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M. Elkassaby
Local Examination
Inspection
Take note of which vein is affected by varicosity, either the long saphenous vein, the
short saphenous vein, or both. In the case of the former, a prominent venous trunk
can be observed on the inner side of the leg, extending from the front of the medial
malleolus to the inner side of the knee and continuing along the inner side of the
thigh up to the saphenous opening. This venous trunk receives tributaries along its
course. In the case of short saphenous vein varicosity, the dilated venous trunk is
visible on the back of the leg, starting from behind the lateral malleolus and extending upwards in the posterior aspect of the leg, terminating in the popliteal fossa.
Swelling can manifest in two ways: localized swelling, as seen in varicose veins
affecting a segment of a supercial vein in cases of supercial thrombophlebitis, or
generalized limb swelling, mostly attributed to deep vein thrombosis.
Local redness is typically indicative of supercial thrombophlebitis or venous
eczema. Generalized change in color may appear as brown discoloration of the skin
resulting from chronic venous insufciency, a condition named
“Lipodermatosclerosis” with characteristic thickened leathery brown skin with
muscle atrophy, rendering the leg into the shape of “inverted Champaign bottle”
appearance.
The presence of ulceration, commonly observed on the inner side of the lower
leg, is referred to as venous ulceration. Ulcers are commonly irregular in shape,
supercial, moist with necrotic oor and commonly secondary infected.
Scarring may be visible on the lower leg, which could be a result of a healed
venous ulcer or a previous surgical procedure for varicose veins.
Palpation
The examination of varices holds signicant importance. The primary objective is
to identify the incompetent valves that connect the supercial and deep veins. The
Brodie-Trendelenburg test is conducted to assess the incompetence of the saphenofemoral valve and other communicating systems. There are two methods to perform
this test. In both methods, the patient is initially positioned in a lying down position,
and their legs are elevated to facilitate the emptying of the veins. This process can
be expedited by gently squeezing the veins closer to the body. The clinician then
applies pressure on the sapheno-femoral junction using their thumb or by applying
a tourniquet just below the junction. Subsequently, the patient is instructed to stand
up quickly.
In the rst method, the pressure is released. If the varicose veins rapidly ll with
blood from above, it indicates the incompetence of the sapheno-femoral valve. This
outcome is referred to as a positive Trendelenburg test.
20 Vascular Examination Sheet
195
To evaluate the communicating system, the pressure is not released but maintained for approximately one minute. If the veins gradually ll during this period, it
suggests the incompetence of the communicating veins, which are typically located
on the medial side of the lower half of the leg and are associated with long saphenous varicosity. This outcome is also considered a positive Trendelenburg test.
Positive test results serve as indications for surgical intervention.
The Tourniquet test, which can be considered as a variation of the Trendelenburg
test, involves the application of a tourniquet around the thigh or leg at various levels.
Prior to performing the test, the supercial veins are emptied by elevating the leg
while the patient is in a lying position. Subsequently, the patient is instructed to
stand up. If the veins located above the tourniquet become lled while those below
it remain collapsed, this indicates the presence of an incompetent communicating
vein above the tourniquet. Conversely, if the veins below the tourniquet rapidly ll
while the veins above it remain empty, the incompetent communicating vein is
likely situated below the tourniquet. By adjusting the position of the tourniquet
downwards, the healthcare professional can further assess the location of the incompetent communicating vein.
To denitively conrm short saphenous incompetence, a specic examination is
conducted. First, the saphenopopliteal junction is marked with a pen while the
patient is standing. Then, the short saphenous vein is emptied by elevating the leg,
and rm thumb pressure is applied to the ink mark. The patient is then made to
stand, and the pressure is released. If the vein immediately lls, it provides nal and
conclusive proof of short saphenous incompetence.
Modied Perthes’ test is primarily used to assess the normalcy of deep veins. To
conduct this test, a tourniquet is tightly secured around the upper thigh to prevent
any backward ow in the vein. The patient is then instructed to walk briskly while
the tourniquet remains in place. If both the communicating and deep veins are functioning properly, the varicose veins will decrease in size. However, if there is a
blockage, the varicose veins will become more distended.
The Schwartz test is applicable in cases of long-standing varicose veins. By tapping on the long saphenous varicose vein in the lower leg, an impulse can be felt at
the saphenous opening with the other hand.
Pratt’s test is performed to determine the locations of leg perforators. Initially, an
Esmarch elastic bandage is wrapped from the toes up to the groin. A tourniquet is
then applied at the groin, causing the varicose veins to empty. The tourniquet is
maintained in position while the elastic bandage is removed. Subsequently, the
same elastic bandage is reapplied from the groin downwards. At the sites where the
perforators “blow out” or visible varices are present, they can be observed.
The Morrissey’s Cough Impulse Test involves raising the limb to drain the varicose veins, followed by placing the limb in a resting position and instructing the
patient to cough forcefully. This manoeuvre elicits an expanding impulse in the long
saphenous vein, particularly at the saphenous opening, indicating incompetence of
the sapheno-femoral valve. Additionally, a bruit may be audible upon auscultation.
Fegan’s test is employed to identify the locations of perforators in patients with
varicose veins. Initially, the patient stands upright, and areas of excessive bulging
196
within the varicosities are marked. Subsequently, the patient lies down, and the
affected limb is elevated to empty the varicosed veins. The examiner then carefully
palpates along the line of the marked varicosities, searching for gaps or pits in the
deep fascia that transmit the incompetent perforators.
Percussion
Percussion can be utilized to evaluate varicose veins by tapping on the most prominent areas. This technique, known as the Schwartz test, elicits an impulse that can
be felt at the saphenous opening. In certain instances, the percussion wave may be
transmitted from above downwards, indicating the absence or incompetence of
valves between the tapping nger and the palpating nger.
Auscultation
Auscultation is primarily relevant in cases of arteriovenous stula, where a continuous machinery murmur may be audible.
M. Elkassaby
General Examination
The examination of the other limb is essential to assess for the presence of varicose
veins and to perform different tests aimed at excluding deep vein thrombosis,
incompetent perforators, and venous ulcers. This comprehensive evaluation aids in
planning the appropriate treatment approach.
Examination of the abdominal region is of utmost importance when considering
a case of varicose veins. Among the various general examinations, this particular
examination holds signicant value. It is crucial to assess the abdomen as conditions
such as a pregnant uterus, Intrapelvic tumors (such as broids, ovarian cysts, or
cancer of the cervix or rectum), or abdominal lymphadenopathy can exert pressure
on the external iliac vein. This pressure can subsequently lead to the development of
secondary varicosity.
Venous Thrombosis
Venous thrombosis can manifest in different forms. One common type is deep vein
thrombosis (phlebothrombosis), which often occurs after surgical procedures performed under general anesthesia. In such cases, the calf muscles remain inactive,
leading to a disruption in the normal blood ow within the deep veins and resulting
in the formation of blood clots. Additionally, deep vein thrombosis can also occur
20 Vascular Examination Sheet
following childbirth, prolonged immobility, or certain debilitating diseases. It is
important to note that deep vein thrombosis (DVT) is predominantly an asymptomatic condition. Only a quarter of DVT cases manifest with minor symptoms. To
detect asymptomatic DVT, various diagnostic techniques have been introduced due
to the potential danger it poses in causing pulmonary embolism.
Supercial vein thrombosis, also known as thrombophlebitis, is an inammatory
condition that typically occurs after intravenous transfusion or in individuals with
varicose veins. The main symptom experienced by patients is pain, often accompanied by an increase in body temperature. The affected skin may appear inamed,
and the vein itself feels hard and tender to the touch. Unlike phlebothrombosis, the
resulting blood clot is rmly attached to the vein, reducing the likelihood of pulmonary embolism. In some cases, thrombophlebitis may exhibit migratory characteristics, known as thrombophlebitis migrans, which can be associated with conditions
such as Buerger’s disease, polycythemia, polyarteritis, and certain types of visceral
carcinoma (such as bronchus, pancreas, stomach, or lymphoma). Occasionally,
thrombophlebitis may have no identiable cause (idiopathic), or it may be iatrogenic, resulting from intravenous injections or injuries. Even if a patient has varicose veins, a thorough examination should be conducted to rule out any underlying
occult cancer.
197
Patient History
Patients with DVT may experience pain and swelling in the leg. There might also be
a slight elevation in body temperature. In cases where the patient has previously
suffered from pulmonary embolism, they may complain of chest pain, shortness of
breath, and coughing up blood (hemoptysis).
Local Examination
Inspection
The most prominent aspect of the physical examination is the presence of swelling
in the leg. This swelling is typically localized around the ankle or slightly higher. In
some cases, the swollen leg can be extremely painful, a condition known as
“Phlegmasia Alba Dolens”. When all the deep veins are obstructed, the skin may
appear congested and blue, a condition referred to as “Phlegmasia Cerulea Dolens”.
198
Palpation
Historically, Homan’s sign was elicited during palpation to check for DVT by forcefully dorsiexing the foot while the knee is extended, tenderness can be elicited in
the calf. Additionally, applying gentle pressure directly on the calf muscles in a
relaxed position can also cause pain. It is currently advised to abstain from performing this test to avoid dislodging a clot, which could potentially lead to pulmonary
embolism. Measurements of leg circumference at different levels and comparing to
the other limb frequently indicate the presence of swollen calf muscles.
M. Elkassaby
Special Investigations
If one solely relies on clinical ndings, there is a 50% chance of failing to diagnose
this condition. In some cases, a fatal pulmonary embolus may be the rst indication
of thrombosis. On the other hand, there may be extensive involvement of veins by
the thrombotic process without any clinical signs. In such instances, the destruction
of venous valves can lead to the development of varicose veins, varicose eczema,
ulceration, and other trophic changes.
Phlebography is a diagnostic procedure that involves injecting a contrast medium
into a vein to visualize the deep veins in the leg. During the procedure, the patient
lies on a movable table in a horizontal position. The contrast medium, is slowly
injected into a vein on the dorsum of the great toe. To direct the contrast medium
into the deep veins, a pneumatic cuff is placed just above the ankle. Another cuff at
the mid-thigh position initially connes the contrast medium to the lower leg. Once
the veins are adequately lled, lms are taken of the leg.
Duplex Imaging is a technique that combines B mode ultrasound with a Doppler
probe. It allows for direct visualization of the deep veins and provides information
about both anatomical and physiological variations. Although it is a more expensive
method, it is gradually replacing venography.
Ultrasound and CT scan are recommended when there is suspicion of secondary
varicose veins caused by abdominal tumors. These imaging techniques can help
identify any underlying pathology that may be contributing to the development of
varicose veins.
The Lymphatics: Exploring theDrainage System
The lymphatic system consists of lymph nodes and lymphatics. For the purpose of
vascular diseases examination discussed in this chapter we will concentrate on diseases of the lymphatics.
Lymphedema is a condition characterized by the accumulation of lymph within
the tissues, primarily affecting the subcutaneous tissues of the limbs. This occurs as
20 Vascular Examination Sheet
a result of lymph stagnation within the lymphatics. The causes of lymphoedema can
be classied into two categories: congenital malformation, also known as primary
lymphoedema, and acquired obstruction, referred to as secondary lymphoedema.
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Patient History
• Age and gender
• In terms of the history of lymphoedema, there are several factors to consider.
Firstly, primary lymphoedema may manifest at a young age, while secondary
lymphoedema is more commonly observed in middle-aged and older individu-
als. Secondly, there is a notable gender difference in the prevalence of primary
lymphoedema, with females being more affected than males. Additionally, sec-
ondary lymphoedema is more frequently seen in women who have undergone
radical mastectomy or have been affected by malignant tumours of the uterus or
ovary that involve the iliac and inguinal nodes.
• Ethnicity and geographical factors:
• The distribution of lymphoedema can vary depending on the underlying cause.
For instance, lymphoedema resulting from lariasis is more prevalent in tropical
countries
• Onset and duration:
• The progression of this condition is gradual enlargement of the limb and the
reproductive organs, which may take several years to manifest, is characterized
by the presence of secondary oedema. This condition is often accompanied by
various symptoms, such as those seen in malignant lariasis or following the
removal of lymph nodes, such as in radical mastectomy. Additionally, this condi-
tion is often associated with the opposite effect of lymphatic growth, resembling
lymphatic uid.
Local Examination
During a local examination, it is important to observe the presence of prominent
lymphatic vessels, which can be identied as red streaks progressing towards the
regional lymph nodes. Additionally, one may notice the presence of brawny oedema
in the surrounding area. This particular manifestation is indicative of acute lymphangitis. Furthermore, subcutaneous nodules may be observed along the lymphatics, resembling those found in cases of malignant melanoma and carcinoma. In
instances of malignant melanoma, these nodules often exhibit a deep brown to black
coloration.
Initially, the oedema in the affected area may exhibit pitting upon pressure.
However, over time, the subcutaneous tissue undergoes brosis, resulting in the skin
200
becoming keratotic, a condition known as Elephantiasis. In cases of secondary
lymphedema, the examination should encompass an evaluation of the regional
lymph nodes, as well as a general examination to aid in the diagnosis.
M. Elkassaby
General Examination
It is imperative to perform a thorough general examination, comparing contra lateral limbs to detect generalised causes of lymphedema versus localized ones. It is
also very crucial to examine different lymph node groups, looking for possible signs
of malignancy, generalised or local infective causes of lymphedema or signs of iatrogenic obstructions secondary to lymph nodes removal or scarring after irradiation.
Special Investigations
Blood analysis is a crucial component of routine examinations in medical investigations. It serves various purposes, such as identifying leucocytosis, particularly polymorphs, which can indicate acute lymphadenitis. Additionally, lymphocytosis may
be observed in cases of tuberculosis, leukaemia, and other related conditions.
Eosinophilia, on the other hand, is commonly associated with lariasis. Raised
erythrocyte sedimentation rate (E.S.R.) levels may indicate tuberculosis, secondary
carcinoma, or primary malignant lymphadenopathy. Furthermore, the W.R. and
Kahn test is employed for diagnosing syphilis, while the presence of microlaria in
peripheral blood vessels during sleep suggests lariasis. Complement xation tests
are recommended for detecting lymphogranuloma inguinale and syphilis.
Aspiration of abscesses plays a vital role in diagnosing conditions such as cold
abscesses or lymphogranuloma inguinale. In the case of cold abscesses, acid-fast
bacilli are sought after. For lymphogranuloma inguinale, pus from an unruptured
bubo is diluted with normal saline and sterilized before being injected
intradermally.
The Mantoux test and guinea pig inoculation test are both specic to tuberculosis
and are employed for diagnostic purposes.
Biopsy is considered one of the most crucial special investigations in this eld.
In many cases, clinical diagnosis alone may not be sufcient, necessitating the use
of additional special investigations. Biopsy is recommended in such cases.
In the case of secondary carcinoma, the tumor cells reach the lymph nodes
through the lymphatics using two methods: permeation or embolism. Initially, the
carcinomatous cells enter the peripheral lymph sinuses and gradually permeate the
sinuses between the follicles and cords, ultimately disrupting the normal architecture of the nodes. Microscopically, the structure of secondary carcinoma closely
resembles that of the primary carcinoma, whether it is epidermoid, adenocarcinoma,
20 Vascular Examination Sheet
201
anaplastic, or other types. In fact, the secondary growth often exhibits a more typical and characteristic appearance than the primary tumour.
Lymphangiography is an invaluable test for determining the causes of lymphedema and lymph node enlargement.
Chapter 21
Breast Examination Sheet
TimHarding
Abstract The ability to perform a comprehensive and reproducible breast exami-
nation is an essential skill for physicians and healthcare professionals. Physicians
should have a detailed process by which a thorough history and examination can be
performed predominantly in the outpatient setting. Although, regularly used as an
adjunct to a multimodal investigation process, a well-performed breast examination
can provide key information with regard to both benign and malignant disease.
Keywords Breast · Examination · Sheet · Axilla · Benign · Malignant · Discharge
· Nipple · Discharge
Introduction
The ability to perform a comprehensive and reproducible breast examination is an
essential skill for physicians and healthcare professionals. Physicians should have a
detailed process by which a thorough history and examination can be performed
predominantly in the outpatient setting. Although, regularly used as an adjunct to a
multimodal investigation process, a well-performed breast examination can provide
key information with regard to both benign and malignant disease.
Prior to performing a breast examination an in-depth history should be obtained
from the patient. Patient’s will provide important information regarding timing and
symptomology. This information can aid in a focused examination and more timely
diagnosis.
Although the step wise process to the breast exam may vary amongst clinicians,
the components of the examination and patient history remain constant.
Timing and use of concurrent breast imaging varies across centers; however, a
methodical breast examination will aid in identifying patients who require subsequent imaging or can be safely discharged from the service. It is vital for clinicians
T. Harding (*)
Breast and Endocrine Surgery SpR, St. Vincent’s University Hospital, Dublin, Ireland
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_21
203© The Author(s), under exclusive license to Springer Nature
204
to remember this is an intimate examination and all efforts to ensure patient comfort
throughout should be sought.
T. H a r d i ng
Anatomy andPhysiology
Although a great variation in breast size and shape amongst patients, breast anatomy and landmarks remain constant. This variation is due to the differing volumes
of fatty tissue and stroma.
Anatomy:
• Overlie the 2nd to 6th ribs
• Comma or teardrop shaped with the tail extending toward the axilla
• Overlying fascia (Scarpa’s fascia)
• Base of the breast primarily overlies the pectoralis major. Laterally, part of the
breast extends over the latissimus dorsi and inferiorly the rectus sheath.
• Multiple suspensory ligaments run through the breast connecting the skin to the
deep layer of the supercial fascia, known as Cooper’s ligaments.
• The female breast contains roughly 15–20 lobes, each of which contains multiple
lobules. Contained within these lobules are the terminal duct lobular units
(TDLU) which are responsible for milk production.
Given roughly 80% of the lymphatic drainage of the breast is preferential to the
axilla, an in-depth knowledge of the axilla is fundamental.
• Pyramidal in shape
• From a surgical perspective the axilla can be separated into 3 distinct levels.
– Level 1: lateral to the pectoralis minor,
– Level 2: deep to the pectoralis minor
– Level 3: above and medial to the pectoralis minor.
The number of nodes lying within each level is highly variable within level 1 containing round 10–20 lymph nodes, whereas level 3 may only contain 4–5
lymph nodes.
The Breast Clinic
The breast clinic is a busy element of working in any symptomatic breast unit. In
many units overcrowding and stafng issues are a regular occurrence. Depending
on the type of clinic, patients may be offered triple assessment during the index visit
or simply a history and examination with radiological examination completed at a
later date. In recent years, some units have began to offer imaging rst outpatient
clinics where a patient will receive a mammogram prior to an initial clinic