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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1060_Библиотеки_им_академика_М_И_Перельмана
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Introduction on Clinical Examination
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more than 1.5 cm in size are significant; seen in von
Recklinghausen’s disease of neurofibromatosis with
regular outline and deep indentations; occasionally also
seen in Albright’s syndrome as irregular outline.
Petechiae: Tiny haemorrhagic spots less than 1 mm in
size.
Purpura: Haemorrhagic spots of 2-5 mm in size.
Ecchymosis: Haemorrhagic spots more than 5 mm in
size.
Haematoma: Haemorrhage causing elevation of skin.
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Fig. 1.20: Herpes zoster infection.
A
B
Figs 1.21A and B: Skin rashes and skin vesicles in
two different patients.
Dry skin: Seen in dehydration and myxoedema.
Moist skin: Seen in myocardial infarction, shock of
sudden onset (haemorrhage), toxic thyroid.
Thick skin: Seen in myxoedema, acromegaly, and
scleroderma.
Thin skin: Seen in old people, and wasting diseases.
Pinched skin a feature of dehydration, malnutrition.
Falling of hair: Seen in infectious fevers like typhoid,
chemotherapy for malignancies, drugs and hereditary.
Patchy hair loss is seen in alopecia areolata, syphilis.
Loss of hair in outer third of eyebrow: Seen in leprosy,
myxoedema. Absence of axillary , pubic and facial hairs
is seen in hypopituitarism, hypogonadism.
Excessive hair growth in women is seen in Cushing’s
syndrome, adrenocortical syndrome.
General examination is done for proper diagno-
sis and differential diagnosis; for selecting the patient
for anaesthesia; to decide type of surgery to be done
(mesh hernioplasty is done in inguinal hernia if
patient is having chronic respiratory disease or if
there is poor abdominal muscle tone); to predict the
prognosis (patients with gastrointestinal cancer
showing palpable supraclavicular lymph node means
poor prognosis; patient with carcinoma breast having
spread to bones/lungs carry poor prognosis).
Fig. 1.22: Radiation dermatitis both sides of neck and
face.
Other General Examinations
Other general examinations to be done are:
Head and neck region: Cranial nerve functions; eyes
(visual field, pupils for equality and reaction, accommodation reflux, conjunctiva, eyeball movements,
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fundus examination); mouth and pharynx (teeth,
gums, soft palate movement, tongue, tonsils, lip);
neck (movements of neck, neck veins, neck nodes,
carotid pulse, trachea, thyroid).
Upper limbs: General look of hands, forearm,
arm (wasting); vascular system; nervous system
(sensation, muscle power, muscle tone, reflexes);
axillary nodes; joints and movements; fingers and
nails.
Thorax: Chest look; dilated veins; swelling (Fig. 1.23);
pulsations; breasts; apex beat; lungs and heart.
Abdomen: Abdominal wall (umbilicus, scar, dilated
veins); reflexes of abdomen; visible peristalsis; visible
pulsation; hernial orifices; palpation; percussion;
auscultation; rectal digital examination; per vaginal
examination if needed in females; examination after
catheterization if needed.
Lower limbs: Examination of feet, legs, thighs; feeling
of peripheral pulses; nervous system in the lower limbs;
oedema feet; varicose veins; examination in standing
position; joints; inguinal nodes.
Examination of genitalia: Testis (its size, texture,
presence of hydrocele); epididymis; vas deferens, skin
over the scrotum; penis for phimosis, balanoposthitis,
chordee, hypospadias.
Skeletal system: spine and skull.
Examination of Faeces
It gives indirect evidence of different pathologies in
the gastrointestinal tract. The quantity—copious/
scanty; consistency—liquid/semisolid/semiformed/
formed/hard; colour—black-in upper GI bleed, iron
or bismuth intake/pale coloured stool is seen in
obstructive jaundice (absence of bile in the bowel),
rapid transit of stool in diarrhoea, malabsorption,
chronic pancreatitis; odour—offensive in jaundice,
semen like odour in acute amebic dysentery,
odourless in acute bacillary dysentery; type—slimy
stool in carcinoma colon, colitis of different causes;
purulent stool in bacterial dysentery; blood in stool
in different conditions. Melaena—is black, tarry, foul
smelling stool seen in upper GI bleed (Fig. 1.24); red
pigmented clots (Maroon coloured) in Meckel’s
diverticulum; red currant jelly in intussusception;
bright red coloured in rectal and anal diseases.
Steatorrhoea is large quantity, pale, porridge-like
stool that, sticks to lavatory and is difficult to flush.
It is due to severe degree of pancreatic insufficiency
causing malodourous, voluminous stool which floats
on the water. Patient passes quantity of fat that
separates from the non-fatty part of the faecal matter
that resembles melted butter that become solid again.
Pipe stem stool occurs in rectal stenosis usually due
to malignant rectal stricture. Toothpaste stool is seen
in Hirschsprung’s disease. Spurious diarrhea is seen
in carcinoma colon.
Fig. 1.23: Systemic examination is a must. Note the chest
wall swelling in this patient. Clothings should be removed
properly while examining the patient. This swelling may be
secondary in the rib or primary tumour.
Fig. 1.24: Typical black, foul smelling tarry coloured
stool—seen in upper gastrointestinal bleeding.
ECOG performance status (Eastern Cooperative
Oncology Group): This performance status is used
as a guide to plan the therapy. Other scale used is
Karnofsky scale.
Introduction on Clinical Examination
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ECOG Performance Karnofsky
(Zubroad) score
scale
0 Fully active and able to carry 100%
out work without restriction
1 Symptoms restrict strenuous 80-90%
physical activity but ambulatory
and able to carry light
sedentary work
2 Ambulatory but unable to carry 60-70%
out work; up and about > 50%
waking hours
3 Only limited self care; confined 40-50%
to bed or chair for more than
50% of waking hours
4 Completely disabled; confined 20-30%
to bed or chair
Local Examination
Inspection
It is observing the diseased area carefully for clinical
features. It should be done with proper complete
exposure of the part; compared with normal side.
Palpation
It is done by feeling of affected part using hand and
fingers.
Percussion
It is tapping of the affected area directly using flexed
finger (direct method) or using pleximeter finger and
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percussion finger (indirect method). Percussion is
used over sternum, abdomen (ascites, over mass to
find out note, liver dullness), respiratory system (in
pleural effusion, pneumothorax).
Auscultation
Stethoscope is used to hear heart sounds, abnormal
sounds like adventitious breath sounds, altered
bowel or absence bowel sounds; bruit over vessel or
organ.
Examination of regional lymph nodes is essential.
Movements and measurements are also often
important.
Note:
Sequence of events needed in approaching all patients
are as follows –
1. Detailed complete proper history.
2. Complete clinical examination.
3. Clinical analysis, diagnosis and differential dia-
gnosis.
4. Evaluation of the patient routine/general and
specific in relation to the patient’s probable
diagnosis.
5. Final diagnosis.
6. Planning the therapy/treatment which are best
suitable for the patient.
7. Implementing the treatment surgical/conservative
(like drugs)/radiotherapy, etc.
8. Follow up of the patient.
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Examination of an
2
Definition
An ulcer is a break in the continuity of the covering
epithelium, either skin or mucous membrane due to
molecular death.
Parts of an Ulcer (Fig. 2.1)
1. Margin: It may be regular or irregular. It may be
rounded or oval in shape.
2. Edge: Edge is the one which connects floor of the
ulcer to the margin.
Fig. 2.1: Parts of an ulcer.
Ulcer
Different edges are (Fig. 2.2):
Sloping edge: It is seen in healing ulcer. Its inner
part is red because of red, healthy granulation
tissue. Its middle part is white due to scar/fibrous
tissue. Its outer part is blue due to epithelial
proliferation.
Undermined edge is seen in tuberculous ulcer.
Disease process advances in deeper plane (in
subcutaneous tissue) whereas epidermis (skin)
proliferates inwards.
Punched out edge is seen in gummatous
(syphilitic) ulcer and trophic ulcer . It is due to end
arteritis.
Raised and beaded edge (pearly white) is seen in
rodent ulcer (BCC). Beads are due to proliferating
active cells.
Everted edge (rolled out edge): It is seen in
carcinomatous ulcer due to spill of the proliferating malignant tissues over the normal skin.
3. Floor: It is the one which is seen. Floor may
contain discharge, granulation tissue.
4. Base: Base is the one where ulcer rests. It may
be bone or soft tissues.
Fig. 2.2: Types of edges in different ulcers.
Examination of an Ulcer
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Classifications
Classification I (Clinical)
1. Spreading ulcer: Here edge is inflamed and
oedematous.
2. Healing ulcer: Edge is sloping with healthy pink/
red granulation tissue with serous discharge.
3. Callous ulcer: Floor contains pale unhealthy
granulation tissue with indurated edge/ base. Ulcer
has no tendency to heal. It lasts for many months
to years (Fig. 2.3).
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3. Non-specific ulcers:
• Traumatic ulcer: It may be mechanical (dental
ulcers in the tongue), physical (electrical burn),
and chemical (alkali injury).
• Arterial ulcer: Atherosclerosis, TAO.
• V enous ulcer: Gravitational ulcer , post-phlebi-
tic ulcer.
• Trophic ulcer: Bed sore; perforating ulcers in
the sole.
• Infective ulcers: Pyogenic ulcer.
• Tropical ulcers: It occurs in tropical countries.
It is callous type of ulcer, e.g. Vincent’s ulcer.
• Ulcers due to chilblains and frostbite (cryo-
pathic ulcer).
• Martorell’s hypertensive ulcer.
• Bazin’s ulcer.
• Diabetic ulcer.
• Ulcers due to leukaemia, polycythaemia, jaundice, collagen diseases, lymphoedema.
• Cortisol ulcers are due to long time application
of cortisol (steroid) creams to certain skin
diseases. These ulcers are callous ulcers, last for
long time and require excision and skin grafting
(Fig. 2.4).
Fig. 2.3: Callous ulcer without any sign of healing and,
without any granulation tissue. It is due to callous attitude
of the patient.
Classification II (Pathological)
1. Specific ulcers:
• Tuberculous ulcer.
• Syphilitic ulcer: It is punched out, deep, with
‘wash-leather’ slough in the floor and indurated
base.
• Actinomycosis.
• Meleney’s ulcer.
2. Malignant ulcers:
• Carcinomatous ulcer.
• Rodent ulcer.
• Melanotic ulcer.
Fig. 2.4: Non-healing ulcer with pale unhealthy
granulation tissue.
Classification III (Wagner’s Grading)
Grade 0—preulcerative lesion/healed ulcer.
Grade 1—superficial ulcer.
Grade 2—ulcer deeper to subcutaneous tissue
exposing soft tissues or bone.
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Grade 3—abscess formation underneath/osteomyelitis.
Grade 4—gangrene of part of the tissues/limb/foot.
Grade 5—gangrene of entire one area/foot.
Different discharges in an ulcer (as well as from a
sinus)
Serous: in healing ulcer
Purulent: in infected ulcer
Staphylococci: yellowish and creamy
Streptococci: bloody and opalescent
Pseudomonas: greenish colour
Bloody: malignant ulcer, healing ulcer from healthy
granulation tissue (Figs 2.5A and B)
Seropurulent
Serosanguineous: serous and blood
Serous with sulphur granules: Actinomycosis
Yellowish: Tuberculous ulcer
History
Name: Sex:
Age: Certain diseases or ulcers may be more common
in certain age groups.
Occupation: Venous ulcers are more common in
individuals whose occupation requires long hours of
standing like nurses, surgeons, traffic policemen,
watchmen and bus conductors.
Place:
Chief complaints: History of ulcer and its duration
should be mentioned. History of specific condition
related also should be mentioned.
Causes of Ulcer Becoming
Chronic in the Skin
Causes of ulcer becoming chronic in the skin are:
Recurrent infection; trauma; absence of rest; poor
blood supply; hypoxia; oedema of area; loss of sensation; malignancy; specific cause like tuberculosis,
fibrosis, periostitis or osteomyelitis of the underlying
bone.
A
B
Figs 2.5A and B: Ulcers with healthy granulation
tissue. Ulcer is ready for split skin grafting.
History of Present Illness
Mode of Onset and Progression
It is the initial way of formation of an ulcer. It may
be after an attack of cellulitis of the part which causes
skin necrosis and later sloughs off, or after trauma
which breaks the continuity of the epithelium or
spontaneously due to any cause. Traumatic ulcer may
heal fast or may progress into chronicity if it is on
a joint or due to improper rest to the part or if patient
is diabetic or due to other precipitating causes.
Common cause of ulcer is trauma. Even minor trauma
can cause extensive necrotising fasciitis and ulcer
later. Often patient will be having the idea of the
cause of ulcer. Tuberculous lymphadenitis leading
into collar stud abscess eventually may form a fistula
or an ulcer. Ulcerative lesion may be rodent ulcer,
carcinomatous ulcer or melanotic ulcer originating
spontaneously. Syphilis may lead into gummatous
ulcer. Ulcer may occur as a result of varicose veins
due to chronic venous hypertension or arterial
insufficiency as in ischemic ulcer or over pre-existing
scars like of burn scar. Regressing or progressing of
an ulcer formed in specific method is important.
Ulcer may often heal spontaneously and reform later
repeatedly in the same site, e.g. Formation of an ulcer
in a pre-existing burn scar or formation of venous
ulcer repetitively around ankle. Here ulcer heals by
rest and reforms by trauma or other precipitating
causes. If it is progressing then method of progressing
is also noted. Change in size, shape, depth, discharge
during progression period should be asked (Fig. 2.6).
Examination of an Ulcer
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smell of discharge is important to be considered,
whether discharge is serous or purulent and often type
of bacterial infection involved like in pseudomonas
infection the discharge is greenish in colour.
Number of Ulcers
Often ulcers can be multiple (Fig. 2.7). If it is so,
which ulcer developed first and which one later
should be asked.
27
Fig. 2.6: Ulcer over lateral margin of the tongue due
to dental injury. It is an acute ulcer.
Duration
Ulcer is of long duration like in chronic venous ulcer
or of short duration like in acute ulcer after trauma
or cellulitis.
Pain
Ulcer may be painful or painless. Often ulcer is
painless to begin with but may eventually become
painful like malignant ulcers due to secondary
bacterial infection or infiltration to deeper plane or
nerve ending. Some ulcers are painful to begin like
acute ulcer, but becomes painless once it turns to
chronicity. Its time of onset, progress, and severity
should be asked. Trophic ulcers, syphilitic ulcer,
ulcers of neurological diseases like spinal injury/
spinal diseases/peripheral neuropathy/tabes dorsalis
are painless. Pain may interfere with patient’s daily
routine activities like walking, eating, bathing,
defecation, etc. T uberculous ulcer is usually painful.
History of Fever
Presence of fever signifies existing acute inflammation in an ulcer or in surrounding area.
Discharge from Ulcer
Whether ulcer is having discharge or not is significant. Discharge can be assessed by looking at
dressing pads also. Discharge may be profuse, scanty
or absent. Patient often gives history of the quantity
of dressing pads soaked and its colour. Colour and
Fig. 2.7: Multiple ulcers all over the body in a
malnourished immunosuppressed individual.
Associated Symptoms
History of presence of varicose veins; claudication,
rest pain of arterial insufficiency should be asked for .
Past History
Past history of ulcer treated by dressing/drugs/skin
grafting/hospital stay should be asked in detail.
Number of days hospitalized, time taken up for
healing of the ulcer should be noted. Previous history
of treatment for tuberculosis, syphilis, diabetes or any
other illness is important.
History suggestive of associated disease/treatment
history like for tuberculosis, tabes dorsalis, spinal
diseases or diabetes mellitus has to be asked. If patient
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is on treatment for any of such ailment, type of drugs
taken, dose and method of intake should be asked.
Personal History
History of alcohol consumption/smoking/tobacco
chewing/history of sexual contact/dietary habits are
also important. Duration of such habits, quantity are
also important. It has got direct relation to ulcer
formation or ulcer healing or treatment strategy.
Altered appetite or weight loss can also be mentioned
under personal history—may be due to advanced
malignancy or tuberculosis.
Family History
Family history of any specific disease should be
asked.
General Examination
Doing a detailed general examination is very essential. Presence of anaemia/oedema/jaundice/clubbing/
lymphadenopathy/raise in temperature/attitude of
the patient/nutritional assessment by skin texture,
subcutaneous fat, weight, body mass index/any other
relevant findings should be mentioned. Rate and
volume of radial pulse/palpation of all peripheral
pulses/blood pressure should be noted. Malignant
tumor infiltrating nerves or ulcer with a chronic scar
or large chronic ulcer or painful acute ulcer can alter
the attitude of the limb. Increased pulse rate and
temperature suggests ulcer with acute inflammation.
Features suggestive of tuberculosis, vascular disease,
spinal disease, syphilis or neurological diseases
should be looked for.
A
B
Local Examination of an Ulcer
Inspection (Figs 2.8A to C)
Site of an Ulcer
Exact anatomical location of the ulcer is noted. It is
mentioned in relation to particular anatomical point
usually bony point. Venous ulcers occur over malleoli
around ankle (Fig. 2.9). Basal cell carcinomatous
ulcer/rodent ulcer occurs in the face commonly above
the line joining angle of the mouth to the ear lobule
(common site is inner canthus of eye) (Fig. 2.10).
C
Figs 2.8A to C: Inspection of ulcer for its site, size,
shape, margin, edge, floor and surrounding area.
Examination of an Ulcer
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Fig. 2.9: Inspect the limb in standing position for evidence
of varicose veins in case of suspected venous ulcer.
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Size of an Ulcer
Ulcer size should be measured both vertically and
horizontally using a measuring tape. Tape may be
placed over sterile gauze covering the ulcer to
measure (Fig. 2.11).
Fig. 2.11: Ulcer should be measured both vertically
and horizontally.
Fig. 2.10: BCC (rodent ulcer) which is pigmented
involving lower eyelid—a common site.
Tuberculous ulcer occurs commonly in the neck,
axilla, chest wall or groin. It can occur anywhere in
the body. Syphilitic gummatous ulcer occurs over
subcutaneous bones like tibia, sternum, palate or
skull. Trophic ulcer occurs in the sole of the foot
(heel, over the heads of the metatarsals). Malignant
ulcers can occur anywhere in the skin. Meleney’s
ulcer occurs over the perineum, groin and lower
abdominal wall.
Shape of an Ulcer
Ulcers of different causes may have different shapes.
Venous ulcer is vertically oval in shape. Tuberculous
ulcer is circular in shape. Malignant ulcer is irregular
in shape. Serpiginous ulcer looks like a serpent. Here
healing occurs in one place; while disease extends
in another/adjacent place.
Number
Malignant ulcer is usually solitary . Venous ulcers can
be multiple. Tuberculous ulcers can be multiple.
Margin of an Ulcer
Margin is whether regular/irregular/well-defined/illdefined should be observed. Margin is the junction
of the normal skin around to the outermost end of
the edge.
Edge of an Ulcer
Edge is from the floor to margin. Different edges
occur in different conditions.
Sloping edge occurs in healing ulcer. It shows three
zones from inside out. First is red zone due to central
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healthy red granulation tissue; second is middle blue
zone consisting of active growing epithelium; third
is outermost white zone consisting of fibrous tissue
and scar. It is seen in healing ulcer (Fig. 2.12).
Fig. 2.12: Healing ulcer with healthy granulation tissue.
Note the sloping edge.
Punched out edge is edge that run deeply perpendicular to the skin margin. It is commonly seen in
trophic ulcer (due to localized deep inflammation)
and gummatous ulcer (due to end arteritis obliterans).
Disease is localized to ulcer area and does not spread
to surrounding structures (Fig. 2.13).
Fig. 2.13: Trophic ulcer heel—typical punched out edge.
Undermined edge is one where edge is burrowed deep
and lateral to the skin margin. Edge in tuberculous
ulcer is typically undermined. It is due to faster spread
of tuberculosis in subcutaneous plane than skin.
Overlying skin which is pointing towards the center
of the ulcer is bluish, thin, and friable (Figs 2.14A
and B).
Raised and beaded edge is seen in rodent ulcer (BCC
ulcer). Beads are pearly white in colour and are due
to actively multiplying malignant cells. Probably in
between these beads are predominantly the dormant
inactive cells (Fig. 2.15).
Everted edge/rolled out edge is one which fills, heaps
and spills outward from the edge towards margin. It is
typical of epitheliomatous ulcer (squamous cell
carcinoma/malignant ulcer). It signifies rapidly growing tissues (Fig. 2.16). Ulcer showing proliferation
(usually in the edge) is proliferative ulcer. Growth
showing ulceration is ulcerative growth.
Spreading ulcer shows oedematous, inflamed edge.
Aphorism-syphilis bites; tuberculosis nibbles.
A
B
Fig. 2.14: Tuberculous ulcer foot with
undermined edge.
Fig. 2.15: Basal cell carcinomatous ulcer
(rodent ulcer) with beaded edge.
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