pass stool/flatus (obstruction)
• Precipitating factors: chronic cough, constipation, straining at micturition (raise intra-abdominal pressure)

• Chronic cough (COPD, smoker)
• Constipation (straining)
• Urinary symptoms - hesitancy, poor stream, straining (BPH)
• Heavy manual labour / lifting
• Previous hernia repair (recurrent hernia)
• Previous abdominal surgery
• Family history of hernias

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6. Diabetic Ulcers

• Site and duration of ulcer
• Onset: was there precipitating trauma (even trivial - new shoes, walking barefoot)?
• Pain: painless ulcer = neuropathic (key); painful = ischaemic/venous; mixed
• Progress: healing, static, or worsening
• Discharge: serous, purulent, foul smell
• Any black or gangrenous tissue
• Fever, systemic sepsis
• Symptoms of neuropathy: numbness, tingling, burning, loss of sensation in feet
• Symptoms of PVD: claudication (leg pain on walking, relieved by rest), rest pain (severe ischaemia), cold feet

• Diabetes: duration, type (Type 1 or 2), control (HbA1c), medications (insulin, oral agents)
• Previous foot ulcers or amputations
• Hypertension, hyperlipidaemia (cardiovascular risk)
• Smoking (major vascular risk)
• Visual impairment (unable to inspect own feet)
• Foot care practices (footwear, nail cutting)
• Nephropathy (renal function)

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7. Ovarian Tumour

• Duration of lump / symptoms
• Rate of growth
• Pain: character, radiation, cyclical vs. constant
• Abdominal distension (ascites suggests malignancy)
• Associated features:
  • Nausea, vomiting, anorexia, weight loss (malignancy)
  • Urinary symptoms: frequency, urgency (pressure)
  • Bowel: constipation, altered bowel habit (pressure)
  • Hormonal effects: virilisation (androgen-secreting), precocious puberty (granulosa cell), post-menopausal bleeding
• Acute presentation: sudden onset severe pain (torsion of ovarian cyst - emergency)
• Rupture: sudden pain with peritonism

• Age at menarche, regularity of periods
• LMP (last menstrual period) - if post-menopausal, new mass = malignant until proven otherwise
• Parity and gravidity
• Oral contraceptive use (protective against ovarian cancer)
• Infertility / nulliparity (risk factor for ovarian cancer)
• Previous pelvic surgeries or ovarian cysts

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8. Appendicular Mass

• History of acute right iliac fossa pain 3-5 days ago (perforated appendix with abscess/phlegmon)
• Did the pain partially resolve but the lump appeared?
• Current status of pain (should be decreasing in a resolving mass)
• Fever (ongoing infection)
• Nausea, vomiting, anorexia
• Bowel habits: constipation, inability to pass flatus (obstruction)
• Any antibiotic treatment received (may partially treat)
• Previous appendicitis episodes

• Immunosuppression (may present atypically)
• Other causes of RIF mass: Crohn's (ask about chronic diarrhoea, blood in stool, weight loss), caecal carcinoma (ask about altered bowel habits, PR bleeding, weight loss, tenesmus - always differentiate)
• Pelvic inflammatory disease in females (right adnexal mass)

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9. Injection Site Abscess

• Site of swelling
• Duration: when was the injection given vs. when swelling appeared
• Character: painful, fluctuant, warm, red
• Discharge: spontaneous pus drainage
• Fever, systemic sepsis
• Type of injection received: intramuscular, intravenous, subcutaneous
• Drug injected (some medications are more irritant - quinine, diclofenac, paraldehyde - common in developing countries)
• Was sterile technique used?
• Number of injections at the same site

• Intravenous drug use (IVDU) - very important to ask sensitively
• Diabetes (impaired immunity)
• Immunosuppression
• Poor nutritional status
• HIV/AIDS
• Previous abscesses in the same or different sites
• Recurrent infections (consider immunodeficiency)

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10. Carcinoma of the Breast (CA Breast)

• Duration of lump
• Rate of change in size
• Pain: most breast cancers are painless - note if painful (more likely benign)
• Skin changes: dimpling, peau d'orange, skin thickening, ulceration
• Nipple changes: retraction, discharge (colour - serous, bloody = worrying), eczema of nipple (Paget's disease)
• Axillary lump (nodal metastasis)
• Systemic symptoms suggesting metastasis:
  • Bone pain (back, hip) - bone mets
  • Breathlessness, cough - lung mets / pleural effusion
  • Jaundice, right upper quadrant pain - liver mets
  • Headache, seizures, neurological deficit - brain mets
  • Weight loss, anorexia

• Age at menarche (early menarche = risk)
• Age at menopause (late menopause = risk)
• Age at first pregnancy (late or nulliparous = risk)
• Breastfeeding (protective)
• OCP / HRT use (slight increased risk)
• LMP

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11. Intestinal Obstruction

1. Abdominal pain: colicky (comes and goes in waves), site (central/periumbilical = small bowel; lower abdomen = large bowel)
2. Vomiting: onset relative to pain, character - bilious (proximal obstruction) vs. faeculent (distal obstruction)
3. Distension: onset and degree
4. Absolute constipation: inability to pass stools AND flatus (key - differentiates from relative constipation); ask specifically about the last time they passed flatus

• Absolute constipation is the hallmark - ask explicitly
• Ask if they passed any stool/flatus since onset (may have partial obstruction)
• Progression of symptoms

• Previous abdominal surgeries (adhesions - #1 cause in developed world)
• Known hernia (strangulated hernia - examine groin)
• Altered bowel habits before this episode (colorectal cancer)
• PR bleeding, mucus in stool, tenesmus (colorectal cancer)
• Weight loss (malignancy)
• Abdominal TB history (strictures)
• Inflammatory bowel disease history (Crohn's strictures)
• Ingestion of foreign body (in children)
• Volvulus risk: chronic constipation, high-fibre diet, psychiatric medications (sigmoid volvulus)

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12. Intestinal Perforation

• Sudden onset (classically) - ask exact time of onset ("Was it sudden like a knife or gradual?")
• Character: severe, constant, generalised (peritonitis) - "board-like rigidity" on exam
• Aggravated by movement, breathing, coughing
• Radiation: shoulder tip pain (diaphragmatic irritation from free gas)
• Vomiting
• Fever (may develop later)
• Cessation of bowel movements

• Peptic ulcer disease: prior epigastric pain, heartburn, water brash, NSAID use, H. pylori treatment, alcohol, stress
• Typhoid fever: fever for weeks, rose spots, diarrhoea (perforated typhoid ulcer - common in developing world)
• Trauma: RTA, stab wound
• Colorectal cancer: prior bowel symptoms, PR bleeding
• Diverticular disease: left lower quadrant pain history, constipation, age >60
• IBD: known Crohn's/UC history
• Appendicitis: prior RIF pain, now generalised (perforated appendix)

• NSAID / steroid use (peptic ulcer)
• Alcohol use
• Previous PUD or H. pylori
• Immunosuppression (atypical presentation)

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13. Diabetic Foot

• Duration and onset of current foot problem
• Precipitating event: trivial injury, nail cut, corn removal, new shoes
• Current symptoms: pain (or painlessness - neuropathic), swelling, redness, discharge, smell
• Extent: single toe, multiple toes, forefoot, whole foot
• Black/gangrenous tissue (dry vs. wet gangrene)
• Fever, rigors (systemic sepsis)
• Classification: Wagner Grade (useful to discuss - Grade 0-5)

• Numbness, tingling, burning ("glove and stocking" distribution)
• Loss of protective sensation (painless injuries)
• Charcot's joint history

• Claudication: which distance, which muscle (calf = femoral disease), worsens with activity
• Rest pain (severe, nocturnal, relieved by hanging leg off bed)
• Cold feet
• Colour changes: pallor, cyanosis, rubor

• Type, duration, control, medications
• HbA1c, last eye/foot check
• Complications: nephropathy, retinopathy, neuropathy, previous amputations
• Other cardiovascular risk factors: hypertension, hyperlipidaemia, smoking

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14. Right-Sided Paralysis (Stroke / Hemiplegia)

• Onset: sudden (ischaemic/haemorrhagic stroke) vs. gradual (tumour, subdural)
• Time of onset (very important - thrombolysis window is 4.5 hours for ischaemic stroke)
• "Last known well" time
• Progression: improving, static, or worsening
• Extent: face, arm, leg (UMN pattern), complete or partial hemiplegia
• Associated features:
  • Speech: unable to speak (expressive/Broca's aphasia), unable to understand (receptive/Wernicke's), or both (global aphasia)
  • Facial drooping (LMNL - whole face; UMNL - lower face only)
  • Dysphagia (swallowing difficulty)
  • Visual field defect (homonymous hemianopia)
  • Headache: sudden severe headache ("worst headache of life") = subarachnoid haemorrhage
  • Vomiting, loss of consciousness (raised ICP / haemorrhagic)
  • Seizures at onset
  • Sensory loss / hemisensory disturbance
  • Bowel and bladder incontinence

• Hypertension (most important risk factor)
• Diabetes mellitus
• Atrial fibrillation (cardioembolic stroke)
• Previous TIA (transient ischaemic attack - sudden reversible deficit lasting <24h)
• Previous stroke
• Hyperlipidaemia
• Smoking
• Obesity
• OCP use, pregnancy (in women)
• Cardiac: rheumatic heart disease, valve prosthesis, recent MI, endocarditis
• Carotid artery disease, peripheral vascular disease
• Sickle cell disease
• Drug use: cocaine, amphetamines

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15. Periampullary Mass / Carcinoma

• Progressive, painless jaundice (classic presentation - Courvoisier's law: painless jaundice + palpable gallbladder = malignancy until proven otherwise)
• Dark urine (bilirubinuria)
• Pale/clay-coloured stools (obstructive jaundice)
• Pruritus (bile salts in skin - ask about scratch marks)
• Epigastric / back pain: dull, boring, radiating to back (pancreatic involvement, coeliac plexus invasion)
• Anorexia and significant weight loss (malignant systemic effect)
• Nausea, vomiting
• New-onset diabetes (pancreatic endocrine destruction) - ask about polyuria, polydipsia, weight loss
• Steatorrhoea: pale, bulky, foul-smelling, floating stools (exocrine pancreatic insufficiency)
• Altered bowel habits
• Symptoms of metastasis: ascites (liver mets), breathlessness (pleural effusion)
• Trousseau's sign history: migratory thrombophlebitis (associated with pancreatic cancer)

• Smoking (risk factor for pancreatic cancer)
• Chronic alcohol use (chronic pancreatitis leading to cancer)
• Chronic pancreatitis history
• Diabetes mellitus (long-standing DM is a risk factor AND a consequence)
• Family history of pancreatic cancer, BRCA2, Lynch syndrome
• Previous ERCP, biliary investigations

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Quick Summary: Common Points to Include for ALL Topics

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Differential Diagnoses

1. Lap Cholecystectomy (Symptomatic Gallstone Disease / Cholecystitis)

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2. Acute Appendicitis

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3. Multinodular Goitre (MNG)

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4. Cellulitis

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5. Inguinal Hernia

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6. Diabetic Ulcers

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7. Ovarian Tumour

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8. Appendicular Mass

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9. Injection Site Abscess

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10. Carcinoma of the Breast (CA Breast)

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11. Intestinal Obstruction

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12. Intestinal Perforation

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13. Diabetic Foot

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14. Right-Sided Paralysis

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15. Periampullary Mass

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Quick Rule of Thumb for Exams

• Always include malignancy as a differential for any lump, ulcer, or obstructive picture
• Always include ectopic pregnancy in any female of reproductive age with abdominal pain
• Always include DVT with any leg swelling
• Always include necrotising fasciitis as a differential for spreading skin infection - it is the one you must not miss
• For jaundice: divide into prehepatic / hepatic / posthepatic before listing differentials

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Clinical Examination Viva Question Bank

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1. Inguinal, Scrotal Area & Hernia

Inspection Questions

• "What are you looking for on inspection of the groin?"
  • Swelling (site, size, shape, skin changes), scrotum symmetry, both groins compared, ask patient to stand and cough
• "Where exactly is the swelling in relation to the pubic tubercle?"
  • Inguinal hernia = above and medial to pubic tubercle
  • Femoral hernia = below and lateral to pubic tubercle
• "How do you identify the pubic tubercle clinically?"
  • Trace the adductor longus tendon to its origin at the pubic tubercle

Palpation Questions

• "What is a cough impulse and how do you elicit it?"
  • Place hand over swelling, ask patient to cough - expansile impulse = hernia
• "How do you differentiate direct from indirect inguinal hernia clinically?"
  • Deep ring occlusion test: press over deep ring (midpoint of inguinal ligament), ask patient to cough
  • Controlled = indirect hernia (passes through deep ring)
  • Not controlled = direct hernia (passes through posterior wall, medial to deep ring)
• "What is Zieman's test?"
  • Three-finger test: index finger on deep ring, middle on superficial ring, ring finger on femoral canal
  • Impulse felt on index = indirect; middle = direct; ring finger = femoral
• "How do you check reducibility of hernia?"
  • Patient lies down, gentle sustained pressure in direction of neck of hernia; gurgling sound = intestinal content
• "What is the difference between irreducible, obstructed and strangulated hernia?"
  • Irreducible: cannot be pushed back, no obstruction
  • Obstructed: irreducible + intestinal obstruction (pain, vomiting, distension, absolute constipation)
  • Strangulated: obstructed + ischaemia of contents (severe pain, tender, no cough impulse, systemic toxicity)
• "How do you distinguish a hernia from a hydrocele?"
  • Hydrocele: can get above it (can place fingers above swelling between it and inguinal ligament), transilluminates, no cough impulse
• "How do you distinguish hydrocele from haematocele?"
  • Haematocele does NOT transilluminate
• "What is a varicocoele and how do you examine it?"
  • "Bag of worms" feel, left-sided (left testicular vein drains into left renal vein at 90°), increases on standing, reduces on lying down, thrill on coughing
• "What is a secondary varicocoele and why is it important?"
  • Varicocoele that does NOT reduce on lying down = possible renal cell carcinoma compressing left renal vein; examine abdomen for left renal mass
• "How do you examine for an undescended testis?"
  • Absent testis in scrotum, palpate along inguinal canal, assess if retractile (cremasteric reflex)

Percussion/Auscultation

• "Why do you auscultate a hernia?"
  • Bowel sounds confirm intestinal content inside sac

Viva Questions on Anatomy

• "What are the boundaries of the inguinal canal?"
  • Anterior wall: external oblique aponeurosis (+ internal oblique laterally)
  • Posterior wall: transversalis fascia (+ conjoint tendon medially)
  • Floor: inguinal ligament (Poupart's)
  • Roof: arching fibres of internal oblique and transversus abdominis
• "What are the contents of the inguinal canal in males and females?"
  • Male: spermatic cord (vas deferens, testicular artery, pampiniform plexus, cremasteric artery, ilioinguinal nerve)
  • Female: round ligament of uterus + ilioinguinal nerve
• "What is Hesselbach's triangle?"
  • Medial: lateral border of rectus abdominis
  • Lateral: inferior epigastric vessels
  • Inferior: inguinal ligament
  • Direct inguinal hernia passes through this triangle
• "Why is femoral hernia more prone to strangulation?"
  • Femoral ring has rigid walls (inguinal ligament, lacunar ligament, femoral vein, pectineal ligament) - unyielding ring causes early strangulation

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2. Umbilical, Paraumbilical, Epigastric & Incisional Hernia

Umbilical Hernia

• "What is a true umbilical hernia vs. paraumbilical hernia?"
  • True umbilical: through umbilical scar (infants); contents = intestine, omentum
  • Paraumbilical: through linea alba just above or below umbilicus (adults); due to weakness of linea alba
• "Why are infantile umbilical hernias mostly managed conservatively?"
  • 90% close spontaneously by age 3-4 years as linea alba strengthens
• "What complications can occur in adult umbilical/paraumbilical hernia?"
  • Irreducibility, obstruction, strangulation (high risk as neck is narrow)
• "How do you examine an umbilical hernia?"
  • Ask patient to strain/raise head - hernia protrudes; assess size of defect by palpating neck; check reducibility

Epigastric Hernia

• "What is an epigastric hernia?"
  • Through a defect in the linea alba between xiphisternum and umbilicus; usually contains extraperitoneal fat
• "Why is an epigastric hernia often painful despite being small?"
  • Pre-peritoneal fat herniates and gets strangulated; small neck with no lumen causes severe pain
• "How do you examine for epigastric hernia?"
  • Examine midline between xiphoid and umbilicus; ask patient to lift head/strain; small firm nodule appears

Incisional Hernia

• "What is an incisional hernia?"
  • Hernia through a defect in a previous surgical scar
• "What are the causes/risk factors for incisional hernia?"
  • Wound infection, obesity, malnutrition, poor surgical technique, haematoma, increased intra-abdominal pressure, steroids, anaemia
• "How do you examine an incisional hernia?"
  • Identify old scar, ask patient to raise head/strain - hernia protrudes through scar
  • Assess: site, size, neck (wide neck = low strangulation risk), reducibility, contents, cough impulse
• "What is the significance of the size of the neck?"
  • Wide neck = low risk of strangulation (incisional hernias); narrow neck = high strangulation risk
• "What are the complications of incisional hernia?"
  • Irreducibility, obstruction, strangulation, skin ulceration over large hernia, progressive enlargement

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3. A Lump / Swelling (General Lump Examination)

"What are the points you assess in any lump?"

• Site
• Inspection (size, shape, surface, skin, number)
• Tenderness
• Size (measure in cm)
• Fluctuance
• Edge (well-defined vs. ill-defined)
• Expansile pulsation vs. transmitted pulsation
• Diagnosis (consistency, transillumination, reducibility, compressibility)

Specific Questions

• "How do you test for fluctuance?"
  • Two-finger test: fix lump with two fingers, press in centre with third - fluid wave felt = fluctuant; or cross-fluctuance in two planes
• "What is the difference between fluctuance and softness?"
  • Soft = tissue compresses; fluctuant = fluid wave transmits in two planes = fluid-filled content
• "How do you test for transillumination?"
  • Darken room, apply torch to one side - if light transmits through = transilluminable (cyst, hydrocele, meningocoele)
  • Positive: clear fluid (serous, CSF), negative: blood, pus, solid
• "What is compressibility vs. reducibility?"
  • Compressible: lump disappears on pressure but reappears immediately on release (haemangioma, lymphangioma)
  • Reducible: disappears on pressure and stays gone until increased abdominal pressure (hernia)
• "How do you differentiate a pulsatile lump - expansile vs. transmitted pulsation?"
  • Place both index fingers on either side of lump:
    • Expansile: fingers pushed apart in all directions = true aneurysm
    • Transmitted: fingers move together in one plane = pulsation from underlying vessel
• "What is the significance of a positive "get above it" test?"
  • Can place fingers above lump between it and inguinal canal = lump is scrotal (hydrocele, orchitis)
  • Cannot get above it = lump extends into inguinal canal (inguinoscrotal hernia)
• "How do you determine if a lump is in the skin, subcutaneous tissue or deeper?"
  • Skin: lump moves with pinched skin
  • Subcutaneous: lump free from skin, moves over deep fascia
  • Deep to fascia: restricted mobility when muscle contracted
• "What does tethering of a lump to skin suggest?"
  • Malignancy (carcinoma breast, melanoma) or previous inflammation/fibrosis

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4. Examination of Breast

Inspection

• "What do you look for on inspection of the breast?"
  • Symmetry, size, shape, contour
  • Skin: peau d'orange (lymphatic oedema), dimpling (Cooper's ligament involvement), erythema, ulceration
  • Nipple: retraction (sudden = carcinoma; chronic = duct ectasia), discharge, Paget's disease (eczema of areola)
  • Ask patient to raise arms above head, lean forward, press hands on hips (contract pectoralis) - reveals tethering
• "Why do you ask the patient to press hands on hips?"
  • Contracts pectoralis major - if lump is tethered to pectoralis, it becomes less mobile; reveals fixity to muscle
• "What is peau d'orange and why does it occur?"
  • Orange peel skin due to lymphatic oedema; skin dimples at hair follicles because they are tethered; indicates lymphatic permeation by tumour

Palpation

• "How do you palpate the breast systematically?"
  • Patient supine, hand behind head (ipsilateral)
  • Use pulp (flat) of fingers in circular/radial/grid pattern
  • All 4 quadrants + tail of Spence + nipple-areola complex
• "What are the characteristics of a breast lump you must assess?"
  • Site (quadrant + o'clock position + distance from nipple)
  • Size (cm), Shape, Surface (smooth vs. irregular)
  • Consistency (soft/firm/hard - hard = carcinoma)
  • Margins (well-defined = benign; ill-defined = malignant)
  • Mobility (mobile = benign; fixed/tethered = malignant)
  • Tenderness
  • Skin involvement (tethering, fixity)
  • Deep fixity to pectoralis / chest wall
• "How do you test for fixity to pectoralis major?"
  • Hold lump, ask patient to press hand on hip (contract pectoralis) - if mobility decreases = fixed to pectoralis
• "How do you test for chest wall fixity?"
  • Lump immobile in all directions even at rest = fixed to chest wall (ribs/intercostals)
• "How do you examine the axilla?"
  • Support patient's elbow, relax deltoid, palpate with other hand high up into axilla
  • Central nodes, anterior (pectoral), posterior (subscapular), lateral (brachial), apical nodes
  • Note: size, number, consistency, fixity, matting
• "What is the TNM staging of breast cancer briefly?"
  • T1 <2cm, T2 2-5cm, T3 >5cm, T4 skin/chest wall involvement
  • N0 no nodes, N1 mobile ipsilateral, N2 fixed matted nodes
  • M0 no distant mets, M1 distant metastasis
• "What is the significance of nipple discharge?"
  • Bloody: ductal carcinoma, intraductal papilloma
  • Milky: galactorrhoea (prolactinoma, drugs)
  • Green/brown: fibrocystic disease, duct ectasia
  • Serous: ductal carcinoma in situ, papilloma

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5. Examination of Thyroid

Inspection

• "What are you looking for on inspection of the thyroid?"
  • Swelling in front of neck (lower part), symmetry, overlying skin, surface (smooth vs. nodular)
  • Ask patient to swallow a sip of water - thyroid swelling moves up on swallowing (attached to pretracheal fascia)
  • Ask patient to protrude tongue - if swelling moves up = thyroglossal cyst (not thyroid goitre)

Palpation

• "How do you palpate the thyroid?"
  • Stand behind patient, use both hands, index and middle fingers of both hands
  • Ask patient to swallow - feel movement
  • Assess: size of each lobe and isthmus, consistency (soft/firm/hard), surface (smooth vs. nodular), tenderness, pulsatility, bruit
• "What is the significance of a hard irregular thyroid?"
  • Suggests malignancy (anaplastic or follicular/papillary carcinoma)
• "How do you check for retrosternal extension?"
  • Percuss over manubrium - dull = retrosternal goitre
  • Pemberton's sign: raise both arms above head for 1 minute - if facial congestion, cyanosis, stridor appear = SVC obstruction from retrosternal goitre
• "How do you check for tracheal deviation?"
  • Palpate trachea in suprasternal notch with index finger, check if central or deviated
• "What is Kocher's test?"
  • Press on lateral lobes to compress trachea - if stridor = tracheal compression (softened tracheal rings - tracheomalacia)

Auscultation

• "Why do you auscultate the thyroid?"
  • Bruit = increased vascularity = Graves' disease (hyperthyroidism)
  • Must distinguish from carotid bruit (place stethoscope on carotid - louder there = carotid bruit)

Thyroid Status

• "What do you look for to assess thyroid status clinically?"
  • Hands: tremor (fine resting = hyper), sweating, palmar erythema, warm peripheries vs. cold; pulse (tachycardia/AF = hyper; bradycardia = hypo)
  • Eyes: exophthalmos, lid lag, lid retraction (Graves')
  • Neck: bruit
  • Reflexes: brisk = hyper; slow-relaxing = hypo
  • Skin: warm moist skin (hyper); dry coarse skin (hypo)
  • Pretibial myxoedema (Graves')
• "What is lid lag and how do you elicit it?"
  • Ask patient to follow your finger moving slowly downward - sclera shows above iris before lid follows = lid lag (sympathetic overactivity in hyperthyroidism)

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6. Examination of Ulcer

"What are the 8 points you examine in any ulcer?"

• Site
• Edge
• Extent/Size
• Depth
• Slough / floor
• Base
• Area around ulcer (surrounding skin)
• Secretion / discharge
• Enduring (duration/chronicity)

Specific Questions

• "What are the different types of ulcer edges and what do they signify?"

• "What is the base and floor of an ulcer?"
  • Floor: what you can see (slough, granulation tissue, necrotic tissue)
  • Base: what the ulcer rests on (bone, tendon, muscle, subcutaneous fat)
• "How do you test the depth of an ulcer?"
  • Probe gently with gloved finger or sterile probe - if reaches bone = osteomyelitis likely
• "What is a Marjolin's ulcer?"
  • Squamous cell carcinoma arising in a chronic ulcer (burn scar, venous ulcer, sinus); everted edges, indurated, regional LN involvement
• "How do you distinguish a venous from an arterial ulcer?"

• "What is the surrounding area of an ulcer and what do you look for?"
  • Pigmentation (haemosiderin = venous), induration (infection/malignancy), oedema, varicosities, skin atrophy, vitiligo, sensation (neuropathic)

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7. Examination of Varicose Veins

Inspection

• "What do you look for on inspection of varicose veins?"
  • Distribution (long saphenous: medial thigh/leg; short saphenous: posterior calf to popliteal)
  • Skin changes: haemosiderin pigmentation, lipodermatosclerosis, atrophie blanche, eczema, ulcer (medial gaiter area)
  • Examine standing - veins more prominent
  • Oedema

Special Tests

• "What is the Trendelenburg test and what does it tell you?"
  • Empty veins by elevating leg; apply tourniquet at saphenofemoral junction (groin)
  • Ask patient to stand: veins stay empty = SFJ incompetence (controlled by tourniquet)
  • Veins fill rapidly from below = perforator incompetence (not controlled)
  • Release tourniquet: rapid filling = SFJ incompetence confirmed
• "What is the tourniquet test / multiple tourniquet test?"
  • Apply tourniquet at various levels (thigh, knee, upper calf) to localise level of incompetent perforators
  • If veins fill below tourniquet = perforator incompetence below that level
• "What is the Perthes test / Schwartz test?"
  • Perthes test: Tourniquet applied, patient walks - if varicosities disappear = deep veins patent; if worsen/pain = deep vein obstruction (DO NOT operate if Perthes positive - operating will worsen drainage)
  • Schwartz test (tap test): Tap upper end of vein, feel impulse transmitted down - indicates valvular incompetence of the long column of blood
• "What is the Morrissey's cough impulse test?"
  • Place finger at saphenofemoral junction; ask patient to cough - palpable thrill = SFJ incompetence
• "What is Homan's sign and is it reliable?"
  • Calf pain on dorsiflexion of foot = DVT - but it is unreliable (50% sensitivity, non-specific), Doppler USS is the gold standard
• "What are the complications of varicose veins?"
  • Eczema, haemosiderin pigmentation, lipodermatosclerosis, ulceration (venous ulcer), bleeding (rupture), superficial thrombophlebitis, deep vein thrombosis, corona phlebectatica
• "What are the important perforators clinically?"
  • Cockett's perforators (medial leg, above medial malleolus): most clinically significant, associated with venous ulcers
  • Hunterian/Dodd's perforator (medial thigh)
  • Boyd's perforator (below knee medially)

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8. Examination of Abdomen

Inspection

• "What do you look for on inspection of the abdomen?"
  • Shape: distension (5 Fs - Fat, Fluid, Flatus, Faeces, Fetus), scaphoid (malnutrition)
  • Scars (note site, suggest what surgery)
  • Dilated veins: caput medusae (portal hypertension - flow away from umbilicus), IVC obstruction (flow upward), SVC obstruction (flow downward)
  • Visible peristalsis: intestinal obstruction, pyloric stenosis
  • Hernias: umbilical, epigastric, incisional (ask patient to raise head)
  • Pulsations: aortic aneurysm
  • Skin: jaundice, spider naevi, stretch marks, Grey-Turner's sign (flank bruising = retroperitoneal bleed/pancreatitis), Cullen's sign (periumbilical bruising = haemoperitoneum/pancreatitis)

Palpation

• "How do you palpate the abdomen systematically?"
  • Start away from site of pain; light palpation first (all 9 regions), then deep palpation
  • Look at patient's face throughout for pain/guarding
• "How do you palpate the liver?"
  • Start from RIF, move up toward right costal margin, ask patient to breathe in and out
  • Feel for liver edge on inspiration (descends 2-3 cm normally)
  • Assess: size (finger breadths below costal margin), consistency, surface, edge, tenderness, pulsatility
• "What is the significance of a pulsatile liver?"
  • Tricuspid regurgitation (TR) - pulsatile liver with large V wave in JVP
• "How do you palpate the spleen?"
  • Start from RIF, move toward left costal margin (spleen enlarges toward RIF)
  • Patient lies on right side (left lateral position) - spleen becomes more palpable
  • Notch on medial border confirms spleen (not kidney)
• "How do you distinguish a spleen from a kidney?"

• "How do you palpate the kidney?"
  • Bimanual palpation: one hand behind in loin, other hand in abdomen (right upper quadrant or left upper quadrant)
  • Ballottement: push with posterior hand, feel it bounce against anterior hand = ballottable = renal (retroperitoneal position)
• "How do you elicit Murphy's sign?"
  • Place hand below right costal margin (gallbladder area), ask patient to breathe in - patient catches breath due to pain = positive Murphy's sign = acute cholecystitis
  • A palpable gallbladder without pain = Courvoisier's law = malignant obstruction
• "What is Courvoisier's law?"
  • A palpable, non-tender gallbladder in the presence of jaundice is unlikely to be due to gallstones (stones cause fibrosis); suggests malignant obstruction (periampullary carcinoma, head of pancreas carcinoma)
• "How do you elicit renal angle tenderness?"
  • Fist percussion over costovertebral angle (12th rib + erector spinae) = positive in pyelonephritis, renal stones

Percussion

• "How do you detect ascites?"
  • Shifting dullness: percuss from umbilicus laterally until dull, keep finger there, turn patient to opposite side, wait 30 seconds, percuss again - if resonant now = shifting dullness = free fluid
  • Fluid thrill: flick one flank, hand on opposite flank feels wave; ask assistant to place hand in midline to prevent fat wave
• "How much fluid must be present before shifting dullness is positive?"
  • At least 1500 mL (1.5 litres)
• "What are the causes of a distended abdomen (5 Fs + 2 more)?"
  • Fat, Fluid (ascites, blood, bile), Flatus, Faeces, Fetus, Fibroid (large), Phantom (psychogenic)

Auscultation

• "What do bowel sounds tell you?"
  • Normal: gurgling every 5-10 seconds
  • Increased (high-pitched, tinkling): intestinal obstruction
  • Absent (for 2 mins): paralytic ileus, peritonitis
  • Bruit over aorta: aortic aneurysm / renal artery stenosis

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9. Examination of Salivary Glands

Inspection

• "What do you look for on inspection?"
  • Swelling: site (parotid - in front of and below ear, lifts ear lobe; submandibular - under jaw in digastric triangle; sublingual - floor of mouth)
  • Skin overlying (red = inflammation; normal = tumour; fixed = malignancy)
  • Facial nerve palsy (parotid malignancy - VII nerve involvement = poor prognosis)
  • Bilateral or unilateral (bilateral = mumps, sarcoidosis, Sjögren's; unilateral = calculus, tumour)

Palpation

• "How do you palpate the parotid gland?"
  • Bimanual if possible; palpate region in front of ear, below zygoma, to angle of jaw
  • Note: consistency, tenderness, skin fixity, facial nerve function
• "How do you palpate the submandibular gland?"
  • Bimanual palpation: one gloved finger inside the mouth on the floor of the mouth, other hand externally under the jaw
  • Can feel a calculus (stone) as a hard tender nodule along the duct (Wharton's duct)
• "Where does Wharton's duct open?"
  • At the sublingual papilla (papilla) on either side of the frenulum of tongue on the floor of the mouth
• "Where does Stensen's duct (parotid duct) open?"
  • On the buccal mucosa opposite the upper second molar tooth
• "How do you look for a salivary calculus?"
  • Ask patient to open mouth; inspect floor of mouth and duct orifice
  • Bimanual palpation of submandibular gland - feel for stone along Wharton's duct
  • Press on gland - does saliva come out of duct? (reduced or absent = blocked duct)
• "What is the classic history of a salivary calculus (sialolithiasis)?"
  • Pain and swelling under jaw at mealtimes (food anticipation increases salivation, blocked duct causes pressure = "mealtime syndrome")
• "How do you test for dry eyes and mouth (Sjögren's)?"
  • Schirmer's test: filter paper on lower eyelid for 5 minutes - <5 mm wetting = dry eyes (keratoconjunctivitis sicca)
• "What nerve is at risk in parotid surgery?"
  • Facial nerve (VII) - its branches (temporal, zygomatic, buccal, marginal mandibular, cervical) pass through the parotid gland; damage = facial palsy
• "What nerve is at risk in submandibular gland surgery?"
  • Lingual nerve (sensory to anterior 2/3 tongue)
  • Hypoglossal nerve (XII) - motor to tongue
  • Marginal mandibular branch of facial nerve - lower lip weakness
• "What is the significance of a hard, non-tender, fixed parotid lump with facial palsy?"
  • Highly suggestive of malignant parotid tumour (mucoepidermoid carcinoma, adenoid cystic carcinoma) invading VII nerve
• "What is the most common benign tumour of the parotid?"
  • Pleomorphic adenoma (mixed parotid tumour): slow-growing, firm, lobulated, mobile, no facial palsy
• "What is Frey's syndrome?"
  • Auriculotemporal nerve damage during parotidectomy → sweating over cheek during eating (gustatory sweating) due to aberrant reinnervation of sweat glands by parasympathetic fibres

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Quick Exam Tips - What Examiners Always Look For

1. Always examine both sides and compare
2. Always examine regional lymph nodes for any lump
3. Always look at the patient's face while palpating for pain
4. Always ask patient to stand and cough when examining hernias
5. Always do bimanual palpation for submandibular gland and kidney
6. Announce your findings as you examine - don't examine silently
7. Always check the opposite breast in breast examination
8. Always check thyroid status (pulse, tremor, eyes, reflexes) after examining the gland